Managing Information

Abstract

Doctors are required to document their examinations of the patient. This task is particularly important in psychiatry, where what the patient says is practically the only source of information available to the clinician. In our article we shall focus on the process of information management in psychiatry and trace the information which was recorded in the patients’ notes back to its origin in the interview. Our data consists of eight recordings of psychiatric interviews along with the patients’ notes.

Our main argument is that the notes are not merely written from the point of view of the psychiatrist, but might have little or nothing to do with the interview. We demonstrate, first, that accurate notes are a record of how the doctor conducted the interview. Second, the notes doctors made also misrepresent the interview with the patient: doctors record false information, distort it, take out of its context.

Keywords

information management patient’s record psychiatric interview misrepresentation discourse analysis

Introduction

Writing notes in a patient’s record is one of the most basic clinical tasks. Doctors are required to document their examinations and observations of the patient, encounters with him/her and descriptions of the care provided (Tasman & Mohr, 2011). A particular role among doctors’ notes is played by the admission note, also called history of present illness. It is extensive information about the patient’s status, reasons for hospitalization along with the initial instruction for the patient’s care written on the basis of the first encounter (Sadock & Sadock, 2007).

Skills in transferring the information obtained during the clinical encounter into the admission note in the patient’s record are part of clinical reasoning skills (Higgs & Jones, 2000) developed during medical studies and residency. The doctor has to organize the data from the interview into a clear note which addresses the specific and diagnostically and therapeutically relevant information. Admittedly, the task is difficult as patients tell doctors much more that might be required clinically (Waldinger, 1997), and so, a note in the patient’s record enforces selection and management of the information collected in the interview. This process is of particular importance in the case of psychiatry, where what the patient says is the only source of information available to the clinician.

In our article we would like to focus on the process of information management in psychiatry and, more particularly, trace the information which was recorded in the patients’ notes back to its origin in the interview.

So far, this aspect of clinical work has been ignored by researchers. Studies examining medical records focused upon the text of the records, pointing out its medicalization: objectivization, use of medical jargon, or objectification of patients (e.g., Barrett, 1996; Berkenkotter, & Ravotas, 1997; Hak, 1992; Sarangi & Brookes-Howell, 2006). The management of information has been studied mainly in the context of technological solutions in health care system and care delivery, such as health information systems (HIS; Ludwig et al., 2010), electronic medical and health records (EMR, EHR; Boyer, Samuelian, Fieschi, & Lancon, 2010; Lewis et al., 2011) or telemedicine (Szeftel et al., 2011). Though the management of information is also linked to the ability to select and use of combined information and strategies in order to deliver the best relevant and valid care (Slawson & Shaughnessy, 2005). Here, authors explore the information management skills and techniques which can improve them (e.g., Khan & Coomarasamy, 2006; Miles, Loughlin, & Polychronis, 2008). Such reading of information management is near to our point of view. However, in contrast to studies where management pertains to evidence-based resources and medical examination findings, we are focused solely on information received from patients during the interview.

In psychiatric literature, an interest in information management can be seen mainly in forensic psychiatry and psychology (e.g., Brown & Campbell, 2010; Scott & Resnick, 2008). The risk of malingering keeps researchers at the evaluation of the quality of information given by patients (e.g., Rogers, 2008; van Beilen, Griffioen, Gross, & Leenders, 2009) and development of techniques and strategies that help clinicians in management of patients’ information (e.g., Clegg, Fremouw, & Mogge, 2009; Rogers, 2008). In such a way such studies are focused on the relationship between patients and the information given. We take a different direction. We are interested in how doctors manage and record the information given by the patient. This approach to patients’ notes is ignored in the literature.

The Study

This study is part of a larger project about interview practices in psychiatric care. Eight recordings of psychiatric interviews along with notes in patients’ records were collected between February 2006 and February 2007, in three psychiatric hospitals in Poland. Each interview was the routine conversation between the patient and the doctor immediately after admission. They were the first encounter between the physician and the patient. Both the doctor and the patient gave informed consent to the interview being recorded, and the notation in the medical record copied and analyzed discursively. This was preceded by the initial clearance from the chief consultant on the ward. Approval for the study was obtained from the ethical committee of the Wroclaw Faculty of the Warsaw School Social Sciences and Humanities.

