Experiences and opinions of general practitioners with patient online record access: an online survey in England

OBJECTIVE

To describe the experiences and opinions of general practitioners (GPs) in England regarding patients having access to their full online GP health records.

DESIGN

Convenience sample, online survey.

PARTICIPANTS

400 registered GPs in England.

MAIN OUTCOME MEASURES

Investigators measured GPs' experiences and opinions about online record access (ORA), including patient care and their practice.

RESULTS

A total of 400 GPs from all regions of England responded. A minority (130, 33%) believed ORA was a good idea. Most GPs believed a majority of patients would worry more (364, 91%) or find their GP records more confusing than helpful (338, 85%). Most GPs believed a majority of patients would find significant errors in their records (240, 60%), would better remember their care plan (280, 70%) and feel more in control of their care (243, 60%). The majority believed they will/already spend more time addressing patients' questions outside of consultations (357, 89%), that consultations will/already take significantly longer (322, 81%) and that they will be/already are less candid in their documentation (289, 72%) after ORA. Nearly two-thirds of GPs believed ORA would increase their litigation (246, 62%).

CONCLUSIONS

Similar to clinicians in other countries, GPs in our sample were sceptical of ORA, believing patients would worry more and find their records more confusing than helpful. Most GPs also believed the practice would exacerbate work burdens. However, the majority of GPs in this survey also agreed there were multiple benefits to patients having online access to their primary care health records. The findings of this survey also contribute to a growing body of contrastive research from countries where ORA is advanced, demonstrating clinicians are sceptical while studies indicate patients appear to derive multiple benefits.

Patient Access to Mental Health Notes: Motivating Evidence-Informed Ethical Guidelines

ABSTRACT

In the last decade, many health organizations have embarked on a revolution in clinical communication. Using electronic devices, patients can now gain rapid access to their online clinical records. Legally, patients in many countries already have the right to obtain copies of their health records; however, the practice known as "open notes" is different. Via secure online health portals, patients are now able to access their test results, lists of medications, and the very words that clinicians write about them. Open notes are growing with most patients in the Nordic countries already offered access to their full electronic record. From April 2021, a new federal ruling in the United States mandates-with few exemptions-that providers offer patients access to their online notes (Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, Available at: https://www.govinfo.gov/content/pkg/FR-2019-03-04/pdf/2019-02224.pdf#page=99). Against these policy changes, only limited attention has been paid to the ethical question about whether patients with mental health conditions should access their notes, as mentioned in the articles by Strudwick, Yeung, and Gratzer (Front Psychiatry 10:917, 2019) and Blease, O'Neill, Walker, Hägglund, and Torous (Lancet Psychiatry 7:924-925, 2020). In this article, our goal is to motivate further inquiry into opening mental health notes to patients, particularly among persons with serious mental illness and those accessing psychological treatments. Using biomedical ethical principles to frame our discussion, we identify key empirical questions that must be pursued to inform ethical practice guidelines.

Open-label placebo clinical trials: is it the rationale, the interaction or the pill?

National surveys of primary care physicians demonstrate that placebo use is prevalent. Against their widespread use, until recently, it was assumed among researchers that placebos must be deceptively prescribed for beneficial effects to be elicited. However, a new programme of research in placebo studies indicates that it may be possible to harness placebo effects in clinical practice via ethical, non-deceptively prescribed 'open label placebos' ('OLPs'). To date, there have been 14 small scale clinical and experimental trials into OLPs. Results suggest therapeutic potential of these treatments for a range of conditions and symptoms. In this evidence-based Analysis we identify conceptual issues that, if not given due consideration, risk undermining research methodologies in OLP trials. Counterintuitively, owing to the nuances posed by placebo terminology, and the difficulties of designing placebos controls in OLP trials, we suggest that experimentalists reflect more deeply when formulating adequate comparison groups. Further research is needed to disentangle which specific components of OLPs are effective, such as: the rationale provided to participants; the quality of provider interaction; and/or the action of taking the pills. We conclude with recommendations for how researchers might take up the significant challenge of devising optimal placebo controls for OLP clinical trials. Although these issues are intricate, they are not merely academic: without due diligence to conceptual, and as a consequence, methodological considerations, OLP effect sizes may be over- or underestimated. We conclude that there may yet be potential to use OLPs in medical practice but clinical translation depends on rigorously controlled research.

