It’s 8.30 am, just before clinic opens. It is 2010. Dr Byte* checks an online forum, and something catches his eye.
A female patient is complaining about a doctor. Her posting has led to strident reactions from other doctors. Patients are taking her side. It looks ugly.
It turns out that the patient had asked her family doctor whether she could use her smartphone to record the encounter. Her doctor was apparently taken aback and had paused to gather his thoughts. He asked the patient to put her smartphone away, saying that it was not the policy of the clinic to allow patients to take recordings.
The patient described how the mood of the meeting shifted. Initially jovial, the doctor had become defensive. She complied and turned off her smartphone.
The patient wrote that as soon as the smartphone was turned off the doctor raised his voice and berated her for making the request, saying that the use of a recording device would betray the fundamental trust that is the basis of a good patient-doctor relationship.
The patient wrote that she tried to reason, explaining that the recording would be useful to her and her family. But the doctor shouted at her, asking her to leave immediately and find another doctor.
Some participants on the online forum expressed disbelief. But the patient then went on to state that she could prove that this had actually happened, because she actually had a recording of the encounter. Although she had turned off her smartphone, she had a second recording device in her pocket, turned on, that had captured every word.
Reactions on the online forum were coming in thick and fast. Doctors were mostly indignant, unable to quite believe that patients would be so underhand, covertly making a record of a confidential and privileged conversation.
Patients had entirely different perspectives. What did doctors have to hide? What was their problem? Many patients said that they would love to have a recording, for many reasons. They wanted to listen again and also wanted to share the recording with their family.
Others said that it would be the evidence they needed if they were dissatisfied, saying that their efforts to get better care in the past had been a waste of time.
Dr Byte had to get on with his work, yet he kept thinking about the online forum and the potential that some patients might be recording his encounters covertly. He became more aware of how he was giving advice, explaining treatment options, referring patients to new sources of information, and making sure that he had time to research things where he was unsure and admitting that to patients.
In short, he became much more careful, behaving in fact as if he were being recorded continuously. It slowed him down, of course. He had to adjust the timing of his clinic and to apologize to his colleagues that he could not keep to the same schedules. On the other hand, he was more confident that his patients were happier, if not even getting better care.
He even considered offering each patient, if he or she wanted it, a digital recording of the encounter.
Over the next three years Dr Byte followed the online forum, a UK one, regularly. The thread continued. There were still examples of angry doctors who turned patients away from their clinic or threatened to report them to the police. But there was also evidence of a gradual change in the nature of the contributions—and evidence of changes in policy. Contributors from medical defense organizations demonstrated clear changes in policy. Accept that patients have a right to record, and welcome it when it happens, was their verdict.
The UK General Medical Council shifted its view, from refusing to accept recordings made by patients to viewing such evidence as admissible when assessing professional practice. Some organizations that had at first “banned” patients from recording their own clinic appointments did U turns and developed formal policies that encouraged patients to record their encounters.
A consensus emerged on the online forum: patients do not need permission to record their own encounters, as it is viewed legally as a form of note keeping. Clinicians, however, are never exempt from needing patients’ consent to record clinical encounters.
The online forum attracted legal contributions, debated the UK Data Protection Act and many other issues, and, when printed out, amounted to 300 pages of written material, documenting that it was not only legal for patients to record their own clinical encounters but that they were not required to get permission. Covert recording may well undermine relationships if discovered, but it is not illegal.
Where does this leave us? It changes almost everything. It will be among the topics covered at a conference called “Keeping Patients in the Dark” at the Dartmouth Institute, Hanover, New Hampshire, in June 2014 (www.siipc.org).
Patient centeredness, built on a firm foundation of evidence based medicine and documented in searchable electronic records, is the unachieved ideal that Engel , Guyatt Sackett  Weed  and countless others have envisioned. But we have never really been able to verify the content of clinical practice, never before been able to analyze what is said, what is claimed, and what is actually done. We have medical records, but they are like the shadows on the wall of a cave, punctuated by codes and jargon.
Imagine being able to analyze all clinical encounters. How much shared decision making was really done? What was the connection between the history, the findings, the decisions made, and the evidence used? How much assessment could be achieved by speech analysis and natural language processing? Although this might seem unrealistic, the research to achieve this goal has already been initiated.
There are, of course, many negative implications, including the concern that practice will become risk averse and defensive  . Yet it is doubtful to think that medicine could remain immune to our capability of creating a digital record of all transactions. Having a record of clinical encounters changes everything: we might want to make sure the change is for better, not for worse.
*Dr Byte is fictitious, but this article is based on data in an online discussion thread called “Audio-recording your consultations with NHS doctors” from the UK Consumer Action Group consumer forum.
Glyn Elwyn, MBBCH, MSC, FRCGP, PhD (@glynelwyn) is a physician-researcher, professor and senior scientist at The Dartmouth Health Care Delivery Science Center and The Dartmouth Institute for Health Policy and Clinical Practice. He leads interdisciplinary research examining the implementation of shared decision making, user-centred design of patient decision support interventions and the integration of these into routine health care. Elwyn is a director of the 2014 Summer Institute for Informed Patient Choice, taking place on June 25-27 in Hanover, NH.
