BMJ 2014;350:g7645 doi: 10.1136/bmj.g7645 (Published 8 January 2015)
Page 1 of 3
Head to Head
HEAD TO HEAD Should doctors encourage patients to record consultations? Patients are doing it legally anyway, and it will lead to better practice and shared decision making, says Glyn Elwyn. But Laurence Buckman worries it could lead to defensive practice and risk the doctor-patient relationship Glyn Elwyn professor, Dartmouth Institute for Health Policy and Clinical Practice, 37 Dewey Field Road, Hanover NH 03755 USA, Laurence Buckman general practitioner, Temple Fortune Health Centre, London UK
Yes— Glyn Elwyn Some patients already use their smartphones to record clinical encounters; many do not ask for permission or make it obvious. In this situation, what should doctors do? Protest? No—doctors should encourage patients to record their meetings openly because it can help improve patient care, encourage more evidence based medicine and shared decision making, and increase trust and openness. It would also circumvent covert recording and support patients’ legal right to record clinical encounters. Arguing that doctors should not support patients who want to record their clinical encounters is like putting our heads in the digital sand.
Improved care By far the strongest argument for encouraging patients to record consultations is that it is likely to improve the quality and safety of patient care. No studies have shown this, but it would be odd if clinicians did not adhere to good practice when being recorded. Evidence that patients like recordings comes from research done over the past 30 years in which clinicians have given patients audiotapes of their clinical encounters, typically in oncology and paediatric settings, and mainly in Europe.1 A review of more than 30 studies concluded that patients place a high value on receiving such recordings, their increased understanding, and the ability to share the recording with family members.1 Similar results would be achieved if patients were encouraged to record their own clinical encounters. Granted, some negative effects could occur if recording became commonplace. Doctors might order more tests and generate more referrals and more follow-up visits. This kind of defensiveness may well lead to overdiagnosis, overtreatment, and increased costs.2 However, I suspect this risk is transient and small, given that awareness of being recorded has not been shown to lead to persistent effects on doctors’ behaviour.3 4 Moreover, more openness will lead to better practice, greater reliance on evidence, and greater patient engagement, which
tends to lead to less interest in aggressive or unwanted treatments.5
Shared decision making Inevitably, recordings will allow encounters to be assessed. Did the doctor mention alternative approaches? Was there any information given to help compare alternatives? Was there some indication about the probabilities of harm as well as the likelihood of benefit? What evidence sources were cited, if any? Were guidelines consulted? Did the doctor consider using a tool to help the patient to make a well informed decision? If not, why not? Did the doctor make any effort to consider the things that matter most to the patient—to diagnose the patient’s preferences? For the first time, verifiable data about a clinician’s ability to deliver evidence based medicine and shared decision making would be in patients’ hands. Although potentially nerve wracking for doctors, this change can only be for the good. It would increase the demand for tools that have been designed to support patients and clinicians to collaborate and deliberate—in short, to practise “minimally disruptive medicine.”6 The possibility of legal use must be considered, of course. Recordings of clinical encounters, unless tampered with or edited, represent transactions and are increasingly considered as admissible evidence in law courts. The UK General Medical Council has allowed recordings by patients to be considered in hearings when there are substantial grievances. So these recordings can serve multiple purposes.
Trust and openness Doctors who are willing to be recorded will be viewed as having nothing to hide. A similar development is the Open Notes concept in the United States,7 which enables patients to comment on the accuracy of their electronic medical record. Initial professional resistance to this initiative may diminish given the positive results of evaluation studies.8
Correspondence to: G Elwyn [email protected], L Buckman [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;350:g7645 doi: 10.1136/bmj.g7645 (Published 8 January 2015)
Page 2 of 3
HEAD TO HEAD
Encouraging patients to record consultations would circumvent their recording encounters covertly, as they already do.9 10 My research shows that they do this because they fear asking permission lest it be denied and they are viewed as difficult patients who don’t trust their doctor (unpublished data).
