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Glimpsing Our Own Health Secrets: The Coming Revolution in Health-Care Transparency

It was a random flip through an old family binder that changed the course of Selina Brudnicki’s career. Brudnicki’s late mother had been diagnosed with breast cancer eight years earlier. A few months after her mastectomy, she complained to her doctors of new pain—a symptom that Brudnicki, a Program Lead of Digital Patient Experience based in Toronto, had assumed was being properly investigated. Brudnicki’s mother passed away of metastatic breast cancer shortly thereafter.

It was in 2015, three years after her mother’s death, that Brudnicki came across that binder, which was tucked away with her mother’s belongings. There were medical test results, pathology and imaging reports, and a few oncologist notes. She also found a note her mother had written herself, commenting on a doctor’s report. It read: “[The doctor’s] report does not seem correct.  I always mention ‘pain’ not discomfort. I kept complaining about a new pain.”

“While there are never guarantees, I always wonder: If [my mother] had access to her complete medical records and notes, would she have realized [sooner] that she and her doctor were not on the same page?” Brudnicki tells me. “Would this have prompted better communication and earlier investigation?”

In most parts of the world, it remains difficult to access one’s own medical data. Typically, a patient has to find the relevant medical-records agency or department, fill out various forms, and, in some cases, spend hours obtaining photocopies of written reports that must be returned.

Over the last three years, Brudnicki and her colleagues at the Toronto-based University Health Network (UHN) have been creating an expedited process, through a program called “myUHN Patient Portal,” which allows patients from any of the UHN hospital sites to access raw documentation—including the daily notes their health providers take in real time. They also can view diagnostic imaging reports and lab results at the same time as their doctors. The program officially rolled out in 2017 as a response to patients seeking to access their own health information, and as part of a global movement called “OpenNotes,” which aims to prod institutions and doctors to openly share their patient notes from existing electronic-medical-record (EMR) systems.

The roots of OpenNotes extend back to the 1970s. Co-founder Tom Delbanco (who is now the John F. Keane & Family Professor of Medicine at Harvard Medical School) was scribbling down the story of one of his patients—a middle-aged man who had issues at work, drank “a few beers a day,” and fought with his wife and children. As the man happened to work at a printing press, he was easily able to read Delbanco’s notes upside down from across the table in the clinic room, and so started making edit suggestions in real time.

Far from being put-off by this unsolicited assistance, Delbanco began working with the patient on a plan of care that resulted in the patient dropping his drinking habit. Over time, Delbanco became eager to explore how this more transparent and collaborative approach could help improve care for other patients. Delbanco recalls: “If patients were able to read their own notes as a standard, and perhaps even participate in this documentation, would patient care and the patient experience improve?”

It was a tough sell, because Delbanco’s model challenged the idea of doctor as medical-knowledge gatekeeper. But Delbanco pressed on, eventually creating OpenNotes, which has allowed 30-million patients—mostly in the United States—to access their medical notes.

In a paper published in the Annals of Internal Medicine in 2012, “Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead,” Delbanco and his team reported that among 13,000 patients studied, more than half reported increased adherence to their medication regimes, and more than three quarters felt it “helped them feel more in control of their care.” Only a small minority reported that access to the notes caused them to feel “confusion, worry, or offense.” Other research indicates that OpenNotes promotes patient engagement, improves patient-physician collaboration, helps patients and doctors prioritize, all while decreasing physician workload.

OpenNotes has been implemented in Sweden, which earlier this year became the first country to put every citizen on a medical record system called the Patient Accessible Electronic Health Record (PAEHR). By logging into the system using an electronic identifier or Swedish personal identify number, Swedes can access notes from all of their healthcare professionals, medication lists, test results, diagnoses, vaccine records, and anything else housed in their medical record. Patients can also leave comments on their notes—a bit like the comments inserted through the track-changes feature of Microsoft Word. If a doctor reports that a patient’s stomach pain came on after a Christmas meal, and the patient realizes that she’d actually been experiencing the pain since Thanksgiving, she can add that into the margins.

* * *

The OpenNotes movement raises questions that, until now, have attracted little research. Does more transparency mean that patients will become responsible for catching errors that doctors themselves should have prevented? Will doctors have to censor themselves, out of concern that something they write might be misinterpreted by the patient? Could doctors become more vulnerable to litigation? Or will greater transparency help prevent litigation by prompting fruitful discussions between patient and doctor in the first place?

