Reading Your Doctor’s Mind

Do you and your doctor speak the same language? You probably think so, but if you peeked at his clinic notes you might wonder.
Doctors like shorthand. It’s faster to scribble q4h instead of writing out “Take every 4 hours.”
Doctors are always pressed for time. As a result, the notes they take while you are chatting in the office are full of abbreviations. SOB, for example, is not a comment on your character, but on your condition–short of breath. NERD is not a computer geek, but rather a doctor’s acronym for no evidence of recurrent disease.
Of course, doctors do have big words as well. “Cephalalgia” is a headache, while “pneumonitis” is an inflammation in the lungs. Chances are, your doctor’s notes are sprinkled with some of these along with an alphabet soup of abbreviations. What would you make of them if you could see them?
As a patient, you have the legal right to read what your doctor writes about you, but most health care systems make it difficult. If you request your medical record, you may have to go to a basement somewhere and pay a hefty copying fee to get your hands on them. That’s partly because doctors worry that patients will be confused by what they have written.
A new study aims to put patients and physicians on the same page, literally. Working from the principle that patients who partner with their health care providers get better outcomes, some doctors are urging their colleagues to make the clinic notes accessible.
This will mean that doctors have to write in language patients understand. Instead of scribbling the words CHF in a chart, the electronic clinic notes will have the words congestive heart failure written out. Instructions about taking medicine will have to be in English rather than Latin code, so instead of tid, the notes will say three times a day.
OpenNotes will provide the patient an opportunity to make sure the physician has heard the most important symptoms and understood what the patient’s concerns were. Even more important, the patient will be able to find out what the physician has diagnosed and what the treatment plan is.
Many people don’t remember everything the doctor says under the best of circumstances. If there is bad news, they may shut down and not even register crucial information.
Trying to sort out what you think the doctor said a day or two later can be an exercise in frustration. Going online and reading her precise clinic notes and instructions in your electronic medical record will tell you exactly what she had in mind. And you can share it with family members who may need to participate in the treatment program.
If a patient needs minor surgery to remove a skin lesion, it can be hard to remember how often the dressing should be changed and how soon it’s okay to take a shower. Having access to notes would make it much easier to follow the doctor’s instructions.
Many physicians are likely to resist this innovation. Slowing down to write in plain English is one challenge. Another is the fear that patients may misinterpret the clinic notes or may react badly to the truth about mental illness or obesity. But if this new OpenNotes project improves communication between doctors and patients, it might also improve health.