Finally, if you are not convinced by these benefits then at least be aware of the law. It is legal for patients in the United Kingdom to record their clinical encounters, even covertly and without the clinician’s consent.11 By contrast, doctors are not permitted to record clinical encounters without the consent of patients.12 In the United States, recording is subject to the laws developed for wiretapping. In 40 states, the consent of only one party to a conversation is needed to undertake a recording, covert or otherwise. Legality in other jurisdictions is often unclear or as yet untested. However, even if they know that recording is legal doctors may not always welcome this activity. To the contrary, if doctors notice covert recording, there is evidence of very negative reactions such as ejecting the patients from the practice, calling the police, and confiscating recording devices.10 It is definitely an area that needs more guidelines. For these reasons doctors should encourage patients to record clinical encounters where they wish to do so. You are not in a position to refuse, and by facilitating the process many good things will follow, especially for patients.
Laurence Buckman—No My objections to encouraging patients to record consultations are not based on some patronising view that the doctor knows best and does not want to be tripped up but rather on a series of practical and professional problems that such recording would cause.
Consultations belong to patients, and they have a right to record what goes on as they choose, but they should think carefully beforehand because it is not what most clients do when they consult a professional. Although most people would deem any clandestine recording by either side unacceptable (even if it is legal for the patient), there may be occasions when both parties agree that they wish to record the consultation. The obvious examples are when a patient is unable to write or read notes on the consultation or when the doctor is recording consultations for training purposes. In the case of training, there are strict rules governing who may play the recording and when and how it must be destroyed.
The motives of someone making a clandestine recording without the permission of the other party must be questioned. It is wrong for either doctor or patient to do this with the intention of deliberately entrapping or tripping up the other party, and this implies that this doctor-patient relationship is at an end. The consultation is a sham, with one party intending to catch the other out. It does not matter whether there is litigation in prospect. This is not what doctors or patients should do to each other. The indemnifier the Medical Defence Union says that the pragmatic approach is to agree an overt recording with copies given to both parties.13
Recording changes in behaviour The reason professionals are not routinely recorded advising their clients is because the act of recording, like any measuring of performance, alters the way the discussion goes. When I record myself for educational purposes, I know the consultation is altered — I speak slower and with half an eye to posterity, even though I have received consent from the patient. Patients are also inhibited, even if they say they are content to be For personal use only: See rights and reprints http://www.bmj.com/permissions
recorded, and they speak and act in a more guarded way. Consultations may take longer and both parties are more circumspect in what they say. Most doctors could not work like that for long. The only (small) published study I have been able to find showed that consultation lengths were increased by a minute or so, although the increase was not significant.3 Given the time pressures on doctors, even the possibility of adding a minute could affect patient care. The interference with the consultation goes beyond the professional relationship. The process of setting up recording equipment, inevitable if the patient is making the recording, would take precious time away from the consultation, even when it all works well. It also offers yet another distraction to doctor and patient, who are trying to get needs assessed and met within too short a time.
Other solutions are preferable For all of these reasons, recording interferes with the precious doctor-patient relationship. This relationship is often unbalanced in power, and patients may think that recording will help redress the balance. My concern is that doctors will react defensively when what they should be doing is looking at why the patient feels so disempowered; could it be the doctor’s fault? Patients do not need to record consultations if all they want to do is to refer later to the details of what has been said. We have a long tradition of giving written material to patients, and a longer one of giving patients a written note of the key facts that they need to take away with them. Many doctors encourage people to take notes in consultations, though this also slows things down. A note is a summary, not a verbatim transcription, and is much more likely to be useful as a result.
Misuse With any recording comes a risk of misuse. The recording can be given to third parties without both parties’ permission; it can be used as evidence about the doctor, the patient, or other people who are being discussed in some way by the patient, or rarely, by the doctor during the consultation; it can be published as “entertainment” on social media; or it can be (mis)used by the media. The only way to mitigate these risks is for the doctor and patient to have a copy of the recording so that both know what truly transpired. A wise doctor should suggest it. Recording consultations has a place for patients who are unable to read or for educational purposes. Although doctors should usually permit recording by patients (because it is the patient’s consultation and a legal right), they should not encourage it. Any recording should be done with mutual consent and copies given to both parties. GE thanks Paul Barr and Arianna Blaine for their comments on earlier drafts. Competing interests: Both authors have read and understood BMJ policy on declaration of interests and declare the following interests: GE initiated and developed the Option Grid Collaborative, which produces tools to support shared decision making. He is part of a research team that has developed the CollaboRATE, a patient reported measure of shared decision making. He acts as an adviser to Emmi Solutions, a producer of patient decision support interventions in the US. Provenance and peer review: Commissioned; not externally peer reviewed. 1
Tsulukidze M, Durand M-A, Barr PJ, Mead T, Elwyn G. Providing recording of clinical consultations to patients—a highly valued but underutilized intervention: a scoping review. Patient Educ Couns 2014;95:297-304.
