Thursday, December 12, 2013

Freedom of Information, Transparency, Confidentiality and Psychiatry

In Canada, a person may see a psychiatrist, directly or by referral to the psychiatrist by another doctor.  In British Columbia, the latter holds, and the psychiatrist reports his or her findings to the family physician, though increasingly as is the case, a walk in clinic doctor who may or may not see the patient again, as they are merely one of many doctors working  in that walk in clinic.
However, without the referral from the GP, in British Columbia, the Medical Service Plan,  the third party government insurance payment plan will not pay the psychiatrist.

If a patient comes to a psychiatrist, the doctor is required, because of the payment schedule to write a report.  This report includes a Mental Status Examination.  A mental status examination includes highly  intrusive questions about a person's cognitive abilities, thoughts, dreams, aspirations, resentments, obsessions, sexual fantasies and desires, among other things.
The psychiatrist records this 'confidential' information in their notes.  The notes used to be stored in locked cabinets but more often are stored in computers.  The "security" of these files is dependent on the institutions which have been notoriously slack in guarding patients information.
In private practice offices the 'security' depends solely on the computer savy of the psychiatrist and the trustworthiness of their staff.  The cost of "security", in my case 'thousands of dollars' ,is an ever increasing cost that few are able to manage in small businesses especially given the evidence that the 'rich' corporations are routinely failing in this regard despite their 'promises' and 'marketting' ploys.
 All psychiatrists who are trained as psychotherapists, especially those psychoanalytically trained as I am, (with additional formal training as a hypnotist, cognitive behavioural therapist, focal therapist, motivational therapist, mindfulness therapist  and strategic family therapist ) record 'process notes' and 'content notes'.
Process notes are commonly paradoxical and ironic with no 'validity' as 'fact' in contrast to 'content notes' which are facts however these 'facts' , in my case, commonly a statement by a patient are wholly referenced to context.  They have no 'true' validity without interpretation or as understood by a similiarly trained and experienced psychotherapist. I have seen the most horrendous misuse of psychiatric records with no one seeming to 'care' . It's indeed frightening the extent of this abuse.
The reports (in contrast to notes)  I share with the general practitioners selectively excludes a great deal of information that was provided in the interview and a great deal of information that was in the notes. This is 'normal' practice and done with no malicious intent or planned malfeance.  Insurance companies and courts knowing this 'norm' have taken increasing to demanding the 'notes' which they proceed to 'interpret' regardless of whether they have a 'code' or not.  The distribution of this material within these 'Borg like"  institutions makes mockery of the very term 'confidential' once a person signs 'a release of information'. 
Increasingly though, money and employment and legal action are all 'withheld' until the bullied patient is 'forced' indirectly to 'sign' the 'release of information' only learning then that the information they shared with their psychiatrist (it's worse with psychologists) about their sexual fantasies about guppies is now common knowledge in a law firm or insurance company. The more unusual or bizarre the behaviour (ie unique) the faster it's movement on the gossip mill.
All psychotherapeutically trained psychiatrists do the very same with regard to 'process' and 'content' note taking..  Note taking in this realm is also highly idiosyncratic but interpretable clearly by the note taker and commonly the patient given that it's in a context, of months or sometimes years of therapy.
Solely psychopharmacologically trained pschiatrists have an easier go of it as their notes are usually simplistic and akin to the standard 'content' notes made by family physicians.  I have been  a member of the Canadian College of Family Physicians and am a fully accreditted psychopharmacologist so I am very aware of the different modalities of note taking.
