OpenNotes: Good intentions gone awry

OpenNotes is "a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians."  According to their website, three million patients now have such access, generally online.  Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, Kaiser Permanente Northwest, and several others.  Patients with a premium account in the My HealtheVet program at the VA have access to outpatient primary care and specialty visit notes, discharge summaries, and emergency department visit notes.  The New York Times recently ran a mostly celebratory piece on OpenNotes as applied to mental health visits at BI Deaconess ("What the Therapist Thinks About You"), garnering over 350 public comments.  Significantly, many of these comments expressed annoyance with any mental health professional who cited potential drawbacks — despite the fact that BI Deaconess doctors who actively participate in OpenNotes concede that such openness may be detrimental for those with "psychiatric or behavioral issues" (e.g., see this promotional video, starting at 2:15). The notion of sharing clinical notes with patients enjoys populist appeal.  On a self-report survey with no control or comparison condition, patients reported that OpenNotes helped them remember what was discussed during visits, feel more in control of their care, and improved their medication adherence.  Advocates also say it improves communication with patients and can correct factual errors in the record.  However, the strongest argument seems to be that patients like it.  Defenders repeatedly invoke "transparency," implying that the status quo is intentionally obscure and aims to hide something from patients.  Some of the rhetoric has a defiant, even self-righteous tone: one promotional video (at 3:16) features a patient who pointedly declares that she'll never be refused this access again.  And there's no clear endpoint: about 60% of the patients surveyed in the OpenNotes study believed they should be able to add comments to a doctor's note, and about a third believed they should be able to approve the notes' contents; the overwhelming majority of participating physicians disagreed with the latter.  If OpenNotes is widely accepted, it will be increasingly difficult to draw clear lines regarding the authorship and authority of clinical notes.

Fifty-five percent of eligible primary care doctors declined to participate in the OpenNotes study cited above.  Of those who did participate:

Several doctors struggled with the notion of a one-size-fits-all note, arguing that one document cannot address the needs of billing, other doctors, and patients.  A few changed their own use of the note; for example, eliminating personal reminders about sensitive patient issues, excluding alternate diagnoses to consider for the next visit, restricting note content, or avoiding communication with colleagues through the note.... A substantial minority reported [changing documentation, in particular when addressing potentially sensitive issues], including their reported change in “candor.” For example, some doctors reported using “body mass index” in place of “obesity,” fearing that patients would find the latter pejorative.

§  §  §

"Progress note," not "visit note," is the traditional term for a physician's written entry into a patient's medical record, documenting an outpatient or inpatient encounter.  (OpenNotes advocates may find "progress note" too quaintly optimistic to be publicly acceptable.)  Physicians write other notes for other purposes, including admission notes, procedure notes, transfer notes, discharge notes, and so forth.  Additionally, many notes are written by nurses and a wide variety of other clinical personnel, particularly in inpatient settings.

The traditional format of a progress note documents (1) symptoms and (2) physical examination, including lab test results, obtained by the physician, (3) his or her differential diagnosis, and (4) the next steps, such as further exams, tests, or treatments, that follow therefrom.  Medical students are taught to write SOAP notes as an acronym for these four components.  Such notes assist in performing and archiving medical work, much as a scientist's laboratory notebook records the design, data, and results of experiments.  Progress notes were not designed to be a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts for patients.  Yet these notes now serve many masters, resulting in excessively time-consuming documentation that squeezes out face-time with patients, and is increasingly cumbersome as a clinical tool.   Some of the additional trade-offs in adding yet another stakeholder, the patient reviewer, are cited in the quotation above, and cannot be casually dismissed as balderdash by defenders of OpenNotes.

OpenNotes presumably works best in primary care, and with an electronic medical record that expands abbreviations (and/or provides templates), corrects spelling, and produces legible output that patients can access online.  In contrast, notes with technical jargon by specialists such as ophthalmologists, anesthesiologists, radiation oncologists, and many others would be incomprehensible unless radically altered to be more patient-friendly.  Less "connected" practices would similarly be left out.  But even in the best-case scenario, progress notes are a poor tool for doctor-patient collaboration.  By nature they are shorthand, telegraphing complex medical reasoning in a few words.  Old-fashioned discussion is paradoxically superior for assuring that doctors and patients are "on the same page." Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.

The real thrust of the OpenNotes initiative is less pragmatic.  Many patients want to feel more in control of their care.  In addition, doctors aren't trusted as profoundly as we used to be.  If given the chance, many patients will gladly join the ranks of those who look over our shoulder.  And of course, if the traditional use of progress notes is framed as paternalistic or elitist, reforming these notes into something "democratic" seems like the only sensible thing to do.  The enthusiastic fervor to empower patients in this misdirected way (further) dulls a useful documentation tool which is no more inherently elitist or paternalistic than the work notes of a car mechanic or the recipe notes of a chef.  Everyone feels good about this newfound "transparency."  And that, apparently, is what really counts.