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;350:g7645 doi: 10.1136/bmj.g7645 (Published 8 January 2015)
Page 3 of 3
HEAD TO HEAD
2 3 4 5 6 7 8
Welch H, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Beacon Press, 2011. Pringle M, Stewart-Evans C. Does awareness of being video recorded affect doctors’ consultation behaviour? Br J Gen Pract 1990;40:455-8. Coleman T. Using video-recorded consultations for research in primary care: advantages and limitations. Fam Pract 2000;17:422-7. Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1:CD001431. May CR, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009;339:b2803. Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012;157:461-70. Walker J, Darer JD, Elmore JG, Delbanco T. The road toward fully transparent medical records. N Engl J Med 2014;370:6-8.
For personal use only: See rights and reprints http://www.bmj.com/permissions
9 10 11 12 13
Elwyn G. “Patientgate”-digital recordings change everything. BMJ 2014;2078:10-1. Vox F. iPhone app makes doctors iRate. Reuters 2010. http://blogs.reuters.com/greatdebate/2010/03/15/iphone-app-makes-doctors-irate/. Clements N. Dilemma: recording consultations. A patient asks to record my consultation—what should I do? 2012. www.medicalprotection.org/uk/your-practiceseptember-2012/dilemma-recording-consultations. General Medical Council. Making and using visual and audio recordings of patients. GMC, 2013. Medical Defence Union. What should you do if the patient wants to record a consultation? 2013. www.themdu.com/guidance-and-advice/latest-updates-and-advice/what-shouldyou-do-if-a-patient-wants-to-record-a-consultation.
Cite this as: BMJ 2014;349:g7645 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Head to Head
HEAD TO HEAD Should doctors encourage patients to record consultations? Patients are doing it legally anyway, and it will lead to better practice and shared decision making, says Glyn Elwyn. But Laurence Buckman worries it could lead to defensive practice and risk the doctor-patient relationship Glyn Elwyn professor, Dartmouth Institute for Health Policy and Clinical Practice, 37 Dewey Field Road, Hanover NH 03755 USA, Laurence Buckman general practitioner, Temple Fortune Health Centre, London UK
Yes— Glyn Elwyn Some patients already use their smartphones to record clinical encounters; many do not ask for permission or make it obvious. In this situation, what should doctors do? Protest? No—doctors should encourage patients to record their meetings openly because it can help improve patient care, encourage more evidence based medicine and shared decision making, and increase trust and openness. It would also circumvent covert recording and support patients’ legal right to record clinical encounters. Arguing that doctors should not support patients who want to record their clinical encounters is like putting our heads in the digital sand.