“Physicians are a conservative group…there’s a lot of inertia,” says Iris Gorfinkel, a Toronto-based family physician who received pushback after recently penning a commentary on the subject for the Canadian Medical Association Journal. “Doctors feel as though this may place additional pressure on them to get more things done in less time; that there are more eyes watching them. But every major change requires growing pains.”

There’s no question that OpenNotes will fundamentally change the (traditionally paternalistic) doctor-patient relationship. It flattens a centuries-old hierarchy, and will push doctors to shed jargon-heavy forms of communication in favour of clear, succinct (and legible) descriptions. As with other changes to the field of medicine, there will be older doctors who never accept the new standard, and much of the change no doubt will be led by a younger cohort.

“We [trainees] are never formally educated about how to properly document the patient encounter,” says Chethan Sarabu, a pediatrician and recent graduate of the Clinical Informatics Fellowship Program at Stanford University. “A movement toward more transparency…can actually be an opportunity to train future doctors about documenting for the purposes of communicating clearly to patients as well as to others who may access [their] chart[s].”

But even younger doctors who are comfortable with transparency and new technology (a category in which I would place myself) should be wary of database protocols that allow tech companies such as Apple and Google—both of which are making large investments in healthcare—access to cloud-based EMRs. Home-testing companies such as 23andMe and LetsGetChecked are placing screening and lab-testing data into the hands of private clients, who will have a dual role as patients within a public system, and who may voluntarily share their data far and wide. No one can rule out a future formal partnership between OpenNotes, EMRs and tech companies; and what this could mean for patient privacy is unclear.

* * *

To diagnose a strange constellation of symptoms a few years ago, a clinician ordered an MRI of my head. As I sat in the scanner, I could hear the buzzing and suddenly felt claustrophobic. I understood what my own patients experienced in that hollow white tube. I could barely move. And if I squirmed, the scan wouldn’t be accurate. It was easier to close my eyes and relax—maybe meditate or, even better, fall asleep.

As I lay there, I could picture exactly what was happening behind the glass wall outside the scanner. I had been on the other side many times before, my mouse scrolling through layers of the brain presented on the screen. Would those behind the glass find a series of lesions—bright spots of inflammation—on my own brain? Or, worse, would they find a large blob indicating a tumor? A stranger would be discovering secrets about my own brain that I didn’t know. My case would be reviewed by a radiologist, then by another, possibly presented at a case conference, maybe involving a consultant neurologist, and possibly a neurosurgeon. All this would happen before I had any clue what was in my own head.

As the procedure finished, I shuffled out toward the changing area, holding my gown closed. I stopped by the glass wall to ask the MRI technician for clues. “I’m a resident doctor,” I said. “I’m just wondering if you saw anything.”  She wasn’t permitted to answer. I knew she couldn’t. Yet I still wondered if part of why she wasn’t answering was because she saw … something.

Weeks later, my family doctor called me. There was nothing unusual on the MRI. I never asked to see the reports myself. Perhaps ignorance, in this case, was bliss. Or not. Either way, it should be the patient’s call. And in coming years, thanks to OpenNotes and similar initiatives, it will be.

 

Amitha Kalaichandran is an Ottawa-based resident doctor and writer. Follow her on Twitter at @DrAmithaMD.

35 Comments

  1. Elena says

    So often I see the “I’m the Doctor, I’m the God!” attitude. Once, I reported to a walk-in clinic doctor that I have allergic reactions to an antibiotic he prescribed to me and asked him to change it. He did that, but later I learned that he also put a note : “More likely had a panic attack. “. I had not, there was nothing in my life to cause that. But hey, he’s the Doctor, he’s the God!

    • I had to go to the ER (zero walkin clinics in my area, ack) for a respiratory infection some years ago. It was turning into bronchitis. I’d had the problem several times before, knew what worked (a z-pack) and what didn’t (amoxicillin), and specifically asked the doc not to give me amoxicillin. She agreed, and promptly wrote me a script for something with an unfamiliar name… that on further investigation turned out to be amoxicillin combined with a decongestant. I took it anyway. It didn’t work. I coughed incessantly for another four weeks, and got stress fractures in my ribs. That adventure cost me $600.

      ….and people wonder why I don’t go to the doctor anymore. How many doctors would I have to go see, out-of-pocket, just to find one who’s listening?

