Do people secretly record their medical encounters?

Of the 130 complete respondents, 128 answered the questions regarding their experience and views on covertly recording a visit with a health professional (table 2). In this sample, covert recording had been performed, or known about, by 33 (26%) respondents. A total of 19 (15%) respondents reported secretly recording a medical encounter, with a further 14 (11%) respondents reporting that they personally know of someone who has secretly recorded an encounter. When asked if they would consider recording a medical visit with a health professional, 45 (35%) respondents stated that they would, and a further 44 (34%) indicated a willingness to record only after asking the clinician for permission. Finally, 98 (77%) respondents indicated that they would like their clinic to allow recordings of medical encounters.

Recording covertly or with permission

Multiple logistic regression analysis indicated that, among respondents, individuals who reported making a covert recording were more likely to be male, OR 3.6 (95% CI 1.16 to 11; p=0.03) and have less than a university education; OR 5.5 times (95% CI 1.35 to 22.4; p=0.02). A second analysis indicated that individuals who would only record with permission from the clinician, compared with those who would covertly record, were more likely to have a university education; OR 11.1 (95% CI 2.1 to 60.6; p=0.004).

Qualitative analysis

Of the 130 respondents who completed the survey, 56 agreed to be contacted. Of those 56, 21 consented and 18 were interviewed. We excluded data from one respondent who was not from the UK. We included data from 17 interviews, 10 women and 7 men, all of whom had college (or higher) levels of education; 70% were 41 years or older and all spoke English at home, save for one individual (for details, see online supplementary appendix S2). Three of the interviewees had covertly recorded in the past, five interviewees would consider secretly recording, seven interviewees would only record with permission and two interviewees would not record. Figure 1 provides a thematic representation of the interview data.

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Figure 1

Thematic data representation.

It was evident that the availability of digital technology had, to a large extent, facilitated patients to consider recording clinical encounters; as one individual said: “we've all got devices that are portable and easy to record with” (interviewee 1). Although not all patients will want to make use of the capability, smartphones and other devices can be used with minimal disruption, making covert recording possible. Patients described their motivations to record, and their rationale for either asking permission or acting covertly. They also described how they made use of such recordings, including the associated benefits and concerns. A recurring concern was that recording would violate the etiquette expected in clinical encounters, a deviation from the passive role of the patient. Consequently, many patients volunteered that the solution to this tension would be to ‘normalise’ the behaviour, to make it part of usual practice. After the interview data were analysed, we compared our findings to the 76 open-text comments in the survey, and found no new themes.

Motivations to record

We ascertained five prominent reasons that motivated patients to record clinical encounters. The chief motivation for patients to record was the desire to enhance their understanding of the encounter and, in addition, to share their experience of the encounter with others, particularly when the problems and treatments were complex. There was one instance of a patient describing a therapeutic motivation, where relistening to the encounter was viewed as an additional and complementary therapeutic input. The less explicitly stated motivations were to have a sense of data ownership, that the experience was somehow more tangible by being on record, acting essentially as a “backup for my brain” (interviewee 17), and was in their possession: “So my real motivation for doing the recordings was so that I had a record of what they were actually doing, what they were saying” (interviewee 7). In some instances, this sense of ownership was motivated by prior negative experiences, and the wish to have verifiable evidence of such an experience, should it recur.

Once a patient has decided to record an encounter, they come to a crossroads, ‘Should I record covertly or with permission?’.

Rationale for covert recording

Decisions to record covertly were based on concerns about negative consequences. Interviewees keen to obtain a recording had considered asking for permission, yet had acted covertly due to a fear of being denied permission. Interviewees felt it was easier “to apologize later” rather than “deal with the refusal” (interviewee 14). A interviewee who was also a clinician, also acknowledged this fear: “I think it's quite possible that my clients might have recorded something, an interview with me, without telling me, possibly if they thought I might say no” (interviewee 2).

Fear of denial was related to the worry that clinicians would be affronted by requests to record, to the point of asking patients to leave their care, a particular concern for those living in rural areas with limited options. One interviewee started out recording with permission, but after “being threatened with removal from the practice” (interviewee 8) began to record covertly.

Another factor leading to covert recording was experiencing “jaw-droppingly awful treatment” (interviewee 8), and wanting to have evidence of such an event. Interviewees felt that without such evidence, it was a situation of “his word versus yours” (interviewee 9), and as “the doctor can never be wrong” (interviewee 9), it was necessary to have “actual tape recorded evidence…to protect yourself [the patient]” (interviewee 17).

One interviewee mentioned an experience of using the recording as evidence of bad care and said that it had led to improvement in the quality of further encounters:“[I] put in the complaint, [and] that I [the patient] have a tape recording of the conversation”. When asked about the clinic's reaction, the interviewee stated that “no mention was made [to the recording] in the reply”, and since the problem had been placed, that “treatment there has been exemplary” (interviewee 14).

Rationale for asking permission

The majority of interviewees indicated a desire to record with permission. Maintaining and protecting the relationship with their clinician was a priority: “It's a real partnership thing, isn't it?” (interviewee 16). They feared that covertly recording an encounter “would be a breach of trust” (interviewee 12) between the patient and clinician, and that as a patient, “you owe the clinician an explanation” (interviewee 13) for wanting to record. Interviewees felt like recording and “not asking permission would be like subterfuge” (interviewee 1). One interviewee who had been covertly recording indicated discomfort and regret of recording without permission, to the extent that the interviewee was considering a change of stance.