This piece originally appeared in the British Medical Journal.
30-50% of medical/hospital services have no value according to Harvard, Dartmouth Medical etc. Almost half a million medical errors annually add to the massive problem. It equals about one trillion dollars. Until every procedure is monitored, and every claim compared to the medical record, the massive waste and abuse will continue. Recoding the patient-provider interactions can be very helpful in improving care and outcomes.. A parallel to pilots and aviation safety is very telling as to why aviation outcomes are superior to those experienced in health care.
I agree with Stan. Many patients leave the doctors office with an incomplete understanding of what was discussed. Having a recording or a transcript may help them remember what was said.
I don’t think that doctors have anything to fear from recording. I think in most cases a recording will buttress a physician legally in a case where a patient claims they weren’t informed of something or something wasn’t explained.
In my mind, the ideal would be that the medical office would do the recording and provide at least a copy of the consultation portion of the visit to the patient. If it is just accepted that you will have a copy as part of the treatment then it avoids the awkward permission negotiation phase of the recording. Perhaps at a point in the visit, the physician just says, ok this is the consultation part of our meeting, which I will record and provide a copy for you so you can refresh your memory at a later date.
I agree with the post of March 20th above, and that agrees with a note added to the 4-yr-old article I read via note  in Glyn Elwyn’s commentary.
“Why on earth shouldn’t a patient be allowed to record the advice which, one way or another, he\she has paid for?”
The more this subject gets discussed, the less valid the objections of physicians seem to be
As a patient I have this to say about recording. I take lousy hand notes. I’m getting so I forget things that have been discussed,especially complex medical issues. I started recording my discussions with my physicians so that I could review the answers to my questions after the visit. Initially I tried to use the visit report that the physician prepares for his office but found that most of these reports were just regurgitating information that I had filled out on the questionnaire prior to the visit. Perhaps a single paragraph summarized what we actually discussed. Most of my physicians have not had a problem with this, though I had a problem with my Orthopaedic surgeon absolutely refused to let me record.
Somehow there needs to be a way to make sure that patients have the capability to access the information covered in these visits without being a world class note taker or have a great memory. My thoughts have always been that if I’m paying for the service, I ought to have a complete record of the meeting.
The company Verilogue, which enables physicians to record their conversations with patients (now owned by Publicis), launched CareCoach, to enable patients to record their conversations with physicians. The former found a business model — that latter continues to work into the market. Here’s a link to what they’re doing – http://www.carecoach.com/home.
I am all for patients recording their transactions. In fact, in my upcoming e-book, Your Personal Affordable Care Act: Making Yourself Scarce in the Dysfunctional US Healthcare System, I advocate it. While laws vary from state to state, if the person gets recorded consent from the other party, they should be fine in most cases, and, if you are very worried about some kind of adverse interaction, why would you ask permission? I would record to document the harm and worry later about potential consequences of the recording.
There is a reason nearly every cop car in America has a dash cam. The recordings don’t lie. In fact, I am for recording surgeries from beginning to end. Let’s see how it looks to indpendent reviewers and hospital lawyers to see and hear surgeons singing, flirting with nurses, or, as the ophthalmologist lowered a whirling blade to my eyes for LASIK in 2004, cavorting with his assistant about last night’s Comedy Central episode. Would not have been too funny if he botched my procedure and that video showed up in a courtroom would it?
As for the lament that people would not like have their other activities recorded. Seems a little late for that argument. The issues are just the fact of the recording of data, but at what level, who sees it or uses it and for what purpose and under what circumstances.
Yes, what a world it would be with everyone having to, “be on guard” every minute of the day and constantly look over their shoulder in case a slipped word or action came back to haunt them by an aggrieved party. Yes, America, your perfect society with recordings, cameras and guns. Better record that coffee barista in case the brew’s just not strong enough, what about your wife, never know when the taped conversation will come in handy.
Vic, you strike me as a freedom kind of guy, you know, the constitution, military supporter, less government, flag and all, yet you seem to endorse surveillance nation – on edge and constantly nervous, double checking every small decision 24/7. Is that the way you want to live, or just other people?
I have to agree with Peter here, I think this recording thing is getting way out of hand.
No, actually I deeply and strongly oppose surveillance nation. The problem is that the healthcare system won’t police itself, just like police forces that consistently denied wrongdoing and so we end up with dash cams to essentially record the truth or, as close to it as we can get given that even recordings can sometimes deceive.
There is obviously no need to record baristas given that baristas don’t operate on the wrong limbs, deny negligence when it’s obvious that an adversity did not result from an innocent ‘mistake.’ I also don’t know much about the impact of impaired baristas on coffee consumption, but I do know there are impaired physicians who should be treating people.