In the form of 'process' note taking it's more like poetry whereas the 'content' note taking is more or less like a 'laundry list'.  The new 'brain' doctors, solely interested in psychopharmacology, do not "mind" so much issues of confidentiality because they are mostly interested in the "symptons' and their notes commonly record bowel movements and 'feel good' 'feel bad' information.  Given the limits of their 'interventions' and their 'psychotherapy deficient"  'training' , asking many of the questions and learning the kind of psychosocial spiritual information essential to psychotherapy, has been construed by some clinicians as akin to 'assault' since the risk of exposure to the patient isn't justified by whether a person choose antidepressant a or antidepressant b  to treat the sympton. The medications in psychiatry are not disease specific but 'symptom' specific. The formal psychiatric evaluations were developped in an era when psychiatrists were more broadly and deeply trained than some of the recent approaches to mental disorders which rely mostly on sympton checklists suggesting a possibility for a wholly different less intrussive and less invasive psychiatric evaluation for psychopharmacologists. Indeed there is a movement afoot to have pharmacists take over this role leaving psychiatrists as traditionally to address the issues of diagnosis, broader biopsychosocial spiritual issues and provide psychotherapy specifically.
Within the bipolar field of psychiatry it is said that the psychopharmacologists would not recognise a lacunae if they were one and the psychotherapists wouldn't recognise as synapse if it was missing.
Most psychiatrists live between these extremes but the note taking and issues of confidentiality, boundaries and transparency reflect to a large degree the dominance or subservience of this body/mind or materialist versus mentalist spiritual split in perception.    A 'hug' for instance might have no place in the repertoire of a psychopharmacologist but be specifically highly beneficial judiciously and strategically used in the course of psychotherapy.
Psychopharmacologists simply don't do 'process' notes and 'lack' dynamic multidimensional consideration of the patient introjects.  They mostly treat the patient in a reductionist way as an 'organ' with 'brain disease' and don't normally address the 'mind', the dream person, the 'projection' and counterprojections, relationships in depth, rarely consider 'quality' over 'quantitative' considerations.   They would never consider  the patient has as part of a multidimensional being in a web of relationships coping with the mystery of life.   
Insurance agencies and legal processes are best understood in their reductionist function as dealing with matters of  materialist 'money' and 'consumer society values'.  The courts are souless entities not completely without humor though.   Indeed they go to great lengths to  put a monetary value on all manner of 'qualitative' aspects of life, their function being monetary based, their answers limitted by the prevailing cultural norms. They do not consider 'intrapsychic' phenomena and put the lowest value on matters such as 'quality' .  Loss of 'earning capacity' gets a higher return on personal injury than loss of 'quality' of life.
There is no judgement from me in this regard, just as statement of the limitation of the 'subjective' once it enters a world more concerned with an 'objective' measure.  At the subjective level what is 'private' is individually considered but the courts and insurance companies and strangers cannot even conceive of the concerns that more sensitive individuals might have regarding confidentiality. Some people live outside and some inside and bullies lack all sensitivity of this.  Psychopaths are defined by their lack of empathy and institutions often appear more psychopathic than human in comparison.  The corporation by definition though a 'legal person' lacks  any of the 'person hood' conceptualized by theologians and to a less degree psychiatrists. The 'legal person' is reptilian at best where as "person hood" in psychiatry engenders considerations of respect and appreciation and sensitivity at a level more mystical than base behavioralism.
When patients had family physicians for life and the family physicians files were confidential and the family physician and the psychiatrist were usually close associates, everything generally went smoothly.  Now a third of Canadians don't have family physicians, the family physician turn over is  high too. The 'walk in' clinic with even it's higher staff turn over and third party 'record keeping' and high support staff turn over with no necessity for training in 'confidentiality', no necessity for 'bonding', nor 'certification' and increasingly low paid 'phone girls' with the  lowest paid 'filing clerks', well frankly,   the medical "system" went to shit.  These changes aren't limitted to the medical system but run through society which is increasingly mobile and diverse. 
Patient's records no longer are by any true means, beyond appearances, truly confidential.  The key word here is 'appearances'  (Owen Barfield wrote a book, Saving the Appearances - it's been one of the most important and telling books I've read in my life.)

