;)
Figure: physician-patient communication, ED recording, medicolegal
FigureMy patient was a middle-aged woman with atypical right-sided chest pain. She was pretty uncomfortable and had a few risk factors, so we did a battery of lab tests.
The results were reassuring: no evidence of COVID, pneumonia, pulmonary embolism, or acute myocardial infarction. In fact, it seemed most likely that she had strained her oblique muscle during a hip-hop dance class. When I told her and her sister this, they appeared relieved and satisfied. Then, before pivoting to leave, I recalled a recent conversation and paused. “It seems as though you both understand what I just told you,” I said, “but I don't mind repeating it. You are welcome to use your phone to record.”
The conversation I remembered was one I'd had with researcher Paul Barr, PhD, MSc, from Dartmouth University. He is an expert in the emerging area of automated and curated recordings of physician-patient encounters.
Dr. Barr grew up in Belfast and as a youngster ended up in the ED a lot. Once, it was with an injury from a Gaelic football match, and the doctor said he would need surgery or his finger would end up “looking like a banana.” Later he wished he could have a do-over of his conversation with the doctor because he hadn't fully grasped the ramifications of his injury, including how long it would be until he could play again.
An Early Experience
Years later with colleagues at the Preference Lab in Dartmouth, Dr. Barr began exploring the nascent phenomenon of patients secretly recording their physician visits. This practice is now common (up to 15 percent of patients report having recorded a doctor's appointment) and guaranteed to rile up physicians. (JAMA. 2017;318[6]:513; https://bit.ly/3xmaBtm.) Every practicing EP has at heard least one story about a colleague who was disciplined or encountered a medicolegal headache due to a secret recording by a patient. Such recordings are clearly a violation of the doctor-patient contract, and the American College of Emergency Physicians has a policy condemning them. (Ann Emerg Med. 2019;74[5]:e101.)
Dr. Barr started researching why patients secretly record visits, despite the clear violation of trust, and one theme kept coming up: Many felt uncomfortable about the secret recordings, but did it because some discussions were too important not to record.
From there, Dr. Barr quickly found a productive career in studying the utility and application of visit recordings with the Open Recordings research group. He received a grant in 2015 from the Gordon and Betty Moore Foundation to support what has morphed into HealthPAL. (https://www.openrecordings.org/health-pal). The concept, informed by a portfolio of case studies, supports patients and caregivers making audio or video recordings of clinic visits, storing and sharing them securely, and reviewing the information they may have missed. “We have seen a positive reaction to sharing recordings, not just among patients and families, but also with caregivers, health care providers, and even insurers,” he said.
A patient with advanced stage 4 cancer referred to his recordings as his “right-hand man,” Dr. Barr explained. He would listen to the recordings several times to lift his mood if the doctor had given him encouraging news, and he would share bad news with his family so that he did not have to experience the pain of retelling it.
Patients have been interested not only in reviewing what their doctors have said, but also what they said to make sure they hadn't forgotten to tell the doctor something. Anecdotal evidence suggested that malpractice claim risks are lower with recordings because they improve patient trust, recall, and understanding and seem to encourage a more shared treatment model that can help defuse a blame dynamic if things go wrong. Some insurers have noticed this and started providing incentives to encourage physicians to offer patient recordings. (JAMA. 2017;318[6]:513; https://bit.ly/3xmaBtm.)
“When you stand back and look at this,” Dr. Barr said, “how can you not think that recordings are a good idea?”
In the ED?
Not all EPs would agree, but even a fast-paced and unpredictable environment like the ED may have room for recordings. Physicians may recoil at the notion of being on camera and worry about medicolegal risks, but we should also be aware of how our reluctance to allow recordings might result in more secret recordings.
Kenneth Iserson, MD, and colleagues wrote a spot-on commentary that laid out a template for ED policies that capture the right balance of privacy and patient advocacy. (Am J Emerg Med. 2019;37[12]:2248.)
My patient and her sister appreciated the offer and smiled. “We are good,” my patient said. “It would be one thing if you just told me I had something bad, like cancer, but this isn't a big deal.”
Until the process becomes more automated, I will selectively encourage recordings when it seems helpful for my patients and look forward to when the timing and technology are safe, secure, and seamless.
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Dr. Ballardis an emergency physician at San Rafael Kaiser, a past chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. Follow him on Twitter@dballard30. Read their past articles athttp://bit.ly/EMN-MedClear.