These considerations apply doubly in the case of mental health notes.  My colleague who writes the Psych Practice blog wrote a response to the New York Times piece on sharing therapy notes.  I agree with her completely.  I'd only underscore that psychotherapy based on psychoanalytic and psychodynamic principles depends crucially on gauged disclosure and the timing of verbal interventions.  These treatments anticipate and rely on the reality that the perspectives of therapists and patients inevitably differ, and that this discrepancy is not a simple error or miscommunication, but instead is the engine that drives psychological change.  Arguing for transparency in such treatment is tantamount to wishing that these therapies disappear (some critics will readily acknowledge this).

The relationship between doctors and patients should always be collaborative, but it is never equal.  One party is ill and needs help, the other offers expertise and resources the other doesn't have.  "Giving everyone a say" sounds democratic, but medicine isn't practiced democratically.  Try asking a car mechanic or a chef at a fine restaurant (or your child's schoolteacher, or an architect, or a police officer...) if you can share in their work-flow and decision making.  Most will initially appreciate your interest and offer you an overview.  A kind one may let you look under the hood.  However, very soon you will be told that you are in the way — that you can watch intently or enjoy a good result, but not both.  There is nothing paternalistic about this, it's how skilled workers do their jobs.  When reminded that this applies to physicians as well, and once the thrill of the "forbidden" behind-the-scenes look wanes, we will see that the remaining advantages of OpenNotes are better served by other means.

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?

"Have you seen a therapist yourself?"

Recently a patient asked whether I'd ever been in therapy myself.  Without answering his question directly (see my post on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him.  It would be a bad sign: "How can you help if you need help too?"  We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient.  He would naturally prefer a therapist who did not share similar defects and deficiencies. Many patients take the opposite view.  They believe a doctor who knows what it's like to be a patient can better empathize with them.  So this patient's concern stood out in my mind — he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged.  I later reminded myself that professionals — and others, everyone really — regularly use services offered by others in the same field.  Lawyers have their own lawyers, doctors see their own doctors.  Chefs eat meals made by other chefs, barbers get haircuts from other barbers.  The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered.  Examples of the former: police officers who require the "services" of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions.  Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help.  How does this apply to psychotherapists, and what light does it shed on patients' feelings about seeing therapists themselves?

The need for psychotherapy feels to many people like a sign of defect/deficiency/damage.  In speaking with patients I often highlight the "need" in that sentence, and contrast it with "want" or "could benefit by."  Some patients make themselves feel worse by telling themselves they "need" therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it.  I don't believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they're frequently optional.  Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships.  Remembering that psychotherapy is a choice may take some of the shame out of it.

That's only part of it, though.  No one worries or cares if one's proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people.  In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy.  Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral.  Moreover, that seeking professional help to "snap out of it" or pull oneself together is self-indulgent and akin to laziness.  While the idea isn't totally groundless — there is some choice in how to act, and even how to feel sometimes — it assumes far too much conscious choice.  Most troubled patients would give anything to be happier, at least consciously.  In returning to my patient's question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course.  It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.

Alternatively, there may be concern that a psychotherapist who needed therapy ("needed" in scare-quotes as noted above) cannot perform well as a therapist.  This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing.  The logic may be pragmatic:  A psychotherapist should have his or her own life in order before claiming to be able to help others.  Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient.  Or it may be a transferential need for an idealized, faultless therapist.  Each of these can be addressed as it arises.  We each have our blind spots, and can help others without necessarily being able to help ourselves.  It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it.  No therapist is perfect.

Any or all of these concerns about the therapist may also apply to the patient himself.  Being in therapy may make a patient feel ashamed, or morally bad or wrong.  It may highlight a fear of incompetence or harmfulness.  It may clash with a need to be perfect.  Asking the therapist "Have you seen a therapist yourself?" may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy.  This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.

Is your therapist biased by money?

Earlier this year, blog commenter TK wrote: "Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?

"In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…

"In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?" 

In a similar vein, a reader named Cynthia more recently posed a challenge:

What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?

To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.

I replied to Cynthia's comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor.  For each of these, financial incentive may be a factor in determining how "important" it is for the customer, client, or patient to return.  However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.

Of course, even having this concrete information may lead to different conclusions.  An underemployed service provider may be relatively unskilled, and/or more desperate for income.  As TK offers: "you don’t ever want to see any psychotherapist who has openings in their practice."  On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention.  Nor is busy-ness always a sign of quality.  Some providers market themselves better, or offer faddish services that are popular at the moment.  All of this applies equally well to hiring a house painter or a psychotherapist.

Seeing a therapist is different than hiring a plumber or painter, though.  Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual.  Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry.  Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.

However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern.  They worry that therapist economic incentive may lead to unnecessarily prolonged therapy.  "Isn't this the greatest countertransference...?"

