Making medical notes more transparent

I read with interest Dr. Suzanne Bennett Johnson's column on "Psychology's paradigm shift: from a mental health to a health profession?" (June Monitor). I am a clinical psychologist who has worked as a health psychologist at the University of Virginia Health System for the last 15 years. Dr. Johnson challenges psychologists to change, as medicine is changing, to become more a part of a patient's treatment team. One area, however, where I notice that psychologists may be reticent to change is the realm of documentation.

About 18 months ago, UVA adopted an electronic medical record system. As a psychologist, I have the option of making my progress notes "sensitive," meaning visible only to others within psychiatry, or completely visible to others who take care of patients here.

It is up to the individual psychologist or psychiatrist how to handle this issue, but the default is the notes are "sensitive." I have chosen to largely make them transparent, however, for several reasons. The pain medicine physicians appreciate knowing what CBT interventions I use, and they read my notes and reinforce my goals, such as activity pacing and smoking cessation. The primary-care physicians read my notes and have a better sense of the patient's mood and functioning than they can get in a 10-minute visit, and also a peek inside what psychosocial factors may be driving blood sugar elevations or an inability to lose weight. And for me, being able to see evaluations from neurology, rheumatology and cardiology help me know when unexplained medical symptoms have been fully evaluated, so I can make a diagnosis of somatization disorder with confidence.

I would urge psychologists working within medical systems to make their notes fully transparent, rather than continuing to do things like we always have. Confidentiality can still be preserved in certain settings, but I believe if psychologists are to be part of a well-functioning medical team, documentation must reflect this cooperative spirit.

Lora D. Baum, PhD
University of Virginia
Pain Management Center

A different paradigm shift

In her June "President's column," Dr. Suzanne Johnson suggests a "paradigm shift" for psychology from a mental health to a health profession, citing a need for a "flexible armamentarium of interventions" and a culture of "evidence-based practice and treatment guidelines." It sounds to me as if we are positioning ourselves somewhere between psychiatric nurses and physician assistants, technicians who treat depression analogous to the treatment of, say, Lyme disease. That's probably not what she meant, but I wonder what our role will be in a health-care setting. Allow me to suggest one that takes into account the fact that while every bacterium causing Lyme disease is pretty much like the next one (and will respond to the same treatment), each depression is different from the next.

Clinical psychology helps people in the context of scientific-mindedness by applying expertise in critical thinking, relationships, conflict resolution, multiculturalism and metaphor. Instead of a paradigm shift, I see the field as employing these competencies outside the consulting office — at disaster sites and in emergency rooms, sports arenas and prisons, to name a few. Same old wine, same old bottle, but poured into new glasses.

Michael Karson, PhD, JD
University of Denver

Online education

As a graduate of advanced degree programs from both traditional (clinical) and accredited online (health) universities, I believe I am competent to comment on the reasons the APA has decided not to accredit online universities ("What you should know about online education," June Monitor). My experience as clinical supervisor of graduates of both types of programs further enhances my competency and credibility regarding this issue. Arguably, my sample size is small, being limited to my own experience and practice.

While I will admit the learning experience is different online, it is no less intense nor does it involve less faculty involvement. If anything, the faculty of my online university, Walden, had very strict guidelines for their responses to students. Good online universities require residencies, as well as practicum experiences, and internships just as brick-and-mortar universities. Advances in technology allow for direct, real-time communication between faculty and students. In my experience, the quality of the relationship between student and faculty is determined mostly by the commitment of the student and the availability of the faculty. Just because the faculty is on site does not guarantee their involvement with students or their ability to teach effectively.

I have supervised people who have participated in both types of programs and have only had to flunk one graduate student from a brick-and-mortar Ivy League university. I have not seen any real difference in the preparedness of interns from traditional or online universities and I do not believe that should be the deciding factor in APA accreditation.

Linda P. Erlich, PhD
Bucks County, Pa.

I find it sad that an organization of professionals who laud research ignores the fact that the research shows that graduates of distance-learning programs learn as much or more than those from traditional programs. Then statements are made about the "socialization" or "enculturation" of students into the profession. I noticed no research was cited to support this contention. Most distance-learners are already in the field and working on an advanced degree and as such are already "socialized" into the field. Moreover, is there any research to show that socialization in a traditional classroom adds any more of this ephemeral quality than does the socialization that occurs during the "face-to-face" practicum and internship? Perhaps the most amusingly specious argument against APA's accrediting online programs was that many boards don't license online graduates. There was no recognition of the tautology of this argument: These state boards don't license online graduates because the programs are not APA accredited. The article quoted several psychologists who stated that online education is good as a supplement. The fact is that you can either educate people online or you cannot. Trying to say that "some" is OK but "too much" is not is ludicrous. Finally, online programs from regionally accredited universities require practicum and internship. This is where you learn how to do psychology, just as in traditional programs.

John Caporale, PhD
Wichita, Kan.

