Friday, September 09, 2011

More on the Shrink's Notes...

Please see my post on Clinical Psychiatry News and yesterday's post What's in a Note? along with the reader comments. 

One reader asked why it's weird to want to see your shrink's notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write "patient denies" as though they don't believe the patient.  These are both great questions worthy of their own post.

Why don't psychiatrists like to show patients their notes?  Are they really going to "harm" the patient?  There are a few reasons why a psychiatrist may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it.
  • Doctor-speak can be cold and clinical and the shrink may worry that the patient's feelings will be hurt.  It can all be quite distancing and who wants to be viewed through the eyes of doctor-speak?
  • The doctor may have things in his notes that the patient views differently.  For example, a patient may be angry that the psychiatrist does not believe him that martians monitor his movements with special cameras inside his body and may want it removed from the chart that he has  "delusions."  I could come up with many more examples.
  • The shrink may be concerned that the patient will misinterpret things he's said and be upset by them.  
  • The shrink may be embarrassed that he has lousy notes.
  • Shrink talk can be rather detailed and insulting.  The mental status exam includes a description of the patient-- the patient may feel very hurt to know his doctor saw him as "unkempt" or noticed he was unshaven, or "malodorous" or that he appeared agitated or anxious.  These are descriptive and therefore useful from a clinical standpoint, but they can also be read as insulting and the patient may feel injured, or put the psychiatrist in an awkward spot if he demands something be changed when the psychiatrist doesn't agree. More importantly, reading something uncomplimentary may damage the relationship.  People want their shrinks (particularly their therapists) to think well of them, and how do you continue to have a warm and fuzzy relationship with someone who has written that you smell bad? 
  • The shrink may worry that the patient will sue him or file a complaint.
  • The patient may want things taken out of the record even if they agree they are true.
  • I think mostly it's about avoiding confrontation, but tell me if I'm wrong.
Psychiatrists are taught to report things in a specific way, and doctor-speak has it's own nuances that don't match everyday English.  There is the 'chief complain'-- oh but saying someone is complaining is pejorative, it's like saying they whine!  We think of it as a problem list, but 'complaint' is the medical term.  Similarly with "denies," though I've heard others say that it sounds like we don't believe the patient, and I've come to avoid the term, except if I don't believe the patient, and then I may say why: "denies depression but sobs throughout the session and looks miserable."   

Tell me what you think.