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.