The preliminary diagnosis of the interviewed patients was depressive illness (F-32-33; WHO, 1998), and the doctors were residents training for specialization in psychiatry. The procedure was as follows. After gaining the permission of the chief consultant one of us met the residents to tell them about the study and its aims. They were informed that it is a study about psychiatric interview with patients preliminarily diagnosed with depressive episode and the aim of the study is to get to know the discursive practices of the first psychiatric interview. The task of the doctors who agreed to take part in the study was, after gaining the patient’s informed consent, recording the interview with a patient (whom the chief consultant qualified for the study on the preliminary diagnosis of mild or moderate depressive illness). The doctors were asked to conduct the interview as usual, as we are interested in everyday practices of psychiatric interviewing rather than their individual competencies or capabilities. The permission to take a photocopy of the doctor’s notes in patient’s record was taken after the doctor made the entry. Thus, none of the doctors knew that we were interested in their records, before he/her recorded the interview. A photocopy was taken by the chief consultant on the ward and all personal information about the patient and the doctor was removed.

The data were subsequently transcribed and discursively analyzed. The analysis was based on the Polish data, however, for purpose of this publication the analyzed data was translated into English. We aimed for the translation which is as close as possible in structure and format to the Polish original, at the same time, trying to render the “flavor” of what was said. This sometimes results in “bad” or “disjointed” English.

Finally, we do realize that the corpus we collected is limited, however, our study does not aim to be representative. We are not trying to demonstrate how widely the phenomena we discuss here occur in psychiatry. Rather, we are interested in describing a certain problem in clinical practice. Its scale remains to be taken up in future research.

Method

Our study is a piece of qualitative research. We shall be looking at the life world taking the perspective of the people who participate in the research. Taking a constructionist view, we assume, principally, that social reality is a continual product of the social exchange of meanings, while objective reality can only be accessed by social participants through socially shared meanings. By taking the “inside” perspective, qualitative research is more “engaged.” As we live in a social world which is becoming increasingly unfixed, it is particularly the in-depth description thereof, and from the point of view of the social actor, that becomes crucially significant. It is also through adopting the bottom-up perspective that we are able to actively engage with increasingly frequent calls within the social sciences to involve research participants, particularly those perceived as disenfranchised, in the research design, its process, and dissemination of results (e.g., Davidson, 2003).

Our study is anchored in discourse analysis. And so in our focus on language we are not so much interested in the language as a system of vocabulary and grammar, but, rather, in how language is used. We focus upon the content and the form of stretches of discourse, with an interest both in the semantics and syntax of an utterance, as well as the functions of what is said within the local context, and the social actions thus accomplished. And so, we understand discourse as a form of social practice within the sociocultural context, while seeing language users not as isolated individuals, but as members of social groups, organizations, institutions, cultures engaged in communicative activities. To a considerable extent, they speak the way one speaks, the way it is appropriate (in many senses of this word) to speak.

More specifically, we anchor our study within the critically oriented analysis of discourse (e.g., Barker & Galasiński, 2001; Fairclough, 1992; Hodge & Kress, 1993; van Dijk, 1993). Thus, we assume that discursive representations, whether linguistic (spoken or written) or visual are not transparent, but, rather, construct reality as much as they represent it. At lexical as well as syntactic-semantic and pragmatic levels language use is associated with a “structure of faith” (Menz, 1989): patterns of belief and values and of their textual representations (often multiple and contradictory). And so we are interested in discourse as a means of systematic social construction of knowledges, subjects, and worlds of which it speaks (Foucault, 1972). Discourse analysis is capable of unraveling those constructions and accessing the host of assumptions and values carried by semiotic choice.

Managing Information

Our analysis shows that the process of information management can be seen in two main strands. First, it is all those notes which have clear reference in what the patient said. Second, it is all those notes which could be seen as misrepresenting the interview’s contents and/or its communicative function.

Before we go on, we would like to make a reservation. We quite deliberately avoid speaking of truthful notes, or doctors writing “the truth.” We do it for two reasons. First, as we indicated earlier, we understand that every note taking necessarily involves decisions as to what to include in them, what is relevant to the physician, what is relevant clinically and nosologically. This process also necessarily involves condensing and summarizing what the patient said and as such cannot render “the truth” in its entirety. It is simply impossible to render “the whole picture.” What can be achieved is a clear relationship between the notes and the interview, which must be evidence for what the physician writes.