      • LauraB says

        Bravo! Hardly unfair to keep patients ignorant about what’s going on in their own bodies. How else can we make informed decisions? Who would want the responsibility for all their patients health status, their lives and/or possible preventable death?

    • antonbabinski says

      Elena is the exemplar of why open records are a problem. Let’s consider two possibilities.

      1-Elena’s doctor has a god complex and his ego is so fragile that even one of the 30 patients he saw that day dared to say that something he prescribed had an adverse effect and so he had to defend his ego by saying she is having a panic attack.

      or..

      2-Elena’s doctor is an experienced professional who has seen 1000s of patient with countless having adverse reactions to medications. He saw an anxious patient with at worst an idiosyncratic minor side-effect or a slightly neurotic woman who is basically a worried well. He doesn’t want to document that she had a bad reaction to the medication because he knows that at some point in time she is going to get really sick and he doesn’t want other physicians to hesitate to give her the most readily available appropriate antibiotic. He knows that the time to antibiotic is the most critical factor to saving her life and that a laundry list of antibiotic side-effects will slow down her care and could worsen the outcome. Maybe he wants to in a small part to save her from herself and so he notes that it may have just been a panic attack. He knows the easier thing would be to document that she can’t receive this antibiotic (or any in its class), because she might be the kind of person that digs into the medical record and likes to right long letters to patient relations, but he does the right thing, because that is what he is trained to do. That is why he went through a kind of training most people can’t even imagine. That is why he stayed at the library when everyone else went out for drinks. He did it to help people.

  2. An honest physician says

    This will be the death knell of medical notes worth reading. I already find that notes have deteriorated over the last 25 years and it will only get worse. They will be much like the pointless report cards that my kids got in school for the last 8 years they were there.

    This has nothing to do with paternalism in medicine, thankfully that is long gone even if many patients of all ages lament it and want both collaboration and being told what to do.

    Symptoms are subjective and what’s the real difference between ‘discomfort’ and ‘pain’? Nothing! Sure, nitpick this but one person’s pain is another’s discomfort.

    I will be curious to see the writer’s opinion after they get more real experience. I already think that death would be preferable in many circumstances to letting our healthcare system try to look after me.

    • V 2.0 says

      Why would notes deteriorate as long as there some safeguard in place to make sure a misinterpretation or offense cannot lead to a lawsuit? I would certainly want to know as much detail about my medical condition as possible especially if that condition was potentially life threatening. Communication is key and the more the better. As I found out recently while taking care of my cancer-ridden SO, the difference between ‘discomfort’ and ‘pain’ is the difference between getting a couple of Tylenols and getting some Hydromorphone.

  3. Lightning Rose says

    I would urge you to read “The Last Well Person” and “Worried Sick” by Dr. Nortin M. Hadler. He shines a bright light on exactly how much of “routine care” is not evidence-based, not necessary, and in many cases can actually do harm. “Health Care” does not keep us well; it can only do damage control (locking the door of a burning barn) once we’re already in trouble. We KNOW what we need to do for most of us to be biologically nominal–but most lack the will to do it.

    • Sally says

      Yes, Hadler is good stuff, as is anything by H. Gilbert Welch (notwithstanding the recent dubious allegation of plagiarism against the latter). Open notes isn’t a bad idea, but I doubt that it will transform the doctor-patient relationship, and it certainly won’t address the much bigger issues of overtreatment, misdiagnosis, faddism and pseudoscience in medicine.

  4. E. Olson says

    I’ve had family members who have needed much medical care and have taken the trouble to get their medical records, and it is amazing how inaccurate and incomplete they are. Things the doctors says during examinations are frequently left out, as are symptoms reported by the patient, but the common denominator is to never include any written statement that might indicate a mistake has been made by the doctor, clinic, or during any previous treatment. For example, we’ve had doctors tell us orally that previous treatments (by other doctors) have been poorly done or that a diagnostic test should have been done (but wasn’t) in response to described symptoms, but then found nothing indicating any mistakes or errors in the written patient record. These “lapses” have occurred across multiple doctors, multiple clinics, and multiple countries, which suggests to me this “forgetfulness” is taught in medical schools. While I can understand a desire to avoid personal liability and/or throw a neglectful colleague “under the bus”, such incomplete assessments also make it more difficult to get help further up the medical food chain because specialists do not get an accurate timeline of patient symptoms or a complete picture of earlier diagnoses and treatment discussions.