The Freedom of Information Act then came along, possibly to 'correct' the increasing divergence from what was once a sacrosanct 'principle' and now was a thing people only paid 'lip service' too. The Freedom of Information Act allowed any patient access to any medical files or reports with their names on them.
I have used the Freedom of Information act to access records pertaining to me and as with all who have used this was surprised  even horrified, by the mis information, false information and major areas of 'deletion' (for questionable reasons).  That said the 'gist' in my case was overall well meaning and mostly correct.
(I was reminded of the  Hitchhikers Guide to the Galaxy one line encyclopedia regarding earth, "Mostly Harmless".)

In contrast I've seen major errors in records in court documents and have had countless patients tell me about major errors in their 'files'.  At one point in my life I had some time in the evening and worked in a locked psychiatric facility so spent hours each evening reading files of patients who were incarcerated under the governor general act for heinous acts (a mother who killed all her children believing them fish, for instance).  The 'thread' ran true through years of hundreds of peoples involvement and reporting but the 'errors' were significant despite in many cases the brightest of the best and the best efforts.
 This is no surprise given perspective. A simple view of journalists mis reporting and gross errors on major networks is evidence of the carelessness in this 'media' and 'entertainment' industry.  Knowing in depth stories I've been involved with I am still amazed at how wholly wrong reporters can be and how much they misinform for some 'agenda' often not known to the naive citizen. Hence whole news agencies can be simply 'propaganda' outlets for a government, a political party, an individual or a general idea.  Similiar individuals reports on a patient in a psychiatric ward would often tell me more about the reporter than the actual patient. It was this reason that I began recording exactly what the patient said rather than 'describing'.
In another community case a woman had the same name as a known violent criminal and whenever she was dealing with beaurocracy this material, misfiled, caused everyone to mistreat her until through the Freedom of Information act she 'righted' a rather difficult wrong.  Dramatic examples are uncommon but 'to err is human' and reports and notes and files are full of minor errors. The question is whether these errors would change outcome or not and usually not.  In one of the psychiatric files I reviewed a man had killed a couple of people and over the years the number fluctated from one or three sometimes in the reports. It didn't matter, though the devil is in the detail, because he still wanted to kill all humans, and no medication or therapy had altered this.

Supreme Court Chief Justice Beverly McLaughlan is waging a one woman fight for 'transparency' in the courts.  A court reporter records what is said mostly but does not include the shouting and bullying by judges or the sideways glances and sneers and various other examples of body language that occur in the court.
Our elected officials are on camera in parliament.  We can watch them being little boys in questions and answer period or dozing.  It helps us remember our own humanity.
We've long had cameras in sports event. Real time 'play back' has been accepted  bythe 'referees' who balked at 'transparency' in the sports arena till someone woke up to the fact that the world is moving faster and we need 'real time' means of correcting errors.  When I reviewed the 'records' of the incarcerated the changes I actually did introduce could have been done years earlier if anyone had taken time then to note the 'errors' . 
In institutions 'reviews' are a gargantuan expense. All those I've done have been mostly pro bono but the difficulty with 'enquiries' is that given their 'agenda' , "terms of reference' and 'mandates' they often simply add a new level of error in the system.  Transparency is about catching the mistakes or areas of disagreement early. 
There are judges who really want us all to return to the good old days of  the 'back rooms'.  Given the 'deal' making now in the courts this is happening to a large extent given the costs of the old forms which cost so much mainly due to the unwillingness to embrace change and accept 'transparency'.
Freedom of information is costly.  It's costly to gather court documents and the 'cost' is where the penny stops.

"Only the rich can afford justice in Canada,"said my now dead friend,Lawyer Dugald Christie,  He was riding his bicycle to the Supreme Court of Canada to burn his robes once again to express his shame as a world renown barrister that the poor and now the middle class could not afford the costs of the courts in British Columbia.
It was equally true that only the truly rich can afford 'privacy'.  But even the paparazzi have made the lives of the rich and famous an open book . Then there is wiki leaks to compound matters, not to mention satellite imaging and fly by drones. 
Privacy was a thing taken for granted, like clean water years past, but today is a truly expensive commodity available to some and very limitted in some other circles. Those in the ghettos long ago said that their crimes were only known because they lived on the street and didn't have mansions on the hills to hide their perversions in.
(I was an expert witness in a court room named after and paid for by a world reknown pedophile whose philanthropy was equally well known)
However, one is taught, never question city hall.  I have personally found it wiser over the years to avoid confrontations wherever possible despite its tendency to find me.   This occurs because I try to defend truth and I defend my patients from abuse to the best of my ability.  My senior colleague laughs aloud when I complain because he says 'truth telling" is always attacked.  He points to his favourite example, Jesus.
The CMA Code of  Ethics states; 1. Consider first the well being of the patient. and 3. Provide for appropriate care for your patient ....including physical comfort and spiritual and psychosocial support.
I have been a  member of the Human Rights Association, the Canadian Civil Rights Associations, Psychiatrists Against the Political Abuse of Psychiatry, and  Physicians for Social Responsibility.
I don't believe I will ever be  forgiven by the authorities for finding famous BC Lawyer, Jack Cram, sane, when he was accused of being 'insane' for calling the BC court, a "Nazi Court'. The court's psychiatrist expert witness, found him "insane" which was at very least politically correct.
My colleague was jailed for her position against war while my other colleague paid dearly and was harassed to no end for his objection to the waste of young soldiers lives  'friendly fire' and 'accidents'.
The cycnical says "no good deed goes unpunished'.  I know personally the most heinous disgusting persons in positions of highest power yet I also know people I admire in those very same places. There's balance and homeostasis to always consider in this world where St. Paul, a great knower of human behaviour, said "we see as through a glass darkly". 

