Clinical truth?

I was asked to talk about my recent research recently and I decided to talk about clinical notes. I was talking to clinicians and I wanted to make it both interesting and surprising. After all, clinical noes are taken to render the institutional truth about what happens to the patient.

The research I talked about was done by Justyna Ziolkowska and me. We were interested in information management in psychiatry; we wanted to trace the information which was recorded in the patients’ notes back to its origin in the interview. As we had access both to the interviews and to the notes made after conducting it, we set off. What we expected was that we would find plenty of expressions which impose the clinicians’ perspective on what their patients said. In other words, we thought the article would be about writing that patients claimed something rather than said something. Indeed, we found plenty of that.

But quite unexpectedly, we also found something else. Here is the bottom line: We have not found a single patient’s record which did not misrepresent an aspect of what the patient said. We were astonished that some notes simply presented a false view of what the patient said. For example, the patient said she didn’t sleep after taking sleeping pills, the psychiatrist recorded it as the patient sleeping well after taking them.

Now, since the publication of the study, I have talked about it to clinical audiences a number of times. What surprised me every time was that clinicians shrugged the study off. It didn’t matter, they said. They gave three reasons.

First, even though the notes were made after the interview and explicitly constructed as such, the information in the notes must have come from a different and significant source. Even though such a source was never identified, any other contact not recorded, misrepresentation was impossible.

The second reason for dismissing what we found was that every psychiatrist (apparently) keeps an informal record of their dealings with patients. And so, inaccuracies in clinical notes might result from deliberate misrepresentation, or perhaps by mistake, but it is the informal documentation which REALLY matters. The official notes became secondary and all arguments about institutional and legal record were simply rejected as secondary. What really mattered was that the doctor did know the truth. No, in the informal documentation mistakes were not possible, while sharing the notes with other doctors did not matter that much.

And then there was the third reason. Yes, we, the researchers, can have access to what the patient said, but it is the psychiatrist who has a special gift of interpretation, a psychiatric sight. So, the patient might be saying that they experience suicidal ideation, but what they really mean is that they don’t (it is a genuine example), but that only can be told by a shrink who sees so much more. In fact, they see more than the patient themselves.

I can never decide which of the reasons is the most astonishing. The unshakeable assumption that the notes are an accurate reflection of reality is extraordinary. They are the clinical truth and that’s it. It is so strong that any evidence that the notes were simply inaccurate is rejected. Indeed, our article was rejected by a few journals and one of the reasons explicitly given by the reviewers was that the data were simply unbelievable and impossible. We were never accused of dishonesty, but it was implied.

On the other hand, the arrogance of knowing best, never even considering that a shrink might be wrong is jaw dropping. But then, over the years, I have met a number of psychiatrists, including quite well-known doctors, who spoke of the ‘special skills/gifts’ that enable them to see right through the patient, regardless of what the patient says. You just look and you see.

Where do such explanations come from? Well, they could come from the wish to ‘defend the system’. If the notes are not an accurate source of clinical information, then medicine is in some trouble. Medics do not have access to information of any quality and they cannot rely on what they read from other clinicians. This would be a significant problem. Another possibility is the inherent investment in the power of the profession. After all, medics are powerful, they continually act on the epistemic injustice they are instrumental in creating. To some extent to be a doctor does mean to know better, to have better answers, and to have the ‘special gift’. The notes must reflect it therefore.

Needless to say, the issue is not or is unlikely to be limited to psychiatry. My own experience with notes-as-reality was when I forcefully told my GP that I was in pain, to which he looked at the notes and said that I had not reported it. I told him that just because his notes didn’t contain reference to what I said, doesn’t mean that it didn’t happen. Silence fell as, I guess, he was considering the likelihood of such a scenario. I did not get a response, as he probably decided that an argument was pointless. Still, he was so surprised that I could suggest that his notes might not reflect what happened that any argument was just about pointless.

The conclusion? I guess I would like to repeat what I keep saying. Even though we all can speak, we all can write, speaking and writing in clinical context is neither simple nor obvious.


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