  5. R Henry says

    I recently served as a juror in a personal injury case related to an automobile collision. Among the many fascinating aspects of the case, were the testimonies by “Expert” witnesses.

    The plaintiff in the case claimed life-changing injuries resulted from a very minor collision (a rear-ender with an impact at approx 12mph). Shortly after the incident, the plaintiff was transported by ambulance to a local hospital where she received a thorough examination, including CAT scans and MRI. Absolutely no evidence of brain injury was noted. No loss of consciousness was reported, no symptoms of traumatic brain injury were reported by plaintiff nor indicated by various screening tests administered that day.

    Interestingly, several days later, presumable AFTER the accident victim was contacted by a plaintiff’s attorney, the victim visited a GP as a first time patient. The patient then described to the Dr that after a recent collision, symptoms including hyper acusia, photo-phobia, balance issues, and cognitive impairment presented themselves.

    The Dr. then diagnosed the woman with Traumatic Brain Injury/Concussion–based only on self-reported symtoms—and having not examined any of the test results/reports from the day of the collision.

    Once the victim received this “diagnosis” of “Concussion”, the patient then visited countless specialists, reporting to all that a concussion had been sustained from a traffic collision.

    I was amazed that so many physicians, and even “expert” witnesses were willing to accept/support the diagnosis of “Concussion” /TBI even lacking any clinical evidence of injury–only patient self-reports of symptoms.

    Finally, the Defense presented an expert witness who outlined what the jurors had all been thinking all along. The very minor accident could NOT have caused a concussion, that the patient had ulterior motives, that whole case was a farce.

    In the end, the jurors realized the patient was suffering depression, anxiety….and was seeking a large settlement to support early retirement.

    The bottom line take-away: MANY physicians and specialists accepted the false diagnosis of “Concussion” without any supporting evidence…and based their own “treatments” on the false diagnosis. It was a sad realization.

    • NoleonMeric says

      Your “sad realization” is based on limited insight into neurological diagnosis; the defense lawyer failed you, or you weren’t paying close enough attention. Concussion is primarily a clinical diagnosis; the patient history IS the supporting evidence, and you generally don’t see brain damage on routine imaging. Also, loss of consciousness may be extremely brief, and on history this may not be recalled by the patient. You may strongly suspect a patient is malingering, or has functional overlay, but this is generally a diagnosis of exclusion and without concrete evidence you can’t make this assumption. A contradictory police report (which a busy physician probably won’t have to track down regardless) is subject to reporting error just as much as a patient history. An assumption that the patient is lying is fraught with potential bias.

      • R Henry says

        @ NoleonMeric

        Thank you for your reply.

        Your perspectives were indeed presented by the plantiff’s witnesses, yet rejected by the jury.

        Plantiff had experienced an impact, according to a bio-mechanical expert, too mild to induce the claimed injury, AND witness had a 30 year history of treatment for depression and anxiety. Several expert witnesses testified depression and anxiety can result in the panalopy of symptoms claimed by plaintiff. Jurors also detected plaintiff fabricated/embellished at least two stories she described during her testimony.

        Back to the key point however: Do you believe it is appropriate for a GP, during the first ov with a new patient, to diagnose TMI/concussion based solely upon patient-supplied history? No records review, no screening tests or studies? Curiously, even Dr’s own summary report failed to mention any observed vestibular issues during the ov, even though he noted balance issues among patient reported symptoms.

        Indeed, a courtroom is NOT a place to to uncover medical truth, but jururs are tasked with finding legal truth. We learned that a single physician rendered a key diagnosis absent any evidence beyond patient reporting, and that subsquent physicians and practicioners automatucally accepted that likely flawed diagnosis as fact.

        • NoleonMeric says

          “Back to the key point however: Do you believe it is appropriate for a GP, during the first ov with a new patient, to diagnose TMI/concussion based solely upon patient-supplied history?”

          Yes, because that’s how you diagnose a concussion; there are currently no sensitive biomarkers to assist with this, including lab testing or imaging studies. And this is also something that a general practitioner should be comfortable with assessing and diagnosing. You may strongly suspect that there is a psychogenic component to symptoms, or even that a patient is lying, but if the patient provides a history consistent with the diagnosis, as an objective evaluator there’s no basis for just dismissing them. That’s not to say that a potential psychogenic component should just be ignored; this should be addressed and treated as well, and it may also help symptoms. But to just dismiss a patient’s reported history because she’s a neurotic middle-aged woman who’s pursuing a lawsuit is fraught with potential bias.