Second, we want to avoid as much as possible the ethical issues resulting from saying that doctors “tell the truth” or, in contrast, deceive. We do not wish to discuss our data in such terms, as we perceive them as unhelpful. We have no access to doctors’ intentions and prefer to focus on the relationship between texts, not on the relationship between writers and their texts (for more discussion, see Galasiński, 2000).

Managing Accurate Information

Let us explore first those records which can be construed as having clear reference in the interview. What we would like to show is how psychiatrists make such references and how they account for the information that they had actually received in the interview. Saying this, we assume that the notes in one way or another render the propositional content (what was said) and the communicative function of what was said in the interview (why it was said)¹. In other words, in this section we are interested in those records which more or less faithfully render what was said by the patient.

And thus, the notes are full of facts and pieces of information that doctors recorded after being informed by their patients about, most typically, times of hospitalizations, diagnoses, family status, occupation and the like. Things, however, are more complicated when it comes to recording patients’ complaints, or, in medical language, their symptoms. We would like to discuss two discursive practices in relation to this data. First, we would like to show cases where the information which is accurately recorded, cannot in fact be taken at face value, as it is a result of the interactional power of the doctor. In other words, physicians record what their patients actually said, yet, the patients are most likely simply to have followed the doctor in labeling their experiences. In the process the doctor’s record is that of her/his perspective and not of the patient’s. The other is a strategy of framing the information with comments undermining its validity, with other information being left without such comment.

Recording the doctor’s perspective

Consider the following two examples.

Example 1²

Doctor’s notes:

(1a)

(She) admits that she is nervous by nature. Easily put out—“I treat nerves by cigarettes.” This is accompanied by internal anxiety—“then I start to stammer. . .”

Interview:

(1b)

Doctor:

By nature, before you got sick, were you a nervous or a quiet person?

Patient:

I was very energetic.

Energetic, so lively, right? So one could say you were a little bit nervous too? Was it easy to irritate you?

I simply got neurosis during my university studies and it all started from the neurosis.

What about these nerves at the moment?

Well, it varies.

Do some trivia put you out easily now?

Also.

It happens yes?

Yes yes.

Example 2

Doctor’s notes:

(2a)

Current repeated deterioration of mental status in the form of slow-flowing anxiety, loss of interest, a significant decrease in daily activity, insomnia, numerous somatic complaints.

Interview:

(2b)

Patient:

No, no, no. I mean, there are no dreams at least. I mean don’t even have such sudden anxiety states because. Because generally I feel unwell all the time

Doctor:

such slow-flowing anxiety all day long, right?

yes and this

with constant intensity.

yes yes yes. anyway something stops me from any action, especially like I say some bills, something has to be cleaned, something has to be done.

The two examples offer clear, in our view, examples in which it is the doctor who imposes the interpretation of what their patients want to say. In Example 1, it is only the psychiatrist’s imposition that introduced nervousness, irritability, or “neuroticism” (Polish “nerwowy” is ambivalent) as the patient’s characteristic. In fact, the patient’s first answer that she “was very energetic” suggests that she initially resists the label offered by the doctor. The doctor, however, persists and offers “a little bit nervous.” In her response the patient can be seen as attempting to match her experience to the category offered by the psychiatrist. However, it is a strategy we see as aiming to soften the interactional resistance towards what the doctor says. So, by pointing to the diagnosis from before nearly 50 years, we think the 67-year-old patient on the one hand pleases the doctor who insists on “the nerves,” on the other hand she avoids saying the doctor is right. The clinician does not give up, though, and the patient eventually yields.

The record of the conversation reflects the fact that the patient acquiesces with the interpretation, yet, obviously, all the interactional wrangling that went on does not find its way into the notes. The doctor simply writes that the patient “admits” she is “nervous by nature.” In other words, the doctor’s notes are a reflection of his initial question, regardless of the interaction in which the patient actually resisted the label. Notably, the introduction of the verb “admit” does indicate that it was not information she volunteered, yet, it hides the patient’s resistance to the label.