In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference.  There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood.  A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to "bracket" his or her own needs and put the patient's first.  I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have.  While I don't believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.

However, this situation passed quickly.  I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not.  Patients come and patients go; the economics surrounding any one patient is not a major consideration.  As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist.  This makes good sense, as the patient only has one therapist, but the therapist has a number of patients.  (And transference magnifies these issues for the patient more than countertransference does for the therapist.)  Thus, a vacation of either party usually matters more to the patient.  Fees and money issues usually matter more to the patient, and so forth.

As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive.  But barring specific evidence of desperation or money grubbing on the part of the therapist, I can't help but think of this as a concern magnified by transference.  Economic incentive is the default situation when hiring anyone for anything.  Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money?  We all need to keep our eyes open, but there's a point at which one's natural suspicion can give way to trust and a sense of security.  Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other.  If suspicion persists, whether in therapy or elsewhere, there is a problem.  Maybe the other person gives subtle signs of untrustworthiness.  Maybe one's own "trust meter" (transference) is a bit askew.  Figuring this out is itself the stuff of dynamic therapy; it can shed light on one's relationships inside and outside the therapy office.

Countertransference, an overview

I attended a very good lecture this week on contemporary views of countertransference.  It inspired me to write a brief overview of the concept here, with more to follow. To understand countertransference, it helps to tackle transference first.  As I've discussed previously, transference was a word coined by Sigmund Freud to label the way patients "transfer" feelings from important persons in their early lives, onto the psychoanalyst or therapist.  Psychoanalysis was specifically designed to encourage transference.  Intentional opacity and non-disclosure by the therapist promotes transference; the patient naturally makes assumptions about the therapist's likes and dislikes, attitude toward the patient, life outside the office, and so forth.  These assumptions are based on the patient's experiences with, and assumptions regarding, other important relationships, such as childhood relations with parents.  In this way the patient's formative dynamics are re-created in the therapy office for both participants to observe.  Patients discover that some of their assumptions about others, and themselves, are unfounded or outmoded and do not serve them well.  This is an important type of insight that can lead to lasting psychological change.

Freud realized that transference is universal, and therefore could occur in the analyst as well.  He did not write much about this, except to say that "countertransference" could interfere with successful treatment.  The analyst experiencing countertransference should rid himself of these feelings by having further analysis himself.

Since the 1950s, psychoanalysts and psychodynamic therapists have held a more benign view of countertransference.  It is no longer seen as an impediment to treatment (at least not inevitably), but instead as important data for the therapist to use in helping the patient.  Countertransference can serve as a sensitive interpersonal barometer, a finely tuned instrument in the field of social interaction.  For example, a therapist who feels irritated by a patient for no clear reason may eventually uncover subtle unconscious provocations by the patient that irritate and repel others, and thereby keep the patient unwittingly lonely and isolated.

In using countertransference this way, the therapist must consider multiple sources of his or her feelings.  Some feelings, positive or negative, may be evoked by the patient.  These are particularly helpful ones to notice, especially when the cause is not immediately obvious, as in the example just given.  Often, however, feelings may be stirred up by irrelevant characteristics in the patient (e.g., the patient physically resembles the therapist's sibling or spouse), by the prior patient, or by factors unrelated to therapy (e.g., bad traffic getting to the office, a quarrel at home, an upcoming vacation).  This strongly argues for dynamic therapists to pursue such therapy themselves: It "tunes the instrument" to better distinguish countertransference evoked by the patient, versus similar feelings that arise from other causes.  Freud's advice for analysts to seek additional analysis themselves in the face of countertransference is wise, although not for the reasons he gave.

I teach psychiatry residents to go through a mental checklist whenever they become conscious of possible countertransference:

(1) Is this feeling characteristic, i.e., does the resident have it much of the time?  If so, it may say a lot about the resident, but probably nothing about his or her patient.

(2)  Is the feeling triggered by something unrelated to the patient?  Feelings caused by hunger, one's personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient.

(3)  Is the feeling related to the patient in an obvious way?  Feeling irritation toward a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating.  And finally,

(4) Is the feeling uncharacteristic of the therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious?  These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient.

Countertransference is not always helpful.  Particularly when it is unexamined — or, worse, unrecognized — it can indeed interfere with effective treatment.  This can occur even with positive countertransference, as when a therapist is so entertained by a patient's jokes that the underlying bitterness is ignored, or when an attractive patient is never challenged because the therapist desperately yearns to be liked.  More often, though, countertransference is problematic when it is negative.  The therapist feels bored, irked, paralyzed, or contemptuous in the presence of a particular patient.  It is the therapist's job to recognize these feelings and deal with them.  Occasionally a therapist must refer the patient to a colleague when the original therapist's countertransference is unmanageable.  Fortunately, in most cases these uncomfortable feelings, once recognized by the therapist, can not only be understood but also used constructively in the treatment.