I am afraid of the courts, which is probably a healthy fear given the element of 'legal lottery''. There's a whole industry in the legal world of assessing judges prejudices, no different from what is done for batters in baseball.  It's the principal reason I say that a person needs a lawyer if they go to court because there's just too much 'back room' dealing, when it comes to 'picking a judge' or 'selecting' a jury.  It's all very much 'rigged' and 'arranged' and no longer the court of Solomon.  Given this complexity of the legal process and the increasing cost of lawyers, all manner of 'bullying' is possible for the rich relative to the poor.  However, when something, especially legal services are offered 'free' there is a great tendency for their abuse given the number of people with an axe to grind.
Lawyer Dugald Christie began the 'pro bono' legal services, getting me to accompany him to jails to provide pro bono psychiatric assessments, something I've done more often than I care to remember.  I think I'd be a millionaire today if I charged for all the pro bono services I provided people who couldn't pay.  Doctors have a long history of that. I'm not surprised the Law Society awarded Dugald Christie for his work with the poor. The lawyers I know personally and the judges I know personally know the value of men like Dugald Christie.

 I've experienced abuse of authority myself but have treated hundreds of patients who were physically and mentally abused by authorities, many who were actually physically tortured.  I served as the psychiatrist for the Residential School abuses treating dozens of Indians chiefs.
I have a serious respect for authority and great admiration for authority. I'm not one to romantacize mob rule and always liked the Beatles song "We don't want a revolution".   I've met 4 sitting prime ministers and dined with a number of judges including supreme court judges.  Those people I have known have to my mind made me confident that Canada is ruled by the finest of people and our institutions are safe and secure in the hands of the very best. There are naturally quirks and blemishes but overall, really, this is a great country. Vancouver is a great city.  British Columbia is a great province. Canada is my home and I am very proud of it.  But concerned.

Because of freedom of information and the clear message it has made regarding relationships between doctors and patients specifically, I have shared all my reporting with patients. It is my 'policy' to have patients read whatever I am writing about them and reporting about them.
This has resulted in my life being threatened in the office on several occasions. I reported that a man should not be allowed to have a gun and he became very belligerent.  I reported  that I believed a man was a pedophile and he told me he'd remove me.  It's clearly the down side of 'freedom of information'. I have had dozens of complaints to the College of Physicians and Surgeons because I have 'diagnosed' patients as having drug and alcohol addiction' and this has affected their employment or insurance.
The Canadian Medical Association Code of Ethics states 4. Consider the well-being of society in matters affecting health.  In psychiatry and addiction medicine this is especially relevant because fundamentally we are routinely asked if a patient is a risk to themselves or other or are 'competent' for work.  The CMA Code of Ethics demands nothing less of doctors, "Practice the art and science of medicine competently, with integrity and without impairment." 
Commonly patients see psychiatrists on referral by family physicians because of work related issues and the question of 'competence' and 'impairment' are therefore central to the examination.
I have been asked by patients if what they say is confidential and I have at length explained that if they sign a 'release of information' for their insurance or go to  court and their records are subpoenead then whatever I record is going to be released.  I have repeatedly told patients that I can not 'lie' for them so find it ironic that I am called a 'liar' directly and indirectly on occasion because 'lying' is extremely lucrative in our society and I am not nearly rich enough to be a liar of any significance.

