How honest are you with your doctor? How well does the doc listen to you? How careful is he in documenting what you say?
Apparently, there’s a problem.
Amid the noise of this week, we received a report on a study by the University of Michigan Kellogg Eye Center. Patients waiting to see a doctor were given a questionnaire to complete, which the doctor did not see. The doctor’s write-up of the subsequent exam was compared to what the patient stated on the questionnaire.
Of the 162 patients surveyed, the doctor’s report agreed with the questionnaire only 38 times.
- This study involved eye doctors. Of the patients reporting issues with glare on the survey, glare showed up only 9% of the time in the medical record of the exam. Among patients reporting redness, that showed up only 20% of the time in the medical record.
Why is this a problem? What the doctor reports is what goes into the patient’s permanent medical history and electronic health record. It’s also what the doctor will reference the next time he sees that patient. If the doctor’s understanding is off for any reason, or if he is simply lax in documenting the exam, that could be the foundation for misdiagnosis and ineffective treatment.
While this is true of eye exams, there’s no reason to believe that this only applies to eye exams. Why should it?
What to do?
It’s recommended that you bring an updated list of medicines to each appointment. In addition to that list, you may want to make a list of current symptoms. The list makes it easier to make sure that everything is mentioned during the appointment, and the doctor in principle could scan the list into the medical record.
There also may be insurance-related reasons for doctors elaborating on what the patient reports.
- Nita G. Valikodath, Paula Anne Newman-Casey, Paul P. Lee, David C. Musch, Leslie M. Niziol, Maria A. Woodward. Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records. JAMA Ophthalmology, 2017; DOI: 10.1001/jamaophthalmol.2016.5551
Michigan Medicine – University of Michigan. “What patients say and what doctors document: Comparison of medical record to self-report of eye symptoms shows wide variation.” ScienceDaily, 26 January 2017. <www.sciencedaily.com/releases/2017/01/170126132633.htm>.