Also in Example 2 the doctor offers to interpret what the patient said using a diagnostic label of generalized anxiety. The patient agrees, yet when the doctor pushes the interpretation asking about the level of intensity, the patient while agreeing, offers a more “lived” account. What we are faced with here is a doctor asking a question about a generalized anxiety, as if the label were commonly understood by patients. Moreover, he uses the obsolete label “slow-flowing,” which, while still in use by Polish psychiatrists, has been replaced by “generalized” (more in line with its English counterpart) in the diagnostic criteria. Thus, it is very likely that the patient, while agreeing, does not really know what the doctor is talking about and, indeed, he offers his own lived account. Once again, the record in the notes, while reflecting the patient’s agreement, offers only a doctor’s perspective, one which might not have been understood and espoused by the patient.

Managing the perspective

Now, another way of recording what happened at the interview is to put an explicit frame ascribing to what had been a dimension of objectivity/subjectivity. Consider the following examples:

Example 3

Doctor’s notes:

64-year-old patient admitted to the ward in significantly depressed mood, with a feeling of fear, anxiety; loneliness, in high tension, without positive symptoms, she reports suicidal thoughts, without tendency to carry out.

Example 4

Doctor’s notes:

Unasked, the patient talks about relationships with men, about a fascination with a priest at the age of 16, about an intercourse with a boy whom she didn’t love and felt bad about it, about a relationship with a married man.

Half way through the note in Example 3, the doctor suddenly changes the perspective. From writing “objectively,” that is by using sentences in the 3rd person, without any qualification, he introduces the verb “reports” (Polish “zgłasza”). All of a sudden the note is transformed from an account made by the writer, to an account made from the perspective of the patient. The psychiatrist accesses the voice of the patient, as if not wanting to commit himself to the existence of the suicidal thoughts. It is not him who offers the information on suicidal ideation, it is the patient.

It is difficult not to see the shift in the perspective as the psychiatrist’s attempt to distance himself from what the patient says. Indeed, in her rare study of patients’ notes Anspach (1988) suggests that such expressions show doctors’ skepticism toward what the patient says. She also suggests that the skepticism results from the training physicians receive in which distinction is made between subjective symptoms and objective signs which can be ascertained through diagnostic technology (such as, for example, blood tests). While her analysis is perfectly plausible in reference to somatic medicine, matters are not as straightforward as regards psychiatry. For, unlike somatic medicine, psychiatry does not have access to any “objective” signs of a disease, basing its pronouncements predominantly on what the patient says. Thus, the first part of the record, which is rendered as objective information, is as much based on the “subjective” symptoms, as the one from which the doctor distances himself. In other words, there is no reason to assume that the information about suicidal ideation has a different epistemological status—rather, simply, the doctor does not believe it, for one reason or another and wishes to distance himself from it.

In Example 4 the psychiatrist uses a similar strategy, except that he prefers to note that the patient volunteered the information. It is difficult to postulate what the importance of such a record is, yet, it indicates that unsolicited information is somehow marked, unusual. Interestingly, this in quite a stark contrast to the dominant psychiatric literature, which is quite adamant that psychiatrists must work with patients’ experiences and encourage their sharing (e.g., MacKinnon, Michels, & Buckley, 2006; Stanghellini, 2007). It is posed that only a conversation that allows an understanding of the patient and their problems is clinically valuable (e.g., Pridmore, 2000; Sullivan, 1970), while creating an opportunity to gain the patient’s trust, satisfaction, and compliance (Cooper-Patrick et al., 1999; Mellor et al., 2006). Moreover, and crucially, theorists commonly condemn focusing upon symptoms of diseases rather than on the suffering of patients (e.g., Haidet & Paterniti, 2003).

If anything then, according to academic and institutional psychiatry, unsolicited information should be welcomed by the doctor, for only in such a way can the doctor reach to the experiences and suffering of the patient. And yet, instead, the record indicates some distance, a veiled value judgment on the volunteering, as if the information has a different status from the one that was obtained by an explicit question.

These two strategies were typical in our corpus. They show that the rendering of the interview, even though substantiated by what was said by the patient, is very clearly done from the perspective of the reporting physician. This is done to the extent that the perspective of the patient is almost entirely backgrounded. What is crucial, however, is that faithful reporting is not so far from reporting which can be viewed as misrepresentation.

