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My experience is in psychiatry and behavioral health, where this issue becomes particularly acute. So much of this field depends on notes and reports — it's not

My experience is in psychiatry and behavioral health, where this issue becomes particularly acute. So much of this field depends on notes and reports — it's not that there aren't test results and so forth but so much of it depends on behavioral observations and the content of what clients and their loved ones and others are saying. The fundamental issue is one of audience. You always have an audience in any writing, and with healthcare notes this is especially true. The problem arises when you try to deny this, and in the process make everyone your audience, as what writing you need for one reader is very different from the writing you need for another reader. In psychiatry this is especially problematic because you're essentially always trying to maintain rapport and a relationship with a client, and there are times when the most tactful and therapeutic thing to do is to withhold information at a moment, or even more often, present that information in a very specific way. The way you communicate with a patient is part of your job. You wouldn't behave toward a colleague in the same way you would a patient, but that's essentially what you're asked to do with open notes. I can imagine the criticisms this might invite — that what I'm saying is an example of how patronizing psychiatry can be at times — but I think there's no way around this. I highly doubt you want your therapist talking to you like you like they would a close friend or colleague, for example, and no professional therapist would do that. Open notes are this sort of weird wormhole through the provider-patient relationship boundaries that typically exist, and in my experience they just lead to this odd coded language in notes, or pushing discussions offline into verbal discussions between colleagues, or something. I do think patient records should be available to them, but I agree with others that it might be better to have certain levels of firewall for different types of notes. Some a patient might get immediately; others they might have to make a request for, or something. It's a difficult needle to thread, but I'm not sure radical record transparency always everywhere is quite optimal.