          • R Henry says

            Again, thank you.

            Yes, your deeply perspective was presented by a number of highly qualified treating physicians, and expert witnesses. Other highly trained and experienced expert witnesses testified “reverse diagnosis” (assigning reported symptoms to a specific cause–as opposed to objectively identifying an injury/condition) is far too subjective to yield reliable results.

            If anything, the scenario we have been discussing illustrates the poor fit between medical diagnosis/treatments and a panel of jurists whose prime qualification is an open schedule. That said, I am nearly certain justice was achieved in this case.

  6. antonbabinski says

    Sentimental drivel. This article has no place on Quillette. Open records is essentially a marketing tool being foisted on the medical community with minimal evidence. It is the last dagger in heart of medical record completing the transition from concise impressions and empiric data to a Frankenstein’s Monster of billing and protection from litigation. Trying to further torture this poor beast by mutilating it into a teaching/patient relations tool is a mistake. The need is not there. There are already plenty of tools to summarize a diagnosis and plan in patient friendly language (e.g result letters, end of visit summaries). Of course these efforts can be improved, but subverting the tool physician need to communicate with other experts and keep notes for themselves is not the right way. We don’t go to a restaurant and expect to see a video of how the cow got turned into a steak. Apple doesn’t show pictures of the sweat shops in China next to their iphones. Transparency is in a general a good but this needs to be balanced with the vital capacity for physicians to communicate in precise and frank terms. The capacity for patients to view their records if they are worried about the care they are receiving has always been there. They can always request their records in full.

    • Lightning Rose says

      Want to hear something even scarier? The WHO has just declared “aging” a DISEASE with the intent that now “health systems” will support every experimental fountain-of-youth quackery under the guise that the natural progress of all animal life is a solvable problem.

      Seems the way to alter reality these days is to change the semantics . . .

  7. Congratulations on a superb article. As a practicing GP, patient portals into their primary care medical records have tremendous potential to greatly advance patient care. Topping this list includes helping to reduce the inherent knowledge gap between patient and their GP’s. This thereby reduces the inherent power imbalance between patients and their physicians.

    In the future, medical records may be transformed into a world in which every aspect of the medical history becomes a hyperlink to educational resources. Such resources would be used and accessed by the patient at will, in the patient’s choice of language and even at their stated educational level. This may not be so far off.

    Iris Gorfinkel, M.D.

  8. Dai Anto says

    And just how long before drug companies and insurers start hacking into such records?

    • TarsTarkas says

      I’d be much more worried about it being used to ration health care or push one-size-fits-all treatment based on statistics.

  9. ga gamba says

    It flattens a centuries-old hierarchy, and will push doctors to shed jargon-heavy forms of communication in favour of clear, succinct (and legible) descriptions.

    Can’t speak for the medical profession, but jargon is used often for succinctness. It’s very common in logistics, information technology, finance, accountancy, shoemaking, and the military, and I would not be astounded to learn it exists in numerous other professions. Using layman’s (or layperson’s) language requires many more words.

    • X. Citoyen says

      I was once told that plain language should be used on a website “to optimize the end-user experience.”

      • ga gamba says

        Haha. Indeed.

        Who is the target audience of medical records? Other healthcare professionals.

        Do we want doctors to sacrifice their time to spend it instead writing (and reading) longer reports in layman’s language? Further, at what level of layman’s language ought it be? Appropriate to those with college-level reading comprehension skills? High-school graduate level? Year six? Do we use the Flesch–Kincaid readability tests – Reading Ease and Grade Level – to measure this? Moreover, as your example sentence shows, the writers themselves may not understand the reading skills of the target audience. It’s quite easy to say “use layman’s language”, but that assumes the person given the directive understands it thoroughly. Seems to me this is a skill requiring training, especially after so many years of training oneself to acquire the expert’s skills and language. Do we need to send doctors to training to learn this? Haven’t they got enough on their plate already?

  10. Psychiatric patients request and argue about their records a lot, and for my entire career we have written our notes with the understanding that the patient is likely to read them during the admission, or that the note will be used by one attorney or another in a civil commitment or guardianship hearing very soon. Doctors, psychologists, social workers, and nurses have all been on the stand many times in acute involuntary hospitals.