Sharing clinical notes, and placebo and nocebo effects: Can documentation affect patient health?

This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.

Primary care providers' use of and attitudes towards placebos: An exploratory focus group study with US physicians

OBJECTIVE

To examine how primary care physicians define placebo concepts, use placebos in clinical practice, and view open-label placebos (OLPs).

DESIGN

Semi-structured focus groups that were audio-recorded and content-coded.

METHODS

Two focus groups with a total of 15 primary care physicians occurred at medical centres in the New England region of the United States. Prior experience using placebo treatments and attitudes towards open-label placebos were explored. Themes were analysed using an inductive data-driven approach.

RESULTS

Physicians displayed a nuanced understanding of placebos and placebo effects in clinical contexts which sometimes focused on relational factors. Some respondents reported that they prescribed treatments with no known pharmacological effect for certain conditions and symptoms ('impure placebos') and that such prescriptions were more common for pain disorders, functional disorders, and medically unexplained symptoms. Opinions about OLP were mixed: Some viewed OLPs favourably or considered them 'harmless'; however, others strongly rejected OLPs as disrespectful to patients. Other issues in relation to OLPs included the following: lack of guidelines, legal and reputational concerns, and the notion that such treatments would run counter to customary medical practice.

CONCLUSIONS

A number of physicians reported prescribing impure placebos in clinical care. Although some primary care physicians were resistant to the possibility of recommending OLPs, others regarded OLPs more favourably, viewing them as potential treatments, albeit with restricted potential. Statement of contribution What is already known? Many physicians report prescribing drugs for the purposes of eliciting a placebo effect. Initial evidence for the efficacy of open-label placebos is promising. What does this study add? A more nuanced description of the circumstances under which primary care physicians report placebo prescribing. A qualitative account of physician attitudes about using open-label placebos in clinical practice.

Attitudes About Informed Consent: An Exploratory Qualitative Analysis of UK Psychotherapy Trainees

Background: Ethical informed consent to psychotherapy has recently been the subject of in-depth analysis among healthcare ethicists. Objective: This study aimed to explore counseling and psychotherapy students' views and understanding about informed consent to psychological treatments. Methods: Two focus groups were conducted with a total of 10 students enrolled in a Masters course in counseling and psychotherapy at a British university. Questions concerned participants' understanding of informed consent including judgments about client capacity; the kinds of information that should be disclosed; how consent might be obtained; and their experiences of informed consent, both as a client and as a therapist. Focus groups were audio-recorded, transcribed, and analyzed using qualitative content analysis. Coding was conducted independently by three authors. Results: Comments were classified into three main themes: (1) the reasons and justifications for informed consent; (2) informed consent processes; and (3) the hidden ethics curriculum. Some trainees expressed significant doubts about the importance of informed consent. However, participants also identified the need to establish the clients' voluntariness and their right to be informed about confidentiality issues. In general, the format and processes pertaining to informed consent raised considerable questions and uncertainties. Participants were unsure about rules surrounding client capacity; expressed misgivings about describing treatment techniques; and strikingly, most trainees were skeptical about the clinical relevance of the evidence-base in psychotherapy. Finally, trainees' experiences as clients within obligatory psychotherapy sessions were suggestive of a "hidden ethics curriculum"-referring to the unintended transmission of norms and practices within training that undermine the explicit guidance expressed in formal professional ethics codes. Some students felt coerced into therapy, and some reported not undergoing informed consent processes. Reflecting on work placements, trainees expressed mixed views, with some unclear about who was responsible for informed consent. Conclusions: This qualitative study presents timely information on psychotherapy students' views about informed consent to psychotherapy. Major gaps in students' ethical, conceptual, and procedural knowledge were identified, and comments suggested the influence of a hidden curriculum in shaping norms of practice. Implications: This exploratory study raises important questions about the preparedness of psychotherapy students to fulfill their ethical obligations.

Corrigendum: Sharing Clinical Notes in Psychotherapy: A New Tool to Strengthen Patient Autonomy

[This corrects the article DOI: 10.3389/fpsyt.2020.527872.].

Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety

Error resulting from missed, delayed, or wrong diagnoses is estimated to occur in 10–15% of ambulatory and inpatient encounters, leading to serious harm in around half of such cases. When it comes to conceptualizing diagnostic error, most research has focused on factors pertaining to: (a) physician cognition and (b) ergonomic or systems factors related to the physician’s working environment. A third factor – the role of patients in diagnostic processes – remains relatively under-investigated. Yet, as a growing number of researchers acknowledge, patients hold unique knowledge about themselves and their healthcare experience, and may be the most underutilized resource for mitigating diagnostic error. This opinion article examines recent findings from patient surveys about sharing visit notes with patients online. Drawing on these survey results, we suggest three ways in which sharing visit notes with patients might enhance diagnostic processes: (1) avoid delays and missed diagnoses by enhancing timely follow up of recommended tests, results, and referrals; (2) identify documentation errors that may undermine diagnostic accuracy; and (3) strengthen patient-clinician relationships thereby creating stronger bidirectional diagnostic partnerships. We also consider the potential pitfalls or unintended consequences of note transparency, and highlight areas in need of further research.

Does Disclosure About the Common Factors Affect Laypersons' Opinions About How Cognitive Behavioral Psychotherapy Works?

Background: Written and online information about cognitive-behavioral therapy (CBT) prioritizes the role of specific techniques (e.g., cognitive restructuring) and typically omits discussion of “common factors” (e.g., the working alliance, or therapist empathy). However, according to extensive psychotherapy process research the common factors may be important mediators of client improvement.

Objectives: This study aimed to assess lay opinions about the role of specific and common factors in CBT for depression. We also aimed to determine how different client disclosure processes might affect lay opinions about the relative importance of specific and common factors in CBT.

Methods: We conducted a web-based experiment involving a sample of US participants who had never undergone psychotherapy. All participants were presented with similar vignettes describing an individual suffering from depression whose doctor recommends CBT. Participants were randomized to read one of six vignettes created in a 2 × 3 factorial design that crossed client gender with type of informed consent (Standard CBT Disclosure vs. Common Factors and CBT Disclosure vs. No Disclosure).

Results: Disclosure type had a significant effect on participants' ratings of Common and Specific factors in psychotherapy. As compared to the CBT disclosure, participants allocated to the Common Factors disclosure rated Empathy and Positive Regard as significantly more important to treatment outcome, and rated the Specific factors of CBT as significantly less important to outcome. There were no significant differences between No Disclosure and Standard CBT Disclosure, and these participants rated Specific factors of CBT and the Working Alliance as more important components in treatment, and Empathy and Positive Regard as less important.

Conclusions: The content of information disclosures influences lay opinions about the importance of specific and common factors in CBT. Further research should investigate ethically acceptable disclosures to CBT and other forms of psychotherapy, including whether disclosure practices affect treatment outcome.

Informed consent and clinical trials: where is the placebo effect?

Lack of knowledge about placebos affects participants’ understanding of trials and breaches the ethical obligations of researchers, argue C R Blease, F L Bishop, and T J Kaptchuk

Talking more about talking cures: cognitive behavioural therapy and informed consent

Cognitive behavioural therapy (CBT) has risen to prominence as an orthodox treatment option which is commonly recommended to patients with anxiety and depressive disorders. Mainstream healthcare institutions (including the National Health Service in the UK (NHS) and National Institute for Mental Health (NIMH)) assume that CBT works by helping patients to challenge and overcome 'faulty cognition'. Even if we accept the empirical evidence which shows that CBT (like other forms of psychotherapy) is a beneficial treatment there are still problems with this therapy: mainstream medicine and psychotherapy are continuing to ignore established research that CBT does not work according to its core theoretical tenets. This paper presents evidence that psychotherapy is entrenched in such conventional 'wisdom' and that practitioners are failing to meet their own codified requirement of informed consent. I examine ethical arguments for and against upholding current informed consent procedures and focus, in particular, on the relationship between respect for patient autonomy and the duty of beneficence. I argue that (so far) there are no strong grounds for the claim that patient autonomy undermines therapeutic outcome. The modest conclusion of this paper is that psychotherapy (including CBT) needs to begin to adapt informed consent procedures to comply with ongoing scientific research into its efficacy.