NoZebra120vClip 4y ago
Psychiatry as a pseudo-science often relies heavily on unscientific and non-empirical methods of diagnosis. There is no brain scan or blood test to detect or even rule out bipolar disorder or schizophrenia, you just go with whatever the doctor feels like when the patient comes in off the street. Psychiatry is worse than veterinary medicine: a dog can't talk to you and tell you what's wrong; neither can a dog lie to you or be a deranged, unreliable narrator. Psychiatrists often ask questions which have a specific context or particular technical meaning to them, and the mentally ill will answer out of ignorance, or with a non sequitir, that seems counter-productive to the process. I have often obtained medical records (it's interesting to see how difficult this can be, and the bureaucratic tricks that can be played to avoid complying with laws that allow us that access.) I've been incensed to see inaccuracies and often dismayed to see the state of things from the provider's perspective when I came to them in crisis. For example, there was one note that just indicated I'd been a chronic, habitual daily user of marijuana for years upon years. Nothing could be further from the truth. But there it is in my medical record, proof against any legal challenge, their word against mine, and God forbid I attempt to challenge it in a followup session, because I'm a crazy, unreliable narrator with a reputation for denying the truth. It is dismaying that so-called "medical" professionals should withhold the truth from patients and are perfectly allowed to obscure anything in the chart that they judge to be detrimental to treatment. My psychiatrist is consistently unwilling or unable to describe the first-order effects of my medication, what benefits I should hope to enjoy from them, or just in a general sense why am I taking this toxic crap. My psychiatrist freely admits to diagnosing me solely on affect. If I am sociable and pleasantly greeting people in the clinic, then I'm having a good day and I'm near baseline. If I'm reserved and sensitive, and have difficulty answering her questions, then I'm a good candidate for hospitalization! I was literally steps away from being forcibly committed after one video appointment that went poorly. A video appointment! I try to read everything I sign, but it's fruitless to try to stay ahead of any medical bureacracy. One day I came in to file a request for my complete chart. The condescending jerk who filled it out put in my name instead of the clinic's, so I was requesting records from myself. Guess how long that took to fulfil.
- breck 4y ago
  Absolutely. Psuedo-science at best. Psychiatry in America is no more scientific than phrenology. These people are charlatans, not scientists. Science only works when you can run repeated experiments in controlled conditions with fast feedback loops. Those conditions are not, and will never be, present in humans. The whole industry is a fraud. I came across a great term the other day: the Mental Health Industrial Complex. If you want to get on the right track for how the brain actually works pickup Minsky's Society of Mind.
  - caddemon 4y ago
    I mean it's true that doing scientific psychiatry is hard, and a lot of the industry is subpar (and actually the majority do not really closely use psychiatric research results, forgetting how good they are or not). But what alternative exactly do you want? To just give up? There are some parts of psychiatry that have fairly well-validated conclusions at present, and hopefully that will (albeit likely slowly) progress.
    - breck 4y ago
      Continue neuroscience research; stop pretending psychologists and psychiatrists are more than cranks; admit the pills don't work. Basically quit pretending that this is a science. The problems are not biological that can be solved by pills, the problems lie in society, not individuals.
      - wkearney99 4y ago
        Yeah, that's just nonsense. There are certainly many societal ills that do not help. But your broad brush there is entirely wrong. Though I doubt any kind of legitimate discussion would sway you from it.
        breck 4y ago
        Many fields of medicine, such as mental health, are far closer to religion or politics than they are to science. Science requires controlling the environment and the ability to do repeated experiments with rapid feedback. The mental health field cannot do that. It can on worms. We could build the most amazing medicine for worms (by killing trillions of them). But we cannot do that with humans. The Mental Health Industrial Complex deserves no respect. It may turn out that psychedelic mushrooms that someone could grow for free in their yard could have saved millions of lives over the past 50 years, but that would have deprived the MHIC of tens of billions in revenue. The field is built on lies.
makeitdouble 4y ago
Great point. To add to that, a patient is often not the only reader on the "patient" side: their close family (spouse, parents etc.) will also be reading them, especially if they're helping with the therapy, and they'll also have their own sensibility to how it's presented. I think in most open record systems there's provision for retaining info from the patient in case it could objectively lead to negative consequences, but this is indeed a complicated choice that arises patient by patient.
- em-bee 4y ago
  therapy notes should be confidential. the patient, and only the patient or a person explicitly authorized by them should have access after the therapy concluded
  - makeitdouble 4y ago
    > or a person explicitly authorized by them That's what I had in mind, with potentially legal representants in specific cases (small kids and/or the patient is diagnosed as needing them to step in) Therapy notes will have a high chance of including observations about these authorized persons and how they affect the patient.
- cheese_van 4y ago
  It is complicated. I was working in a state psychiatric ward during university, and the ward psychiatrist had noted in the patient's chart that after meeting the patient's mother, he suspected a genetic etiology of the patient's condition. In other words, the patient's mother was also crazy. The patient's mother, having received legal access to the chart, read that, and was now suing the state. The earlier comments in the thread about the target audience was spot on. Radical record transparency may perhaps not always benefit health professionals, unless of course, some things are just not recorded - and that may not benefit the patient.
  - Bran_son 4y ago
    > and was now suing the state. On what grounds? This sounds like a problem with the legal system, not medical transparency. Though I can empathize with medical professionals having to work in the legal system that we have, not a hypothetical perfect one, I'm very apprehensive of restricting transparency on the grounds that, if people saw what was going on, they may take legal action. It may have been frivolous in this case, but...
zmgsabst 4y ago
I find it interesting you didn’t give a specific example of needing to “keep secrets” from a patient. You’re right — this comes across as patronizing and focusing on your own needs ahead of patient needs. Your field cauterized off clits to treat hysteria and mutilates children despite no proven benefit today. What makes you think you have the credibility to decide what needs to be secret? — or that we’ll believe this is anything other than an attempt to obscure wrongdoing, as in most government secrecy?
- caddemon 4y ago
  Have you interacted with someone actively experiencing a psychotic episode?
  - mtlmtlmtlmtl 4y ago
    Or someone who went through an intense trauma. Or someone who's done something terrible in a dissociative fugue. Or several different anxiety disorders/phobias. Or certain personality disorders come to think of it. There's a lot of cases where certain information, if presented in the wrong way or at the wrong time, can be harmful to the patient, the relationship between patient and therapist, or both.
    - zmgsabst 4y ago
      How does keeping secrets help any of those situations? “I’m manipulating you for your own good!” sounds like you’re validating their delusions and fears. I’m just hearing the same excuse the government gives when they, eg, censor facts and promote misinformation for the “public good”. Go ahead; explain to me specifically how it would help any of those cases — because this comes across as prioritizing the therapist’s convenience ahead of honesty with the patient.
      - xboxnolifes 4y ago
        > How does keeping secrets help any of those situations? >“I’m manipulating you for your own good!” sounds like you’re validating their delusions and fears. Do you not see the obvious one here? The secret is not telling them exactly what would heighten their delusions.
dm319 4y ago
Particularly so if you're trying to treat a patient with limited insight.
ajb 4y ago
When you use a consultant (not specifically a medical one) there is a continuum between the following types: 1. Template driven: the consultant has a few templates which your problem has to match. A good consultant will tell you when your problem is outside their scope of their advice, or is nevertheless not actionable, but they don't always have the context to do this. Your responsibility as a client is to make sure that their advice will work and not cause other problems in your context. 2. A mentor: more flexible than the previous, they help analyse the situation and may do some (book) research for you. But their responsibility is limited to increasing your understanding and proposing solutions, the final decision and strategy for evaluating their solutions is still the clients. 3. Strategist: they take responsibility for ongoing management of the issue and making decisions. Actual execution of actions are still the clients responsibility but if there is an issue the consultant takes responsibility for figuring it out and either devising a way to proceed or finding an alternative approach. The problem with medical professionals, especially mental health, is that the impression is given that they are going to be 3, but often end up being 1 or 2, and the patient or carer needs to be the strategist. There can be an annoying motte and bailey situation, with the professional insisting that they are the strategist when the patient wants to question the approach, but falling back to being the mentor when progress isn't being made. Anyway the problem for records is that in mental health transition between these approaches needs to happen. The patient might have needed the psychiatrist to be the strategist when they were in a crisis, but then need to take over that role if the proposed solutions aren't working. When they do, they need honest and open records.