Patients ask me to lie knowingly or unknowingly routinely. I must assume that patients ask others the same thing.  It's never that overt.  But that's what it comes down to.  Similarly patients ask me for narcotics and increasingly to sign papers saying they can't work when it's not really apparent to me that they can't or can.
I once diagnosed patients as 'malingerers' but have been advised that this is no longer 'politically correct'.  I have had to pay enough thousands of dollars for diagnosing people psychotic and a danger to society only to have that very same society's overpaid representatives punish me for my conscientiousness.  When I learned that police for a time were avoiding responding to emergencies of various kinds, especially those involving violence, I certainly couldn't blame them. 
I was the only Canadian physician to work in northern manitoba reserves after a 2 year attempt to recruit because of the dangers. My colleagues are admittedly smarter than I am.  I am a spiritual fool.  I got tb, beat up, nearly drowned, was chased by polar bears, chased by a mob and was in a plane crash but looking back it was good experience if anything.   What's TB and PTSD compared to knowing you've done good.  It's certainly hard to continue to do good however with the pompous and mighty arrogantly condemning everything that's not overtly lucrative and safe. Only that which is 'valued' in a materialist way is 'protected' institutionally.
 I am very careful in my diagnosis, according to DSMIV and now DSMV and have always been considered one of the very best of 'diagnosticians' in physical medicine and especially in psychiatry.  It takes a lot of training, experience, and careful consideration to make 'correct diagnosis'   I've  found the courts at times no longer as respectful of the significance of diagnosis or why doctors consider this so important, yet they themselves make a major distinction between 'murder' and 'manslaughter' and expect society to respect their 'language'.   The courts have also never been accused of a lacking in hypocricy. Jesus did poorly in the courts of his day and it was his outrageous idea to say, "take the timber out of your own eye before you try to take the sliver out of your neighbours eye". 
Perhaps in this regard we have ourselves to blame in psychiatry because especially in the area of 'mood disorders' there are diagnosis with no inherrent validity lacking specifity and having no end of 'sensitivity'.  This has been an ongoing serious complaint especially internationally about diagnostic  'cookbook' approach much maligned by leading specialists and even discouraged directly by the APA and authors on the  DSM committees. 
Mostly I try to avoid conflict but increasingly the 'complaints process' of the college is such that any doctor who doesn't 'sign' or 'agree' with the patient is faced with a complaint which can cost the doctor on average $5000 to $10,000 even when they are cleared. I am routinely cleared of wrong doing, but never unscathed,  but the cost of doing 'the right thing' and being 'moral' and 'ethical' is millions of dollars loss of income. I don't' recommend it.  The richest colleagues I know in psychiatry are the greatest rogues I've personally known.  They're a minority and I know in my heart of hearts I don't want to be like them.  No amount of money can buy back a soul or cleanse one of their stink no matter how entertaining they are.

Further, the most ignorant and inexperienced, those in positions of being 'critics' , always imply or suggest that 'you could do better' and if 'you spoke softer' or 'phrased your questions' or 'chose the time' .then the 'triggering event' would not have occurred.  This simply is not true, and at worst, downright ignorant, pretentious and arrogant.  Everyone who is in the front lines knows that 'perfection' is impossible and only those 'critics' who avoid reality have such space station notions of life on earth.
Do anything to interfere with a persons income, freedom, sex or ambition and you will create a resentment. If 'kill the messenger is 'lucrative'  then this will occurr.  If there is no protection for the individuals who are obligated to tell the truth then people will eventually lie or walk away.
Today mentally ill and addicted patients are being again marginalized and ostracized because no one can afford their complaints. 
Cherry picking is the process where doctors avoid seeing sick patients.  Increasingly doctors are not only cherry picking their patients but they're cherry picking their practices finding any niche where they have the least contact with the front line.  Administrative medicine and  radiology have no shortage of applicants. 
Patients are 'black listed' by diagnosis such as 'Borderline Personality Disorder' (the kiss of death for a female patient) or "Antisocial Persnoality Disorder " (the kiss of death for a male patient).  Further the more diagnosis a patient has the less willing is a doctor to see them.  Commonly, some of the patients I see, have been 'rejected' by 30 to 50 psychiatrists.  This doesn't look good for me that I'm not the 'first choice' but it more a  reflection of my colleagues who try to spread the 'joy' knowing my willingness to accept multiple problem patients despite the high cost.  "I knew you'd see this person but I didn't want to burden you with yet another patient like this so tried to see if anyone else would take them on and no one would."   