It’s one thing to surveil people going about their lives and another to record the interactions of a group of people whose judgment and skill directly impact the lives of others and do so in a massively tax subsidied industry that is largely one of their own making and designed to advance their economic interests.
Way back when I was in PA school, I completed a rotation in surgery that I greatly enjoyed. One patient suffered a serious intraoperative complication that the team was able to resolve successfully. It was my job to write the post-operative note, and I wrote exactly what happened. The chief resident went ballistic telling me that you never write exactly what happened, but that you write a clinically realistic impression the surgery that would not allow a reader (i.e., a lawyer) to conclude that mistakes were made. I don’t know how that patient fared, but that kind of stuff went on 30 years ago, and it goes on now.
The comparison of cops, doctors, soldiers on patrol and other people for whom the veracity of video might serve a valuable purpose to someone such as myself is a straw man. If my wife wants to surveil me, she is certainly free to do is she not? She can hire a PI and surveil away. The distinction is that she knows she has no reason to, just as the government has no reason to surveil most citizens. But, until there are no more bad cops, rogue soldiers, or incompetent/impaired physicians that the system will not weed out, this is as good an idea as any because the industry certainly is not giving people anything to work with .
Most people want a relationship with their doctor, they don’t want a relationship with the cop who pulls them over. If you equate adversarial relationships of police with care giver relationships something is very wrong. Surveillance is not the solution.
It Is the only answer when Drs lie through their teeth in med records to cover med mal or for any other reason. Stop bold faced lying and tell the truth. Ya wont mind the recording notes then. Why should the truth hurt any dr /patient relationship unless there is untruth.My my how the drs fear their lie !!!!! Stop Lying and you wont be crying!!!!
Just one more thing before I depart for Spring break. The issue breaks down along lines of power. When cops beat a suspect, draw their weapons unncessarily, or when the government surveils innocent people going about their daily lives, it is an abuse of power.
In the relationship between the medical care industry and most people using it, there is an imbalance of power. Hospitals, doctors, and health plans all hide behind obtuse language, economic advantages, and armies of lawyers and lobbyists intended to divest even the most deserving aggrieved patient of compensation and a fair adjudication of complex claims.
The recordings could not only help to balance power, but it might prove an interesting way of rewarding the most accomplished and skillful docs (skillful at both procedures and non-procedure patient interactions) because their excellence is as out of view as the problematic behavior bad actors. Surveillance (such as a customer service lines recording all calls) can indeed serve as valuable teaching tools.
I am now leaving for spring break. Fare the well until March 24.
What goes around comes around, if the NSA wants to record us without telling us then we should do the same to doctors, police, lawyers etc.
Although I am a specialist who only interacts directly with patients in a minority of cases, I have no problem with recording of conversations. But I don’t want the patient recording me without me being able to record the patient.
My recording would serve as a record that I did discuss points A, B and C with the patient, even if the patient doesn’t remember. And it could protect me in a situation in which a patient says “My doctor never told me …..” In fact, it might be nice for the patient to be given a copy so they could review it later if they have and questions.
In my state, any recording must be agreed to by the recorded party. So at the beginning of any discussion the patient would hear a blurb: “This conversation will be recorded for your protection.” Is this the way we want the doctor patient relationship to go?
These days it’s hard to distinguish between policy and parody.
“The following consultation may be recorded for quality, training, research and medicolegal purposes”.
I am waiting for open air consultations viewed by millions. The ultimate reality show.
“Afraid doctor, what do you have to hide?”
White shining teeth smiling theatrical physicians will be playing to the gallery. I can imagine the circus giving “Keeping up with the Kardashians” a run for its money.
Bring it on!
I wonder how patients would feel if all their conversations at work were recorded – and video taped? I bet not good.
In U.S. secret recordings can be illegal depending on state.
You’re right about that. Varies from state to state. You’d have to get a signature, a waiver.
I am trying to imagine the average patient reaction if I volunteered to record them. Hey, there is case to be made for it – right?
The first time a physician thwarts a medmal action via having A/V’d an encounter will spur the rapid deployment of a new breed of EHRs with built-in real-time audio-video capability. Given that capacity for data storage (e.g., YouTube, Vimeo, etc) has become essentially infinite and the cost of it increasingly cheap (approaching nil), we might be seeing it sooner rather than later. It’d be of more utility to the average doc than EHRs that could capture and display genetic data (given the utter dearth of competent genetic counseling chops out there).
“This encounter may be recorded for quality purposes.”
Now THAT I’d be happy to participate in! Really, I’d be delighted to have any clinical encounter recorded, by patient or clinician, as long as both have access (but NOT edit rights!) to it. IOW, once it’s in the can, it’s in the vault. No edits allowed.
THAT could drive some culture change right there …
“We have medical records, but they are like the shadows on the wall of a cave, punctuated by codes and jargon.”
“Shadows on the wall of a cave.” I like that. I also use the digital analogy that the medical record comprises a “lossy compression” document of the encounter.
See Chuck Webster, MD, on the similar, also-relevant issue of “pragmatic interoperability.”