NoZebra120vClip 4y ago

Psychiatry as a pseudo-science often relies heavily on unscientific and non-empirical methods of diagnosis. There is no brain scan or blood test to detect or even rule out bipolar disorder or schizophrenia, you just go with whatever the doctor feels like when the patient comes in off the street. Psychiatry is worse than veterinary medicine: a dog can't talk to you and tell you what's wrong; neither can a dog lie to you or be a deranged, unreliable narrator. Psychiatrists often ask questions which have a specific context or particular technical meaning to them, and the mentally ill will answer out of ignorance, or with a non sequitir, that seems counter-productive to the process. I have often obtained medical records (it's interesting to see how difficult this can be, and the bureaucratic tricks that can be played to avoid complying with laws that allow us that access.) I've been incensed to see inaccuracies and often dismayed to see the state of things from the provider's perspective when I came to them in crisis. For example, there was one note that just indicated I'd been a chronic, habitual daily user of marijuana for years upon years. Nothing could be further from the truth. But there it is in my medical record, proof against any legal challenge, their word against mine, and God forbid I attempt to challenge it in a followup session, because I'm a crazy, unreliable narrator with a reputation for denying the truth. It is dismaying that so-called "medical" professionals should withhold the truth from patients and are perfectly allowed to obscure anything in the chart that they judge to be detrimental to treatment. My psychiatrist is consistently unwilling or unable to describe the first-order effects of my medication, what benefits I should hope to enjoy from them, or just in a general sense why am I taking this toxic crap. My psychiatrist freely admits to diagnosing me solely on affect. If I am sociable and pleasantly greeting people in the clinic, then I'm having a good day and I'm near baseline. If I'm reserved and sensitive, and have difficulty answering her questions, then I'm a good candidate for hospitalization! I was literally steps away from being forcibly committed after one video appointment that went poorly. A video appointment! I try to read everything I sign, but it's fruitless to try to stay ahead of any medical bureacracy. One day I came in to file a request for my complete chart. The condescending jerk who filled it out put in my name instead of the clinic's, so I was requesting records from myself. Guess how long that took to fulfil.

breck 4y ago
Absolutely. Psuedo-science at best. Psychiatry in America is no more scientific than phrenology. These people are charlatans, not scientists. Science only works when you can run repeated experiments in controlled conditions with fast feedback loops. Those conditions are not, and will never be, present in humans. The whole industry is a fraud. I came across a great term the other day: the Mental Health Industrial Complex. If you want to get on the right track for how the brain actually works pickup Minsky's Society of Mind.
- caddemon 4y ago
  I mean it's true that doing scientific psychiatry is hard, and a lot of the industry is subpar (and actually the majority do not really closely use psychiatric research results, forgetting how good they are or not). But what alternative exactly do you want? To just give up? There are some parts of psychiatry that have fairly well-validated conclusions at present, and hopefully that will (albeit likely slowly) progress.
  - breck 4y ago
    Continue neuroscience research; stop pretending psychologists and psychiatrists are more than cranks; admit the pills don't work. Basically quit pretending that this is a science. The problems are not biological that can be solved by pills, the problems lie in society, not individuals.
    - wkearney99 4y ago
      Yeah, that's just nonsense. There are certainly many societal ills that do not help. But your broad brush there is entirely wrong. Though I doubt any kind of legitimate discussion would sway you from it.
      - breck 4y ago
        Many fields of medicine, such as mental health, are far closer to religion or politics than they are to science. Science requires controlling the environment and the ability to do repeated experiments with rapid feedback. The mental health field cannot do that. It can on worms. We could build the most amazing medicine for worms (by killing trillions of them). But we cannot do that with humans. The Mental Health Industrial Complex deserves no respect. It may turn out that psychedelic mushrooms that someone could grow for free in their yard could have saved millions of lives over the past 50 years, but that would have deprived the MHIC of tens of billions in revenue. The field is built on lies.