The patient who had sex with 500 children is likely still very unhappy with me for reporting him to the authorities and assuring he was deported to the US where he was wanted for crimes against children in 4 states.  The stoned pilot who was required to get treatment and urine testing still tries to find ways to hurt me. There is a man who beat prostitutes leaving a couple near dead, in psychotic rages, and I don't believe that he has ever forgiven me for making the diagnosis of him that required his treatment.  I have on several occasions been threatened to remove from my reports information that a patient doesn't want but I have felt is necessary to the integrity of the report and the basis of the diagnosis.  I have never lied for a patient knowingly.  I suspect if I was the psychiatrist for Mayor Ford he would very surely disapprove of my diagnosis and likely hurt me more, as the richer and more powerful who have objected to certain diagnosis, have  more power to harm.
The matter of diagnosis simply was never such a serious matter for me in general practice except on those occasions when I diagnosed a person partially blind and they lost their driver's license. I remember too that when I worked one summer as the doctor in an STD street clinic people were often angry with their diagnosis and sometimes insisted that their diagnosis not be 'written' down, for fear their husband might find out.  This was an issue to in early years with the diagnosis of HIV.  Patients were so abused and punished for this illness then and so many were afraid to see doctors.  A major public health initiative had to take place before people felt safe about seeing doctors. This is true increasingly with addiction medicine and psychiatry in general. 
Addiction Psychiatry specifically is not a place that people are likely to go saying, "I sure hope this specialist finds out whats wrong with me?" as is commonly the case with other areas of medical specialty.
I have however spent years defending patients who were mis diagnosed especially when there  has been a conflict of interest and extreme predjudices or biases and made major errors for profit or through negligence.  
When a patient is in dispute with the courts, the patients lawyers and the lawyers for the other side subpoena the file and all information. A doctor must release their full and complete records or go to jail.
My psychiatrist colleague fought the courts in an attempt to conceal her 'notes' from the courts and lost. I believe she went to jail for a night or eventually simply caved before she spent a night in jail. It's a celebrated case. Indeed even ministers and their congregation communications are no longer sacrosanct and last I learned priests could not conceal what they heard in confession if subpoenaed.
The key in all this is 'what is recorded'.  So increasingly people don't record anything.  By contrast look at the notes of Louis Pasteur, Freud, Carl Jung, and Einstein.  Science is about 'records'.
The consequence of this 'approach' to the present problem is that it contravenes CMA Code of Ethics "Refuse to participate in or support practices that violate basic human rights.'  It's a basic human right for patients to get good medical and psychiatric care and yet if doctors can't 'record' what transpires for fear of misuse of the files,it's a problem. This is indeed is the tendency of 'medicopoliticolegalese' and political correctness yak yak.  The notes become 'spam' .
So when I share transparently, my reports with patients, they commonly ask is it necessary that I include some detail or other.  I then agree if its not relevant.  I do not let their employers insurance company know in the report that they had sex with a pig on friday night drunk if their job is not pig rental for a brewery outfit.  These are not far from true stories.  I've seen more cases of beastiality and various perversion and seen more unexplainable behaviour than I care to recall.  Maybe the SPCA has an invested interest but others interest would be prurilent.
Commonly people do not want their gp to know information that they have shared with me and I will not report information of a decidedly personal and private nature with a walk in clinic physician the patient may have seen once whose secretary chews bubble gum and is paid minimum wage.
I once had such a secretary for a while and she stole information and materials from my office and I learned that the police do not respect or prosecute theft of files from Psychiatrists office. So much for even physicians ensuring confidentiality of files since there is no consequence for the abuses. If one is concerned about private practice offices ,the institutions are a nightmare in comparison.
Indeed, the police  told me that they believe this sort of thing happens often but that I was indeed the first person to report it.  The cost of that exercise  was thousands of dollars.
Further I learned from dozens of colleagues that when they have fired 'help' they have been threatened with 'sexual harassment' allegations and have been extorted thousands of dollars.
I learned the hard way on that occasion that despite my best efforts with the highest level of security available, computer geeks up the ying yang, and locked files with chain of custody keys etc, a temporary help girl who turned out to be a crack addicted psychopath on the side, could breach all security and steal files without any consequences.