Improved care By far the strongest argument for encouraging patients to record consultations is that it is likely to improve the quality and safety of patient care. No studies have shown this, but it would be odd if clinicians did not adhere to good practice when being recorded. Evidence that patients like recordings comes from research done over the past 30 years in which clinicians have given patients audiotapes of their clinical encounters, typically in oncology and paediatric settings, and mainly in Europe.1 A review of more than 30 studies concluded that patients place a high value on receiving such recordings, their increased understanding, and the ability to share the recording with family members.1 Similar results would be achieved if patients were encouraged to record their own clinical encounters. Granted, some negative effects could occur if recording became commonplace. Doctors might order more tests and generate more referrals and more follow-up visits. This kind of defensiveness may well lead to overdiagnosis, overtreatment, and increased costs.2 However, I suspect this risk is transient and small, given that awareness of being recorded has not been shown to lead to persistent effects on doctors’ behaviour.3 4 Moreover, more openness will lead to better practice, greater reliance on evidence, and greater patient engagement, which
tends to lead to less interest in aggressive or unwanted treatments.5
Shared decision making Inevitably, recordings will allow encounters to be assessed. Did the doctor mention alternative approaches? Was there any information given to help compare alternatives? Was there some indication about the probabilities of harm as well as the likelihood of benefit? What evidence sources were cited, if any? Were guidelines consulted? Did the doctor consider using a tool to help the patient to make a well informed decision? If not, why not? Did the doctor make any effort to consider the things that matter most to the patient—to diagnose the patient’s preferences? For the first time, verifiable data about a clinician’s ability to deliver evidence based medicine and shared decision making would be in patients’ hands. Although potentially nerve wracking for doctors, this change can only be for the good. It would increase the demand for tools that have been designed to support patients and clinicians to collaborate and deliberate—in short, to practise “minimally disruptive medicine.”6 The possibility of legal use must be considered, of course. Recordings of clinical encounters, unless tampered with or edited, represent transactions and are increasingly considered as admissible evidence in law courts. The UK General Medical Council has allowed recordings by patients to be considered in hearings when there are substantial grievances. So these recordings can serve multiple purposes.
Trust and openness Doctors who are willing to be recorded will be viewed as having nothing to hide. A similar development is the Open Notes concept in the United States,7 which enables patients to comment on the accuracy of their electronic medical record. Initial professional resistance to this initiative may diminish given the positive results of evaluation studies.8
Correspondence to: G Elwyn [email protected], L Buckman [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;350:g7645 doi: 10.1136/bmj.g7645 (Published 8 January 2015)
Page 2 of 3
HEAD TO HEAD
Encouraging patients to record consultations would circumvent their recording encounters covertly, as they already do.9 10 My research shows that they do this because they fear asking permission lest it be denied and they are viewed as difficult patients who don’t trust their doctor (unpublished data).
Finally, if you are not convinced by these benefits then at least be aware of the law. It is legal for patients in the United Kingdom to record their clinical encounters, even covertly and without the clinician’s consent.11 By contrast, doctors are not permitted to record clinical encounters without the consent of patients.12 In the United States, recording is subject to the laws developed for wiretapping. In 40 states, the consent of only one party to a conversation is needed to undertake a recording, covert or otherwise. Legality in other jurisdictions is often unclear or as yet untested. However, even if they know that recording is legal doctors may not always welcome this activity. To the contrary, if doctors notice covert recording, there is evidence of very negative reactions such as ejecting the patients from the practice, calling the police, and confiscating recording devices.10 It is definitely an area that needs more guidelines. For these reasons doctors should encourage patients to record clinical encounters where they wish to do so. You are not in a position to refuse, and by facilitating the process many good things will follow, especially for patients.
Laurence Buckman—No My objections to encouraging patients to record consultations are not based on some patronising view that the doctor knows best and does not want to be tripped up but rather on a series of practical and professional problems that such recording would cause.
Consultations belong to patients, and they have a right to record what goes on as they choose, but they should think carefully beforehand because it is not what most clients do when they consult a professional. Although most people would deem any clandestine recording by either side unacceptable (even if it is legal for the patient), there may be occasions when both parties agree that they wish to record the consultation. The obvious examples are when a patient is unable to write or read notes on the consultation or when the doctor is recording consultations for training purposes. In the case of training, there are strict rules governing who may play the recording and when and how it must be destroyed.
The motives of someone making a clandestine recording without the permission of the other party must be questioned. It is wrong for either doctor or patient to do this with the intention of deliberately entrapping or tripping up the other party, and this implies that this doctor-patient relationship is at an end. The consultation is a sham, with one party intending to catch the other out. It does not matter whether there is litigation in prospect. This is not what doctors or patients should do to each other. The indemnifier the Medical Defence Union says that the pragmatic approach is to agree an overt recording with copies given to both parties.13
Recording changes in behaviour The reason professionals are not routinely recorded advising their clients is because the act of recording, like any measuring of performance, alters the way the discussion goes. When I record myself for educational purposes, I know the consultation is altered — I speak slower and with half an eye to posterity, even though I have received consent from the patient. Patients are also inhibited, even if they say they are content to be For personal use only: See rights and reprints http://www.bmj.com/permissions
recorded, and they speak and act in a more guarded way. Consultations may take longer and both parties are more circumspect in what they say. Most doctors could not work like that for long. The only (small) published study I have been able to find showed that consultation lengths were increased by a minute or so, although the increase was not significant.3 Given the time pressures on doctors, even the possibility of adding a minute could affect patient care. The interference with the consultation goes beyond the professional relationship. The process of setting up recording equipment, inevitable if the patient is making the recording, would take precious time away from the consultation, even when it all works well. It also offers yet another distraction to doctor and patient, who are trying to get needs assessed and met within too short a time.