Before we continue, there is an important point to be made. We have found no records which could be seen as rendering “unmanaged” accurate information—the notes invariably contained some management of the perspective from which the doctor recorded the information. When we asked ourselves the question of what “unmanaged” representation would be like, our answer was two-fold. First, the information recorded would need to be accurate and undistorted (see the next section), while, second, the perspective of the doctor would have to be kept at bay, with any commentary recorded as such. In other words, the doctor would need to record what the patient said (ideally, perhaps, as a quote) with her/his commentary, both explicit and implicit, separated from it.

We realize, of course, that the task we set for “unmanaged information” could be seen as quite onerous. After all, there is no language use which is neutral, which does not make assumptions or which is not made from a particular perspective. Still, we do believe that physicians should be much more aware of the language they use and more sensitive to the perspective they impose upon their interviews. We shall come back to it at the end of the article.

Shades of Misrepresentation

In our analysis, we shall follow Galasiński (2000), who, in his linguistic study of deception and misrepresentation, notes three types of misrepresentation: falsifications, distortions, and “taking words of context.” And so, for this study, falsifications will be those records which consist in ascribing to the patient words which are in contradiction with what s/he actually said. Distortions consist in recording a claim made by the patient as stronger/more general or weaker/more particular. Finally, “taking words out of context” consists in ascribing to what the patient said a different function from the one it had in the interview. These types are not mutually exclusive and can and do occur together. As Galasiński (2000) notes further, the first two of the types are distinguished on the basis of the representation of the propositional content of the target utterance and the third one relates to the representation of its functions.

Finally here, we decided not to deal with omissions in the doctors’ notes. Although omission, that is to say intentionally withholding relevant information, is commonly taken to be a type of deceptive strategy, it is difficult to argue such cases here, as dropping information from the notes might well be a result of a decision on clinical significance of the information. We shall, however, return the issue later on.

Falsifications

There is no doubt that falsifications are an extremely significant and worrisome element of physicians’ record making, as they potentially render a false clinical picture of the patient’s complaint. On the other hand, for a discourse analyst, they are the least interesting cases of “information management,” as they simply are cases of physicians recording the opposite of what the patient said. And so, we note them as critical from the point of view of clinical practice. Consider the following example:

Example 5

Doctor’s notes:

(5a)

(She) has problems with sleeping “I sleep better after (taking) a pill”

Interview:

(5b)

Doctor:

And how is your sleep?

Patient:

Various.

Are there problems with sleep?

There are problems.

(. . .)

What does it look like?

I am on sleeping pills for the moment, right?

So how is sleep after pills? What time do you go to sleep?

usually I try about 10 o’clock.

and do you fall asleep quickly?

no. I have a difficulty with it. with falling asleep.

There is no doubt that the record in the notes is simply inaccurate. In fact, the doctor makes a note which contradicts what was conveyed by the patient. As we are not psychiatrists, we cannot offer an account of the possible consequences of the record, if the notes were to be taken at face value.

Furthermore, what was surprising was the extent of such records, they were considerably more numerous than we expected. Patients’ words that they cannot remember the names of their medicines were recorded as medicines contributing to memory loss; being tired with city noise was recorded as tiredness with open spaces; difficulties with concentrating as difficulties with doing things. Whether mistakes, forgetfulness, or simply “knowing better,” doctors’ notes were not only full of inaccuracies, but also full of information which was simply false.

Distortions

As we said earlier, distortions are those misrepresentations that consist in making the original claim stronger/more general or weaker/less general. These are records in which doctors exaggerate, overstate, or alternatively, minimalize, diminish what was said by the patient. Consider the following examples:

Example 6

Doctor’s notes:

(6a)

(She) feels resignation thoughts sporadically (without suicidal thoughts and suicide attempts).

Interview:

(6b)

Doctor:

Have any thoughts of resignation appeared with you? That life has no sense, or even, I’d say, suicidal?

Patient:

Indeed.

yhm

I am a believer so I try to pray not to do it. (They appear) obviously.

Have they appeared in the last few (unclear)

Yes, in the last few months.

and now, in the last days? After leaving the inpatient ward?

Maybe not.