Most of us on the front lines are doing our best with very little resources and only the arm chair quarterbacks on Monday morning are right.  But then they don't have to be accountable for their actions as we on the front lines do. And everyone knows armchair quarterbacks are always right.

This is true of social media "confidentiality" too,  where increasingly communications are being openly 'interpreted' and used in all manner of ways other than that which was deemed their original purpose.  If one had been paying attention they would have learned our ally, the United States of America, under President Obama, has accessed all our electronic communication, that's every text message and email. This is not paranoia. It's just a fact regarding the lack of 'confidentiality' available to Canadians today and the 'appearances' which are continued till someone learns to deal with this game changing dramatic reversal of our lives.

Our insurance body, the Canadian Medical Protective Association, advisees us to write 15 minutes of notes for every 15 minutes of examination which has literally halved the available doctors in the country and doubled the cost of health care to every citizen. This followed a judge say, "if it isn't written down,it didn't happen".  "Loose lips sink ships".
I keep copious notes and records, typing as I do at the speed that people talk.
I do not believe there is any 'confidentiality' in the 'system' since I learned that the most confidential material the government collects is tax reports and with our tax information the following has happened
- over a hundred government departments have access to them
- in addition to the US,  there have been a half dozen computer attacks on the canadian government files, thought to originate primarily in a chinese military facility and all, not just some, but all information on Canadians has been accessed for foreign agents.

But if you had sex with father's mistress and told me, I recorded it.  That information and any other information that anyone has on you is available through the freedom of information act, however since this is the law, I've always shared what I write with patients and have been 'transparent' with the information I gather. When I write letters to doctors I will remove information which is not necessarily pertinent to their 'care' as I understand that to be.
I do this not to 'deceive' or through 'ill intent' but because I have a 'therapeutic relationship' with a patient and to maintain that we must have mutual respect.

This was a major concern when I was working with HIV patients and we were being asked to disclose information about patients that would get them 'fired' not because of a public health risk but because of the prejudice in their accounting industry against homosexuals or diseased persons.

Pscychologists, nurses, counsellors and all others care givers in Canada are under similiar strict requirements regarding shareing information with the courts at risk of jail themselves but in contrast I know that I am usually the most rigorous in explaining my limitations to patients.  Nobody wants to face reality that we are all really very naked today.  Even the emperor has new clothes.

Even lawyers are highly restricted in the lawyer-client 'priviledge' according to my Canadian lawyer friends. So while American TV has lawyers and police and Dr. House are doing all manner of silly business this is not true in Canada.

People say and write nonsense all the time in British Columbia.  We only consider them truly insane if they believe and act on the nonsense they sometimes spout.

Unfortunately in Canada, a young country, by any means, there is alot of "false witness', and people forget that the Ten Commandments given to Moses put 'bearing false witness' as up there with murder.

I take the matter of truth seriously and am not in the habit of 'bearing false witness'.  

The best news about confidentiality though is really most people don't care. They are in fact too busy minding their own business to care about yours. 

The great thing about Canada is we really do care, individually and collectively, and despite the lapses, we muddle along and with a combination of checks and balances, freedom of information acts, Honorable Beverly McLaughlan, the Colleges of Physicians and Surgeons, Dugald Christie, the Law Society, the Canadian Medical Association and psychiatrists things work out well overall.  The sun rises in the morning even though it seems a bit sooty and smoggy.  Truth prevails.  Good wins out in the long run. We are, if you are at all a student of history, doing way better as peasants than the vast majority of our forebears.
When I question my home I think of Cambodia where I just was and know that only a few years ago 3 million people, a quarter of the nation, were murdered by Aetheist Communist Pol Pot in 4 years.  This is simply not going to happen with Harper, Mulcair and Troudeau in parliament. Locally our courts and institutions aren't perfect but they are way better than the next best thing. 
That said, I'm concerned.

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