As a leader in online higher education, we at Walden University were pleased to see the June Monitor article on online education. We were concerned, however, that despite presenting compelling data from reports conducted by independent organizations such as the Department of Education and the Sloan Consortium that support the viability of online and blended education programs, the balance of the article focuses on anti-online education opinions, beliefs and "professional judgment." The author even notes that APA "agrees" with the minority of educational leaders who believe online education to be inferior to in-person instruction, despite empirical evidence to the contrary.

In addition to not interviewing experts on online curricula, the article fails to note that other health-care accrediting organizations accredit online education programs without prejudice to the delivery format. These include the Council for Accreditation of Counseling and Related Educational Programs, the Commission on Collegiate Nursing Education, and the Council on Social Work Education, which demonstrates that such programs meet the same national standards of quality and relevance to the profession as face-to-face programs.

As a profession that prides itself on empiricism and data-based decision-making, psychology has an opportunity to follow the lead of these other disciplines to work with educational institutions to examine how best these programs can demonstrate the quality of their learning outcomes. Walden welcomes the opportunity to explore with APA and COA the ways to ensure standards of quality and relevance to the psychology profession.

Cynthia G. Baum, PhD
Walden University

Editor's note: The intent of this article was to report on both positive findings concerning online education as well as concerns about such programs. Readers should remember that there is an important distinction between online education and an online degree program. APA has no position on online education. The association's position vis-á-vis online degree programs is that while online coursework is often useful in preparing for professional practice, a fully online doctoral program does not provide the ongoing in vivo interaction and monitoring with and by faculty supervisors, which are essential to ensuring competency in delivery of health services to the public.

Mindful meditation has deeper roots

The July-August Monitor article on mindfulness attributed this group of emerging psychological practices to Buddhism, beginning with alleging that mindfulness originated from Buddhist concepts over two millennia ago and ending with advocating for integrating Buddhist-oriented clinical applications within psychology. However, mindfulness is not solely a Buddhist practice, as its roots stem from many ancient religious traditions, such as shamanism going back to antiquity and Hinduism predating Buddhism by a millennium. In addition, all religions have forms of mindfulness, including the Abrahamic traditions (e.g., in Christian contemplative, Judaic Cabalistic and Islamic Sufic practices).

To attribute mindfulness solely to Buddhism elevates that tradition at the expense of others, but such assertions are not uncommon within psychology. For example, a recent article in the American Psychologist proclaimed Buddhism as the most psychological religion. I find it intriguing that positive prejudice toward one religious tradition can be unnoticed by psychologists, while any similar attempt to privilege Christianity would immediately find strong resistance.

All religious traditions have potential for enriching psychology, but all need to be kept separate from psychology as secular science. Mindfulness practices, as in the psychoanalytic free-floating awareness, have a long history within psychology and should not be confounded with any singular religious tradition.

Harris Friedman, PhD
University of Florida

Solitary confinement

The May article on solitary confinement ("Alone in the ‘hole'") cites a study by Keefer and Klebe that, to the researchers' surprise, did not find an overall deleterious effect of segregation on the mental health of convicts. This is only the latest of several studies to arrive at the same conclusions. Such studies are usually those that employ objective measures and control groups, unlike the clinical reports that emphasize negative effects on selected prisoners, many of whom are suing the prison administration or the government. In opposition to the findings, Craig Haney argues that the study had methodological flaws, and once again reiterates that "enforced isolation is psychologically stressful and for some people will be harmful." No one would argue with the second part of that statement; the first part should also have the "for some people" qualifier.

Research I conducted in a number of U.S. and Canadian prisons decades ago found a surprising number of interviewees who preferred solitary confinement to the pressures and stresses of living in the general prison population; we, like Paul Gendreau, Ivan Zinger, and Keefer and Klebe, found no evidence of a generally adverse effect. We also found that complaints tended to be not about isolation per se, but about such things as less access to educational or reading material, food getting cold on the way from the kitchen to the segregation unit, and so on. No doubt these studies also had methodological flaws; I would be interested in seeing a field study in prisons that does not, given the many variables that are not under the researchers' control.

It is high time that the argument over general good or bad outcomes is abandoned in favor of a serious attempt to discover 1) which inmates are likely to have serious problems in solitary confinement, which are not, and which may benefit from it; and 2) which specific conditions in segregation units are beneficial, which are harmful and which are neither.

Last, whether isolation units are "used too much," as the article states, raises the question of who decides what is too much, and by what criteria.

Peter Suedfeld, PhD
The University of British Columbia


The June Monitor article "Inappropriate prescribing" had a factual error. The article listed several states where prescription privilege bills had been considered but rejected by legislators. New Jersey was erroneously included in that list. The New Jersey Prescription Privilege legislation (A2419/S137) has not been rejected by legislators. The first of the two companion bills, A2419, was heard in committee on May 10 with good response, and the bill is expected to have an affirmative committee vote when the Legislature reconvenes after summer hiatus. The New Jersey Legislature is in the first six months of its two-year session and the RxP initiative is fully under way. 

Also, the article in the June Monitor, "Agent of change," a profile of Dr. Patrick Canavan, should have noted that Canavan has a PsyD, not a PhD.

Please send letters to Sara Martin, Monitor  Editor. Letters should be no more than 250 words and may be edited for space and clarity.