This example is the most clear in the corpus we collected. There is a double distortion of what the patient said in the doctor’s record. First, the actual question in the interview referred to suicidal and resignation thoughts. It is of course unclear what exactly the patient had in mind when answering—the psychiatrist asks two questions at the same time. However, the response stating that the patient is a believer (in Poland this almost certainly means Catholic), coupled with prayers “not to do it” is more than likely to imply suicidal thoughts. Yet, the doctor chooses to record resignation thoughts as the only interpretation of what the patient said underscoring this by explicitly noting absence of suicidal thoughts. This is no doubt a weaker statement than that made by the patient. But the psychiatrist also chooses to make a note that that these thoughts are sporadic. Once again, there is nothing in what the patient said that would suggest the frequency of those thoughts. Yet, the doctor decides to play it down, exactly as with the label of the patient’s potential suicide ideation.

In the next two examples, the doctors’ records distort what the patient said by making their claims more general.

Example 7

Doctor’s notes:

(7a)

Current deterioration of mental state since November—she stopped taking medication, eating, sleep disturbances, lack of activity, apathy.

Interview:

(7b)

Doctor:

What happened that you arrived here? Because you came from the inpatient ward.

Patient:

yes.

yhm

I simply felt very unwell. It was a recurrence of depression and simply in this depression for the first time I stopped eating, drinking.

yhm

simply, I had difficulties with swallowing. I don’t know whether it was because of depression, I stopped taking medication. I couldn’t eat at all.

when did it happen?

it was about more than month ago.

Example 8

Doctor’s notes:

(8a)

The patient avoids contacts with other people, feels the fear of dealing with daily affairs.

Interview:

(8b)

Patient:

[. . .] my friend lives in [she gives the name of district] and now she has a granddaughter so our contacts are limited to telephone conversations. Besides, an acquaintance came to see me and I, whoever I meet, I haven’t got close friends. There are two persons who are closer because the rest either died or went away. Or they moved the flat and moved to another district. Therefore I am quite alone.

Doctor:

And with your neighbors, do you stay in touch

No, I don’t stay in touch.

Not at all? Even to talk to them in the street

I do, of course. I talk to many people on the street

Isn’t it a source of stress for you? An anxiety.

No. I mean it has never been a source (of stress). I needed it and I even liked it, except that now when I meet and talk for 10 minutes I feel tired.

In Example 7, the patient explains that she stopped taking medication because of difficulties with swallowing. Yet, her file indicates something quite different. The doctor’s notes indicate a straightforward unwillingness to take medication—a statement which seems to be much too strong in view of what the patient actually said. It is also difficult to see how what the patient said in Example 8 can be construed in terms of avoiding contact with other people. In fact the initial explanation of the patient’s loneliness is constructed as resulting from others’ actions (moving away) or for biological reasons (friends dying). She is clearly unhappy with the state of affairs. Now, as she denies lack of any contact with her neighbors, she also indicates that such contacts are fatiguing, and as such she cuts them short. The doctor’s record transforms her very narrow statement into a generalized rule which simply has no reference in the interview. Incidentally, the note that the patient experiences anxiety when going about their daily matters is a falsification, the patient denied that a number of times in the interview (unquoted here).

Taking Words Out of Context

The last two examples we shall discuss here show instances of taking words of context by psychiatrists writing their notes on the patient. These are cases where the misrepresenting text attributes a different function to what was said originally. The interpretation it offers cannot be sustained by what the patient said in the interview. Consider the following two examples:

Example 9

Doctor’s notes:

(9a)

She doesn’t feel like housework, though. She feels better in the evening, worst in the morning.

Interview:

(9b)

Doctor:

Is there a will to act? To cook a dinner? To tidy up?

Patient:

No. Unfortunately. I have to force myself. It is very difficult for me. I can’t.

But when you force yourself, does it work?

It works somehow.

Example 10

Doctor’s notes:

(10a)

Negatively predisposed towards treatment—“nothing can help me”

Interview:

(10b)

Patient:

[. . .] there is no help for me. I am, so to speak, pushed aside. To take, kick, and throw away, this is how I see myself, someone who cannot give anything more, because she cannot. I can’t force myself to do anything. They tell me you must, you must. How am I supposed to have the strength? After all this strength is in the head. Depression is in the head and perhaps the beginning of Alzheimer’s.