Other solutions are preferable For all of these reasons, recording interferes with the precious doctor-patient relationship. This relationship is often unbalanced in power, and patients may think that recording will help redress the balance. My concern is that doctors will react defensively when what they should be doing is looking at why the patient feels so disempowered; could it be the doctor’s fault? Patients do not need to record consultations if all they want to do is to refer later to the details of what has been said. We have a long tradition of giving written material to patients, and a longer one of giving patients a written note of the key facts that they need to take away with them. Many doctors encourage people to take notes in consultations, though this also slows things down. A note is a summary, not a verbatim transcription, and is much more likely to be useful as a result.
Misuse With any recording comes a risk of misuse. The recording can be given to third parties without both parties’ permission; it can be used as evidence about the doctor, the patient, or other people who are being discussed in some way by the patient, or rarely, by the doctor during the consultation; it can be published as “entertainment” on social media; or it can be (mis)used by the media. The only way to mitigate these risks is for the doctor and patient to have a copy of the recording so that both know what truly transpired. A wise doctor should suggest it. Recording consultations has a place for patients who are unable to read or for educational purposes. Although doctors should usually permit recording by patients (because it is the patient’s consultation and a legal right), they should not encourage it. Any recording should be done with mutual consent and copies given to both parties. GE thanks Paul Barr and Arianna Blaine for their comments on earlier drafts. Competing interests: Both authors have read and understood BMJ policy on declaration of interests and declare the following interests: GE initiated and developed the Option Grid Collaborative, which produces tools to support shared decision making. He is part of a research team that has developed the CollaboRATE, a patient reported measure of shared decision making. He acts as an adviser to Emmi Solutions, a producer of patient decision support interventions in the US. Provenance and peer review: Commissioned; not externally peer reviewed. 1
Tsulukidze M, Durand M-A, Barr PJ, Mead T, Elwyn G. Providing recording of clinical consultations to patients—a highly valued but underutilized intervention: a scoping review. Patient Educ Couns 2014;95:297-304.
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;350:g7645 doi: 10.1136/bmj.g7645 (Published 8 January 2015)
Page 3 of 3
HEAD TO HEAD
2 3 4 5 6 7 8
Welch H, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Beacon Press, 2011. Pringle M, Stewart-Evans C. Does awareness of being video recorded affect doctors’ consultation behaviour? Br J Gen Pract 1990;40:455-8. Coleman T. Using video-recorded consultations for research in primary care: advantages and limitations. Fam Pract 2000;17:422-7. Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1:CD001431. May CR, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009;339:b2803. Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012;157:461-70. Walker J, Darer JD, Elmore JG, Delbanco T. The road toward fully transparent medical records. N Engl J Med 2014;370:6-8.
For personal use only: See rights and reprints http://www.bmj.com/permissions
9 10 11 12 13
Elwyn G. “Patientgate”-digital recordings change everything. BMJ 2014;2078:10-1. Vox F. iPhone app makes doctors iRate. Reuters 2010. http://blogs.reuters.com/greatdebate/2010/03/15/iphone-app-makes-doctors-irate/. Clements N. Dilemma: recording consultations. A patient asks to record my consultation—what should I do? 2012. www.medicalprotection.org/uk/your-practiceseptember-2012/dilemma-recording-consultations. General Medical Council. Making and using visual and audio recordings of patients. GMC, 2013. Medical Defence Union. What should you do if the patient wants to record a consultation? 2013. www.themdu.com/guidance-and-advice/latest-updates-and-advice/what-shouldyou-do-if-a-patient-wants-to-record-a-consultation.
Cite this as: BMJ 2014;349:g7645 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
