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.


Anonymous said...

My previous psychiatrist refused to give me my medical records, so that made me more determined to obtain them. What was he needing to hide? He ignored two medical records requests, so I sent the third request via certified letter with the records to be sent to a friend of mine who is a therapist. I gave him the time line off the state medical board's website. Guess what? The medical records appeared! Like magic!

Had he not sent them I would have gone to plan B which is to have them sent to a friend from college who is an attorney. I have a right to read medical records that are about me.

It really helped me to read them because it was reassurance for why things had broken down so badly. He couldn't have been honest to save his own life.

Having worked in the medical field myself I don't take things like "patient denies" personally. It's not just psychiatrists who write that and it's not personal. It is doctor speak.

What I had a problem with is that he put something I said in quotes and then wrote next to it "doubtful." He never let on that he didn't believe me so I wasn't able to confirm it for him (which I could have because it was true). That, and many other things he wrote but didn't address showed me that he was so jaded and so cynical. He could write all kinds of negative crap about me but didn't have the cajones to address any of it. If I had made up a bunch of stuff (which I didn't), wouldn't it have made sense to address it instead of continuing to just take my money? How is helpful to the patient to not have the guts to address things? What a waste of time that was.

My therapist has always been open and when I asked about reading my records, she was fine with it. She had nothing to hide.

Anonymous said...

Oops, I misspelled cajones, should have written cojones.

Anonymous said...

If a client can be denied access to his or her psych notes/evals, then he or she should absolutely be able to prevent them from finding their way into the "cloud", even if that "cloud" is non-electronic and wending its way purely through the US mail.

I just this week read an eval from my new pdoc which said my contamination fears included plague. What I actually expressed during the session was dismay that problems which seemed to be well on their way to complete eradication in my youth (TB, plague) seemed to be making a comeback. I don't think I'm going to pick up a case of plague on the subway, DOCTOR.

Lu said...

My analyst doesn't take notes, at least not in front of me. It's for privacy reasons, I believe. Sometimes I need to remind him of things I've said, which is not a problem to me. What is stunning to me, however, is the amount of stuff I *don't* have to remind him of (as Sunny in CA in the other thread said). How does he do it??

In one sense, I admire his apparently superhuman recall. In another, I wonder what really is in whatever records he is keeping under lock and key. I have no interest in seeing them; I've spent enough time worrying about what he thinks of me, and I am familiar enough with the discomfort of learning peoples' true impressions of me, that I don't want to know.

I've heard the saying, "What other people think of you is none of your business," and in the psychotherapeutic venture, a dash of that sentiment is a healthy part of the mix.

jesse said...

Re Lu's comments above: Besides having true interest in your patient and listening carefully to what he says (two things which are among the more important factors in psychotherapy), in analysis or analytic therapy we pay attention not only to the patient's associations but to our own. Those associations often let us connect data and recall what is important. It is not simply memory on a blank page. At times patients whom I have not seen in years are amazed at what I remember, but they too, on meeting a friend by chance whom they may not have seen in a decade, will recall details of the friend's life that astounds the other person.

Notes can be helpful, but sometimes the act of taking notes gives us permission to forget.

No patient has ever asked to see my notes. Your last comment is very perceptive, and may be an indication of the good that is coming from your analysis. If a patient wants to see his doctor's therapy notes, they might talk about what is happening to create that wish. Simply handing over the notes without exploring the reasons may miss the most important issues, and will likely not be satisfying for the patient in any case.

Anonymous said...

Well, if I'm paying for someone's opinion I'm not sure how it's helpful for me not to hear what they think. I think being honest with each other is how relationships grow. I didn't always love my therapist's opinion, and at times we got frustrated with each other. But, I respect her because she had the guts to address the difficult things. I think it's kind of cowardly to write stuff in a person't medical record but not have the courage to address it.

Anonymous said...

