Digital clinical encountersBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2061 (Published 14 May 2018) Cite this as: BMJ 2018;361:k2061
All rapid responses
I read with interest the article from Professor Elwyn and Co and the subsequent responses. The authors have given a very good one sided view of the digital recordings of clinical encounters but did not expand on the impact it can have on the clinicians and the hospitals in the UK, if some of the patients decide to use such recordings in 'different ways' when they are not particularly satisfied or happy with their encounters. They have given a passing reference of a PubMed article issued in July 2001(1) which states that there were no increased malpractice issues or exposure, as a one liner. Expenditure on clinical claims by NHS Resolution increased by 72% (11.5% a year on average) over the five years to 2015/16. Should this trend continue it risks becoming wholly unsustainable for the NHS and wider society, which ultimately pays for these costs (2). Also, the fear of being sued and hence the anxiety level amongst clinicians is already high (2) with a significant shortage of doctors, NHS has faced for years but much more so recently(3,4). This, in my view will have a direct impact on the issue. I, as an ordinary citizen think I have a choice of being recorded (audio or video) or otherwise. If I chose not to, would I be forced in to such conversations and recordings?
This appears to be a volcano waiting to be erupted as the scale of problem it will lead to is phenomenal. The number of doctors leaving the profession will be even bigger than what has happened in the recent past (5). We should have a clear ruling/guidelines as to who can record, where could it be recorded and what purpose should it serve. Clinicians need to be reassured that 'under no circumstances' these recording could be used in a court of law as voice tempering and digital alterations could lead to a totally different conveyed meaning.
Competing interests: No competing interests
There are some consultations where the benefits of recording are at first sight clear- the son or daughter of someone with poor memory, perhaps mild dementia who usually attends their appointments with them, cannot make it, so asks if the consultation could be recorded. Someone comes for the first follow-up appointment after their diagnosis of cancer to discuss treatment options. Parents and a child with Type 1 diabetes come to their first education session.
Most consultations are not like this, especially in Primary care. As an educator I watch a lot of doctors of different grades and levels of experience consulting. One thing that happens with experience is that the doctors listen more, explore more, empathise more and explain less. If patients really need and want explanations about the effects of medication, how to use devices, exercises for their back pain, how to titrate their insulin or how long their symptoms are likely to last - there are excellent online resources. Unlike a brief discussion with me, these are comprehensive, up to date, and linked to videos, patient experiences and more. They are not subject to my biases nor limited to a few minutes or even seconds in a consultation that is about far more than information giving.
In an average consultation I am for the most part engaged in assessment and dialogue. Assessment of their social context, psychological state, values and assumptions, their ideas, concerns and expectations. I am also distracted by and attentive to the needs of the electronic record, prompting me to ask questions about their smoking, diet, alcohol consumption, depression and then to check their weight and blood pressure and collect a urine sample for ACR. I am bothered by the fact that I am running 20 minutes late and messages keep popping up on my screen to say that the previous patient has just arrived and could fit them in, and the next patient has called to say they're running late and could I fit them in too. In spite of this, I am focused as hard as I can be on the patient in front of me, trying to figure out if the problem they've asked to talk about it what's really bothering them most of all, or if it's something else they're too ashamed to bring up.
The digital evangelists in healthcare have a tendency to think in very simple terms about consultations - either as diagnositic events or question and answer sessions. They're much messier than that perhaps best described as improvised jazz by Paul Haidet http://www.annfammed.org/content/5/2/164.full The main digital disruption however is the imposition of technology with the electronic system demanding that we ask questions that are irrelevant to the patient's present concerns.
The spectre of a digital record bloated by every consultation digitally recorded and converted to text, is an environmental, organisational and aesthetic nightmare.
Competing interests: No competing interests
I am delighted to hear innovative ideas to improve the healthcare system and clinical outcomes.<1> But I wonder whether clinicians can rightfully refuse to be recorded by their patients’ smartphones? Consultations are part of clinicians’ intellectual property, but clinicians have no control over the use and distribution of their recordings. As an analogy, I cannot make recordings in cinemas so that I can re-watch a scene and share it with a family member or friend. I cannot say I want to revisit and clarify plots that are forgotten, check that the film director has clearly communicated important information to the audience, and monitor agreed goals before the director’s next film.
Besides, most clinicians are trained to deliver care rather than perform in front of cameras and microphones. Not everyone feels comfortable to see their video and voice recordings being posted online. Some may fear their images and speech being mocked in public.
This editorial suggested that recording clinical encounters could reduce administrative burden.<1> Would clinicians be exempt from typing their notes if their clinical encounters are already recorded? Or would they require additional administrative time to manage these recordings? Good clinicians communicate differently when talking colloquially to patients versus writing professionally to colleagues. “This morbidly obese woman with a BMI of 44 is at risk of MI, OA, HTN, and T2DM.” Would a reasonable clinician say that exact same phase for the patient, camera, and documentation altogether?
If my above concerns can be addressed with clear regulations, we should then consider recording of clinical encounters, as well as communication between clinicians. It has been suggested that recording phone calls for training purposes may reduce rude, dismissive and aggressive communication among clinicians.<2, 3> These recordings would be stored internally to ensure clinicians being accountable for their advice and professional behaviour.
1. Elwyn G, Barr PJ, Piper S. Digital clinical encounters. BMJ. 2018;361:k2061.
2. Lakhani M. Sticks and stones: investigating rude, dismissive and aggressive communication between doctors. Clinical Medicine. 2016;16(2):207-208.
3. Whitelaw BC. Response. Clinical Medicine. 2016;16(2):208.
Competing interests: I have been paid for working as a medical doctor, but not writing this letter.