The expression “doesn’t feel like” (“nie ma ochoty”) indicates that not doing housework is a patient’s whim, a more or less temporary decision to do or not to do something. It also indicated the patient’s ability to actually do the task, but taking a sort of laissez-faire attitude. In such a way she is represented as expressing carelessness, indifference. Yet, what the patient actually said was quite different. She showed herself as not being able to do housework, she was complaining to the doctor, clearly, in our opinion, wanting to do it. She was showing herself as concerned about not being able to do things. Quite similarly, the ascription of negativity to treatment in extract 10 we think has little to do with what the patient said. While the psychiatrist shows her as simply rejecting treatment, the patient shows resignation, despair. She might not believe in treatment, but that it is quite different from having a negative attitude (with all its connotations in psychiatry) toward it.

It is also worth noting that the psychiatrist records quotations from the interview, even though the words were not actually spoken by the patient. This does, however, make the record more credible.

Once again, contrary to our expectations, the notes we analyzed contained a full variety of misrepresentations—from recording information which was at odds with the facts, through distorting it, all the way to interpretations of patients’ words which had no basis in what was said. While we did not try to ascertain the extent of the presence of misrepresentations (practically, counting such cases and comparing with accurate record is fraught with extreme difficulties), yet it is possible to say that misrepresentation was common. All the notes we analyzed contained elements which misrepresented the interview.

Discussion

As we indicated at the outset, every act of representation carries with it decisions as to which aspects of reality to represent and how to represent them. These decisions make every piece of discourse (every language use) ideological, written from the point of view of a particular system of representation shared the speaker. This ideological potential of discourse applies also to such texts which are culturally expected to be neutral. Textbooks (e.g., Apple & Christian-Smith, 1991), laws (e.g., Gibbons, 1994), diagnostic manuals (Crowe, 2000) are all known to represent reality from a particular ideology-laden point of view.

At its more general we argue that patients’ notes are no different and are guided by the “interest” (see Kress & van Leeuwen, 1996) of the sign-maker—the writing doctor. He or she makes selections as to what they see as the criterial aspects of the interview and the patient. And so we take the argument that patients’ notes medicalize their stories, which has been made in the literature (e.g., Barrett, 1996; Berkenkotter & Ravotas, 1997; Hak, 1992; Sarangi & Brookes-Howell, 2006), further. We have demonstrated that the there is a significant process of managing information on the part of the writing doctor, information that s/he puts her/his perspective on. Accurate or faithful recording of what the patient said is far form a transparent record of what happened. It is a record of how the doctor conducted the interview and how s/he constructed what was said.

This, of course, immediately raises the issue not only of how to manage the information from the interview, but also how to conduct the interview itself. For psychiatry expects the doctor to open as much as possible space for her/his patients to be able to share their experience with the clinician, minimizing as much as possible the clinician’s role in the encounter (see: Craig, 2005; MacKinnon et al., 2006; Pridmore, 2000; Sullivan, 1970). Although we do not wish to be prescriptive in our discussion, we believe that clinicians would benefit greatly from more clarity as to what the function of their interview is. More specifically, following Kvale’s (1996) distinction of the psychoanalytic interview (one which is therapeutic with the knowledge gained through it seen as “side effect”) and the qualitative research interview (with the reverse relationship between information and therapy), one could certainly ask the question what exactly the interviewing psychiatrists attempt to achieve. And what exactly do they attempt to record? Much more clarity with regard to the aims of the interview would seem to lead to an encounter offering a much easier source of information for the doctor to record. But the reflective interviewer not only opens the space for the patient, but also understands her/his role in the exchange (Kvale & Brinkmann, 2009).

Moreover, the arguments about ideological underpinnings of language use propose that there is no escape from the doctor’s perspective in the patients’ notes. We agree with such arguments, yet, we also think that there is much to be done with a significant training of clinicians sensitizing them to the language their patients and they themselves use, and particularly the issue of nontransparency of language (Gask, Coskun, & Baron, 2011). And so, a more reflective use of language in patients’ records would make them significantly better insofar as managing the information from the patient.

Our argument here stresses a hiatus in the expectations placed upon psychiatrists. As they are required to communicate both with the patient and with other clinicians, they are offered no training in communication at least in Poland, although this is true to different extents in other countries as well, particularly with regard to note-taking, which is seen as something obvious and transparent.