Dinah and Jesse, I agree with the points you make. I have found that with therapists whose notes I found myself wantitng to see it was more because I was not happy with the treatment and did not have confidence in the therapist. With therapists in whom I've felt confident, I have never felt a real desire to see the notes. Of course at times I'm curious but for the most part I trust him as well as his ability to know what would or wouldn't be helpful.

I am curious about one thing. Given the reasons you both listed, what grounds could a hospital (brief, inpatient care for mood disorder) have for refusing medical records because it would be "harmful" to the patient? There is no therapeutic relationship to be damaged and highly unlikely to be any confrontation. And is not wanting to hurt the patient's feelings really a legitimate reason to refuse access to medical records without either of the above applying?

jesse said...

Anon, in the situation you mention, a hospital should not deny the records. The patient has a right to see them. A hospital situation is very different from one in a private office.

If a patient came into my office and said "I am going to request your notes. I want to see everything you write," then that would be a very important issue to discuss. If it is not discussed a very important issue is being missed, and whatever treatment then occurs ill be compromised.

Anonymous said...

I have to say that I really had no interest in getting my therapy notes and only got them because I needed them for my disablity insurance appeal. There was nothing surprising in those notes.

I am really surprised about a hospital hassling a patient about their notes. I got records from a couple of hospitals and had no problems at all.

I was charged more than a dollar a page for handwritten notes, and it was many pages from many years. The therapy offices had some sort of BS loophole they used to charge me more, I think. I spent like $200 getting my notes.

Anonymous said...


I'm the Anon who had the big gripe with "patient denies" being supplied all over my records. The phrase doesn't bother me when it's used in the way of "Patient denies SI/HI" or even in your example about the patient sobbing through the whole visit--I have seen that one in my own records about denying depressed mood but appearing sad (I wasn't sad). What gets me is the other example you give when you use the phrase because you don't believe a patient's self-report. Sometimes shrinks will put down in the records that the patient "denies" because they really don't believe the story, and this bugs me because the therapist has no way of knowing what happened 1 year before treatment with the therapist began. And anyone else reading the records will read between the lines that the statement was untrue, unlikely or not corroborated.

Also, I have no problem ordering records from past shrinks whom I did not particularly like and who were not good matches for me. I don't care what shows up in their notes. It's my current shrink whose records I would not feel comfortable reading--because I like him and I don't want things to get all awkward and damage the relationship. And I think this is the crux of the whole thing.

Don't think this is weird, but instead of bringing a tape recorder to my 15-minute med checks (I'd never do that), I try to memorize everything we each say during the visit and then go home and transcribe all the dialogue ASAP before I forget it. I started this practice a couple of years ago quite innocently. I couldn't sleep and was all "keyed up" after switching shrinks and the MSE assessment (long) appt. I'd had that week. I started repeating dialogue in my head and it soothed me--it was cathartic. So, every subsequent visit, I wrote down (of course not word-for-word, but with 87% accuracy) what was spoken. Now, I use these as reference notes for things like what the doctor told me about tapering off of a med (how many pills on Week 2), what lab results were at a particular point in time, whether the doctor was running late that day, etc. These are just for my use, but let me tell you, if something important comes up, and the shrink tries to tell my spouse, "She never mentioned that to me" or exhibits other selective memory, MY transcription could always be used to refresh the recollection, LOL. Now the records don't rule me--I have control too.

Anonymous said...

Regardless of the reason, I still think patients have a right to read their medical records and if they are refused, patients should know there are ways to obtain them. The reason I wanted them from the psychiatrist was because things had already gone south, and I knew I would not be returning. He attempted to keep them from me, because he knew he would be caught in his dishonesty.

I much prefer therapists and psychiatrists who are open and honest, even if the truth is sometimes difficult to hear. I have no respect for those who write derogatory comments but won't address it with the patient.

Alexis said...

The last thing I want to do is see my notes. I spend enough time worrying about what people really think of me. Actually, you could probably argue that it would be harmful for me to see my notes, since I would invariably latch on to anything negative that was written while discarding any positives. I have enough trouble trusting therapists or believing that their positive comments are more than what they're expected to do; actually having "proof" that this was the case would make that even worse. It was bad enough reading fictionalized accounts of patients like me; it made me self-conscious to the point of being unable to speak.