makeitdouble 4y ago

Great point. To add to that, a patient is often not the only reader on the "patient" side: their close family (spouse, parents etc.) will also be reading them, especially if they're helping with the therapy, and they'll also have their own sensibility to how it's presented. I think in most open record systems there's provision for retaining info from the patient in case it could objectively lead to negative consequences, but this is indeed a complicated choice that arises patient by patient.

em-bee 4y ago
therapy notes should be confidential. the patient, and only the patient or a person explicitly authorized by them should have access after the therapy concluded
- makeitdouble 4y ago
  > or a person explicitly authorized by them That's what I had in mind, with potentially legal representants in specific cases (small kids and/or the patient is diagnosed as needing them to step in) Therapy notes will have a high chance of including observations about these authorized persons and how they affect the patient.
cheese_van 4y ago
It is complicated. I was working in a state psychiatric ward during university, and the ward psychiatrist had noted in the patient's chart that after meeting the patient's mother, he suspected a genetic etiology of the patient's condition. In other words, the patient's mother was also crazy. The patient's mother, having received legal access to the chart, read that, and was now suing the state. The earlier comments in the thread about the target audience was spot on. Radical record transparency may perhaps not always benefit health professionals, unless of course, some things are just not recorded - and that may not benefit the patient.
- Bran_son 4y ago
  > and was now suing the state. On what grounds? This sounds like a problem with the legal system, not medical transparency. Though I can empathize with medical professionals having to work in the legal system that we have, not a hypothetical perfect one, I'm very apprehensive of restricting transparency on the grounds that, if people saw what was going on, they may take legal action. It may have been frivolous in this case, but...

zmgsabst 4y ago

I find it interesting you didn’t give a specific example of needing to “keep secrets” from a patient. You’re right — this comes across as patronizing and focusing on your own needs ahead of patient needs. Your field cauterized off clits to treat hysteria and mutilates children despite no proven benefit today. What makes you think you have the credibility to decide what needs to be secret? — or that we’ll believe this is anything other than an attempt to obscure wrongdoing, as in most government secrecy?

caddemon 4y ago
Have you interacted with someone actively experiencing a psychotic episode?
- mtlmtlmtlmtl 4y ago
  Or someone who went through an intense trauma. Or someone who's done something terrible in a dissociative fugue. Or several different anxiety disorders/phobias. Or certain personality disorders come to think of it. There's a lot of cases where certain information, if presented in the wrong way or at the wrong time, can be harmful to the patient, the relationship between patient and therapist, or both.
  - zmgsabst 4y ago
    How does keeping secrets help any of those situations? “I’m manipulating you for your own good!” sounds like you’re validating their delusions and fears. I’m just hearing the same excuse the government gives when they, eg, censor facts and promote misinformation for the “public good”. Go ahead; explain to me specifically how it would help any of those cases — because this comes across as prioritizing the therapist’s convenience ahead of honesty with the patient.
    - xboxnolifes 4y ago
      > How does keeping secrets help any of those situations? >“I’m manipulating you for your own good!” sounds like you’re validating their delusions and fears. Do you not see the obvious one here? The secret is not telling them exactly what would heighten their delusions.

dm319 4y ago

Particularly so if you're trying to treat a patient with limited insight.

ajb 4y ago

When you use a consultant (not specifically a medical one) there is a continuum between the following types: 1. Template driven: the consultant has a few templates which your problem has to match. A good consultant will tell you when your problem is outside their scope of their advice, or is nevertheless not actionable, but they don't always have the context to do this. Your responsibility as a client is to make sure that their advice will work and not cause other problems in your context. 2. A mentor: more flexible than the previous, they help analyse the situation and may do some (book) research for you. But their responsibility is limited to increasing your understanding and proposing solutions, the final decision and strategy for evaluating their solutions is still the clients. 3. Strategist: they take responsibility for ongoing management of the issue and making decisions. Actual execution of actions are still the clients responsibility but if there is an issue the consultant takes responsibility for figuring it out and either devising a way to proceed or finding an alternative approach. The problem with medical professionals, especially mental health, is that the impression is given that they are going to be 3, but often end up being 1 or 2, and the patient or carer needs to be the strategist. There can be an annoying motte and bailey situation, with the professional insisting that they are the strategist when the patient wants to question the approach, but falling back to being the mentor when progress isn't being made. Anyway the problem for records is that in mental health transition between these approaches needs to happen. The patient might have needed the psychiatrist to be the strategist when they were in a crisis, but then need to take over that role if the proposed solutions aren't working. When they do, they need honest and open records.