The arguments on the management of perspectives, even though not yet made in the social scientific literature of psychiatric practices, are, however, at least to an extent to be expected. What is not expected is the fact that the information management goes much further than that of “tinting” the process by imposing the doctor’s perspective. We have shown that the notes doctors make also misrepresent the interview with the patient. Doctors falsify information, distort it, take words out of their context. The notes are not merely written from the point of view of the psychiatrist, in parts, crucially, they have nothing or very little to do with the patient and what s/he said.

Furthermore, we also would like to argue that there is an affinity between the imposition of the doctor’s perspective in the first set of data and the misrepresentations. They are in fact cases of radical impositions of the psychiatrist’s perspective, an imposition so strong that it brushes away what the patient said completely.

Now, what is the source of these misrepresentations? One could argue first that it is doctor’s forgetfulness. However, the explanation is doubtful, as they record facts from the patient’s history quite well, whereas misrepresentations focus around the patient’s mental health complaints. It is untenable to argue that the psychiatrists somehow lose the ability to remember the “symptoms,” while can remember the patient’s life. The only argument that we consider plausible is centered around psychiatric training and, more generally, the dominant psychiatric discourse.

As the model of quantifying the experience of mental illness gains more and more support, and the discourse of nosology, rather than the patient’s story (see for example, Kleinman’s (1988) classical study of patients’ narratives), it is the doctor’s perspective that must dominate the diagnosis process (e.g., Pilgrim, 2007). The patient’s experience cannot surface as s/he plays the game, becoming more “professional” in getting the answers in the right language, as Ziółkowska (2009) demonstrated showing that patients were required to use psychiatric categories in describing their experiences.

As psychiatrists are inculcated with notions of objectivity, they practically have no reflection upon the power relations in clinical setting, happily deciding that an illness is invoked by their decision (Galasiński & Opaliński, 2012). Patients are scarcely empowered to challenge the decision of the doctor, as it is the doctor’s perspective that matters the most. S/he simply knows better and the misrepresentation is, in our view, an embodiment of this power to know.

Now, we would like to be very clear that we are not trying to argue that the psychiatrists whose records we analyzed set out to manipulate the information and willfully misrepresented what their patients said. In other words, the misrepresentation we dealing with is not deceptive (deception is commonly defined through the speaker’s intentionality, Galasiński, 2000). The psychiatrists did not set out to deceive anyone, did not set out to misrepresent intentionally what their patients said. Instead, it simply happened, a result of the dominance of the psychiatrist in the clinical setting.

Psychiatrists operate in a discourse that does not notice its own perspective, seeing psychopathology much in an all-or-nothing manner that excludes the patient’s experience. The dominating psychiatrist, in other words, is supported by the dominating psychiatry and its discourses, thereby forcing the psychiatrist to behave in a way appropriate for a psychiatrist. After all, the recipients of patients’ notes are in fact other doctors. They are written for the benefit of the doctor making the records and for other physicians on the therapeutic team. The misrepresentation is part of the system of perpetuating the dominant discourse of psychiatry and the position of the psychiatrist within it.

The arguments we have made quite closely resemble the well-trodden paths of antipsychiatric sentiments. We would like to explicitly distance ourselves from them. We do not aim to take yet another swipe at institutional psychiatry. Our arguments are data-driven and we try to interpret what we have found in the data. And what we have found has potentially significant clinical consequences.

The psychiatric interview is the most fundamental instrument in the work of a psychiatrist. It gives a crucial insight into the patient’s complaints, their suffering. As it ends, only the patient’s notes remain as a record of what happened. Any misrepresentation of what happened in the interview gives an inaccurate picture of the patient and their distress. And as doctors provide therapy also on the basis of such notes, one wonders what they actually treat. The only postulate that remains to be made here is: Physician, heal thyself.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Justyna Ziółkowska received financial support for this project from Foundation for Polish Science.

Notes

Author Biographies

Dariusz Galasiński, DSC, PhD, MA, is professor of discourse and cultural studies at the University of Wolverhampton. His current research interests focus upon experience of mental illness.

Justyna Ziółkowska, PhD, is assistant professor in psychology at University of Social Sciences and Humanities (SWPS), Poland. Her research interests concentrate on experience of mental illness and discourses of psychiatric care.

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