Anonymous said...

Psych patients should have the same rights as any other medical patient including the same access to medical records. Hiding behind the "it's not good for the patient" is a cop out. You could argue that a patient reading SOB in their medical record is going to upset them because they might not understand that SOB stands for shortness of breath, yet that argument is not sufficient for a pulmonologist to keep medical records from a patient. The same rights should apply to psych patients.

Those who don't want their records already have the option not to look at them.

Lu said...

Jesse, thanks for your response to me and your other contributions to this thread. Very helpful to hear how analysts and other psychodynamically oriented therapists listen, from the point of view of one who does it. It's a real gift to listen that closely.

Yes, analysis has been great for teaching me boundaries, even if just to show me where they are, where it is appropriate or inappropriate to cross them, and where I would wish to cross them nevertheless.

Jen said...

Respectfully disagreeing with you, Lu, I found that with some psychodynamic (analytically trained) therapists, certain boundaries existed only because they were supposed to - they were not helpful and did not serve to teach or learn about anything. I have found that there are basic guidelines that of course apply, but that for most of the rest, flexibility is really needed to tailor to the individual patient. Boundaries for the sake of boundaries don't seem to serve much of a purpose beyond keeping an analytic ego high above itself.

Lu said...

But I was talking about my experience, Jen, not offering a verdict on the field as a whole. I am lucky to have an excellent, mature, and dedicated psychoanalytic psychologist.

Sarebear said...

During the process of applying for SS Disability, halfway thru the process when I had a lawyer, we got some medical records. I didn't see the psych ones because those went straight to him, and my psychologist really didn't want me to see them. After some other experiences, including what I'll relate here, I can understand a little bit of why.

I picked up the copies of medical records from my family doc. I of course couldn't resist looking through them before passing on to the lawyer; well some years back I was diagnosed with PCOS (Polycystic Ovarian Syndrome, for those who don't know). One symptom is, well, excess facial hair, for me chin hair. As I was reading the records I startled and re-read again, the doctor's description of me as "hirsute". I felt like making monkey noises, after getting over my initial surprise, embarrassment, chagrin, and a bit of upset at being described so. I tend to be silly and punny, thus the urge for monkey noises, lol.

I read further, and saw this description repeated on other occasions. You'd think I sported a full beard, the way it came across to me but then of course I was obviously sensitive to being described repeatedly as "hirsuite".

Nowadays, I do tend to have a five-o'clock shadow; I refuse to shave like a man like a dermotologist recommended; I trim as close as I can and try to forget I have this problem. Chemical burns from other hair removal products that thankfully faded away leave me leery of other methods and you probably don't want to hear all this lol.

Anyway, I re-read the initial description, and how he thought I may h ave, probably had PCOS. I became a bit upset when I realized that he knew this 6 months to a year before he ever told me; perhaps though in hindsight he wanted to see if various symptoms persisted over time?

Anyway, now I have a bit of a chuckle about it, but it is something I keep in mind when I get curious about information about me; sometimes it's better not to know (and sometimes it is, based on what I learned from the ER records from my suicide attempt.)

I guess this is a bit of a When Hairy met Sally story, since Sally is a nickname for Sara . . . (trying too hard? yes.)

Laura said...

Noticed that people complained about therapist's not believing them but it shouldn't be an issue. As a therapist, we are trained not to get lost in "the story." What happened rarely means something to us except how that made you feel and how it affects you today. Doctors who write things like "denies being depressed, but appears sad" will wait to see if it persist over time. Maybe you had a bad day or you simply woke up not feeling great. Besides these doubts eventually are clarified throughout different sessions.

I also agree with the post that sometimes the therapist doesn't share the notes because it has to with him not the patient. Just ask your psychiatrist/therapist what reason he has. Only be worried if he refuses to even provide an explanation.