    It probably makes us choose our wording more carefully, and make sure we include items we might otherwise slide, which are good things. We are also more aware of what we could justify if challenged, which is a mixed blessing, because it means the standard of proof is higher, so things get left out. I think the way we have to write notes is probably a net plus, but I doubt it’s large.

    As for language used, it can have its own precision that is different from everyday usage. Listing “average intelligence” only means that is the minimum – that it’s not a factor in diagnosis. It doesn’t mean the doctor hasn’t noticed your world-class IQ. “Denies substance abuse” does not mean you have it but won’t admit it, only that you said you don’t. Most doctors I encounter, especially dentists, routinely use the word “discomfort” instead of “pain,” unless they are specifically using a pain scale.

    As for improving adherence by involving the patient more, this is true, sometimes very true. However, it only happens with those patients who will work with you, which is not everyone.

  11. R Henry says

    The scientific/meducal community has a miraculous history of life saving and life-improving treatments. Practitioners have cause for great pride.

    That said, I remain perplexed that surgeons today routinely remove perfectly functioning sex organs. This, of course, solely due to patient request, so that patients can more effectively prepetuate the fraud of pretending to be the opposite sex.

    Truly, the medical community is repeating the mistskes associated with the era of frontal lobotomy. Physicians can’t treat mental disorders with irreversible surgical procedures!

    How long will it take for the medical community to realize it is doing great harm here?

    • The director of the Johns Hopkins clinic that did sexual reassignment surgery closed it down because of the number of suicides and the number of patients who returned asking to have the surgery undone. He, of course, is being vilified by the current advocates.

  12. Can’t speak to the idea of physicians’ notes but I have lived in other countries where I found myself astounded to have custody of my own x-rays, blood tests, etc. Only then did I realize (in the U.S.) how like children we patients are treated. Medical records are passed from doctor to doctor or from lab to doctor and are interpreted for us on a need to know basis.

    Also, I’m sure it drives doctors nuts but the internet has changed the game beyond all expectations. People are learning to treat themselves. There is danger there, of course, but also new hope in that terrifying freedom.

    • @benita
      Funny, you should see my doctor roll his eyes when I say ‘I looked it up on Google’

      They do get pressured by patients that insist they have this, that or the other. They also live – at least in the U.S. – with the constant threat of medical malpractice lawsuits. We have way too many lawyers…

  13. As a hypochondriac, I appreciate not having to go through the doctor’s office for the results of a dexascan or a blood panel.

  14. Sydney says

    Bewildered why this was published in Quillette. STATnews.com is obviously a more appropriate venue. It’s merely one of thousands of little tweaks that regularly drip down the pipe and into the broken conventional medical system. But they’re all just tweaks, because the only part of the conventional health system that works is emergency medicine. The rest is a failure of epic proportions.

    The actual, radical, positive change replacing this broken old system is Integrative (also known as Functional) medicine. It treats humans – not components – and its objective is root-cause resolution (not band-aid pharma or often unnecessary surgery).

    Do yourself a favour. Read up on it, and see an Integrative clinician for your issues (including 95% of so-called psychiatric issues). The conventional system (apart from emergency medicine), tweaks and all, heals nothing.

  15. I always told my patients to keep their own copies of their medical records. I have one. It is especially important now as electronic records are being destroyed all the time. They are supposed to be kept 7 years and until age 21 for children but that is not being done.

  16. X. Citoyen says

    I’m having a little trouble believing there are no trade-offs. The cost alone must be astronomical.

  17. Andrew S says

    Hospitals in my city are already jumping on this bandwagon to some consternation. I have two suggestions for the author to consider: 1, doctors already spend most of their working hours in front of a computer, so maybe allow them to continue writing in specific and succinct jargon for use by other doctors and have someone else translate it into the layman’s terms for the patient, (other physicians or nurses perhaps). 2, maintain an ability for doctors to opt into withholding some portion of the note from patients, like concerns about malingering, potentially fabricated symptoms (they do happen on rare occasion), drug seeking behavior, etc. I fear that doctors will choose to not list these important and potentially life-saving concerns instead of deal with irrate patients screaming about libel all day. You need to find a way to balance frank inter-physician communication with patient transparency, and this proposal is potentially too far skewed towards transparency, likely to the detriment of patients’ health.

    At the very least, doctors will fight you less with these concessions made.

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