Several interviewees felt that obtaining permission would have more impact, and lead to greater benefits, “…because, as I say, the physician would know that there was accountability” (interviewee 17). Whereas, “If you do it covertly, they [the clinicians] wouldn't know, would they, so I don't think it would change what was said in the room” (interviewee 6). Acting covertly would, they argued, lead to only “getting half of the benefit out of the recording” (interviewee 8). Requesting permission was also viewed as a means of increasing mutual respect: “I think if it was done openly, and with agreement to both parties, I think it could help develop more trust in the relationship” (interviewee 12). In addition, on a purely practical level, gaining permission enables a device to be used openly, facilitating a “…better quality recording” (interviewee 14).

Use of recording

Those interviewed described four distinct uses of the recordings. Relistening was the prime use, “…to help me better understand what they said, because sometimes they talk so quickly” (interviewee 15). The ability to share the recording with others was very important to many individuals. One mentioned that the recording could be used for therapeutic purposes, particularly if the clinician was prepared to collaborate and support such a goal. The recording could also be used as proof of care received, with the clear implication that such data could constitute evidence of unsatisfactory care, should such a situation occur.

To relisten to information exchanged

Interviewees who found it difficult to recall clinical encounters were often unable to follow what was said, either because it was unclear, or delivered too quickly. It was widely felt that even though a patient might refer “back to it [the recording] once or twice…[many] just found it useful to have as a reference” (interviewee 7).

Share with others

A common frustration reported by patients was an inability to give a good account of their clinical encounter. Interviewees acknowledged the significant benefit of: “…bringing people into the process” (interview 4) by replaying the recording. This was viewed as a more reliable way of ensuring that others were able to understand the advice given, and as help to “follow whatever instructions were provided” (interviewee 13).

For therapeutic purposes

An unexpected use of a recording was to revisit “the emotion of the conversation”, to relisten to the “tone of voice” to “get all that reassurance and attachment stuff” (interviewee 5). This therapeutic use of the recording was made possible by the ability to replay the encounter: “…when I listen back, I feel very supported and validated by those little things which I've missed first time round…that sort of reinforces the benefits of the therapy” (interviewee 5).

Proof of care received

The interviews indicated there was a desire by some to use the recordings as proof of interactions experienced. This was triggered by a sense that without having proof, concerns had too often been dismissed in the past: “I think it could have helped to support my story of what happened” (interviewee 16). Patients reported the need to have verification, and that if they were unsatisfied, their word alone was insufficient: “When you're experiencing poor engagement with your clinician…it [a recording] would be really useful as a kind of evidence” (interviewee 6). A recording was viewed as less open to dispute: “…he was being unsupportive, he said the wrong thing…and here is the proof” (interviewee 5).

Outcomes: benefits

Four benefits of recording encounters were described. The prime benefit was that of empowerment. As one patient said: “In this context, it shifts the power dynamics. It doesn't revolutionise them, but it makes us less passive” (interviewee 5). Reflecting on the benefit, a patient said, “In the NHS, I felt I had no power. So I just wanted to level the playing field a bit” (interviewee 7). Having a record of the encounter enhanced its value and served multiple purposes. This benefit occurs whether the recording is undertaken covertly or with permission. However, three of the benefits were predicated on the recording being conducted overtly, with the explicit permission of the clinician. Recording openly was viewed as a mechanism to focus the clinician's attention, to reduce the power imbalance and potentially reduce future needs: “I think it's just so important because it doubles or triples the value. Why wouldn't you do it?” (interviewee 5). Patients also noted that the process enhanced their ability to check whether they had explained themselves well, to “actually listen to what I said” (interviewee 17).

Outcomes: concerns

Multiple concerns were voiced about the act of recording clinical encounters. Some patients were worried about the new burden of owning such data, of having to listen and make sense of the new form of information “…but, of course, that depends on you being able to pick out…the crucial points…pick them out and talk about them” (interview 11). In addition, the behaviour is not only novel, it also cuts across the established etiquette of patient–clinician interactions and, in part, questions the established status of the professional as the one who legitimately documents the interaction. There is therefore a clear challenge to status, and this, in turn, leads to patients reporting concern about damaging existing, or potential, professional relationships, or being denied access to care by a clinician who has been angered by the process. One patient worried “…that [the doctor] wasn’t being as open and honest, that he would give me a different sort of care, because he would be worried that I was trying to catch him out” (interviewee 12). Concerns were also raised about the potential use of recordings for entrapment, for litigation against the clinician, as well as the possible loss of control of the recordings, and concerns about confidentiality and privacy.

Normalisation

As the interview data made clear, recording was viewed as a threat to established norms, and despite the willingness of some patients to seek permission, it was viewed as a request that would be viewed negatively by most clinicians. The suggested solution, widely made, was for “people to do this routinely” (interviewee 9), that is, to normalise the process and develop a policy where recording would not only be encouraged, it would be facilitated by the clinic. As one interviewee said: “Maybe they are slowly coming to the realisation that there ought to be nothing wrong with this” (interviewee 8). This strategy was viewed as a way to alleviate most, if not all, the concerns, and to enable the benefits: “if a sound recording was made just as a matter of routine…They'd just be so used to it; it would just be a normal part of their day” (interviewee 14).

Many interviewees contrasted recording with written summaries of the encounter, made by the clinician or by the patient. Some preferred summaries, feeling that they were less burdensome. Others highlighted challenges, such as concerns about the accuracy of summaries and the disruption of trying to “keep up” (interviewee 5), and difficult to catch “new long words…” (interview 17).