The other day my Twitter feed contained a link to a study on trends in suicidal behaviour in Dutch general practice. After seeing it, I tweeted that I am always amazed by studies which treat medical records as transparent windows into reality. For me, someone interested in representations (constructions, really) of reality, such a view is quite untenable. And this is what I am going to write about now.
Before I do, however, that the authors do consider problems with the study and the limitations which are pertinent here are a. that the notes go back to the time before ‘correct coding’ was introduced, and b. that they reflect memories of the GP after the notification of suicidal behaviour. The researchers do not question the notification itself – it clearly is assumed to be correct (within certain criteria). And this is what I really object to.
I object to it, because I have experience of analysing patients’ notes. In our article on information management, Justyna Ziolkowska and I did was that we compared the transcript of the assessment interview (the first ever interview in the hospital and hence the first encounter between the doctor and the patient) and the notes the interviewing doctor made.
One of the things we expected to find was something that Trisha Greenhalgh showed in her lecture. Her story of a bicycle accident (which in the lecture included a demonstration of the position of her arms of over her head at the time of heavily landing on concrete) was condensed into:
55 yr old female.
Fell off bike.
And so, we expected high levels of selection in transformation of patients’ stories into the notes. Obviously, not all the story can go into the notes, so a doctor must ‘prune’. You might, of course, wonder about he criteria of such selection, and the point at which the notes lose a relationship with reality. The second thing we expected was value judgements and, indeed, there were plenty of them. Psychiatrists indicated their (mostly negative and disbelieving) attitudes towards what they recorded as what patient said.
What we also expected to find was the notes would get the facts right. In other words, that doctors would be able to note the Prof. Greenhalgh did fall off her bike. Astonishingly, we were wrong.
So, even though the patient said she had trouble sleeping after taking sleeping tablets, the psychiatrist noted the opposite. Patients’ words that they cannot remember the names of their medicines were recorded as medicines contributing to memory loss; being tired with city noise was recorded as tiredness with open spaces; difficulties with concentrating as difficulties with doing things. Even more significantly, we didn’t find a single record which did not have such inaccuracies.
So, yes, basically, the notes doctors made were full of falsehoods. Why? We don’t know. Mistakes, forgetfulness or ‘knowing better’, still the fact remains that much information was false, while much more was distorted. The notes offered a construction of reality which in significant parts had no relationship with the world which it was aimed to record. We were sometimes reading pure fiction and it is for you, clinicians, to assess the import of someone saying that a patient sleeps well after taking sleeping pills while in fact they do not.
And here is my problem with studies based on this study. What exactly do they study? Well, they predominantly study the records doctors make, which is a valuable pursuit and I actually think doctors’ notes are a very underresearched set of data. The problem, however, is that claims as to the world outside the notes must be made with caution.
And yet, I doubt very much that such caution will be applied to medical records. I think, they will continue to be taken as sources of objective information, which will be picked much like berries off their plants. There are many reasons for this and they include, for example, assumptions of power and its investment into the knowledge created by a doctor (yes, Michel Foucault waves hello). And as the notes which my doctor takes during and after my appointment are still inaccessible to me, they remain an important bastion of doctor’s power and hence the truth about me.