One of the Lindsay Clancy Trial’s Most Instructive Moments for Physicians

The Lindsay Clancy murder trial, which was just declared a mistrial, has forced the public to confront extraordinarily difficult questions about postpartum mental illness, criminal responsibility, and psychiatric care. But one of its most instructive moments for physicians was a brief courtroom drama, overshadowed by the debate over culpability.

During cross-examination, defense attorney Kevin Reddington questioned Clancy’s former psychiatrist, Jennifer Tufts, MD, about a note describing Clancy as “not hyper, pressured speech.”

Pressured speech — rapid, difficult-to-interrupt speech — is often associated with mania. Tufts testified that during her treatment of Clancy, she had not observed mania or psychosis. But Reddington read the note differently. According to his interpretation, “not hyper” was one observation; “pressured speech” was another.

Tufts disagreed. She said “not” was intended to apply to both descriptions: Clancy was not hyper and did not exhibit pressured speech. Then came the sentence physicians should remember long after the Clancy trial ended: “I don’t care what it says. I know what I meant,” Tufts remarked.

I, too, understand the clinical meaning of Tufts’s notation. As a psychiatrist, I would likely have interpreted it the same way she did. Medical records are filled with compressed phrasing. We write “denies chest pain, dyspnea, palpitations” without repeating “denies” three times. Within a profession — or even a specialty — the meaning may seem obvious.

But a courtroom is not a psychiatric clinic. Reddington’s job was not to read Tufts’ note through the lens of another psychiatrist’s collegial assumptions. His job was to test the reliability of her testimony and expose ambiguities favorable to his client.

The lesson is not that doctors need to become grammarians or that every misplaced comma constitutes substandard care. Nor can anything about Tufts’ overall treatment of Clancy be reasonably inferred from this isolated phrase. The lesson is more fundamental: the author of a medical record does not retain ownership of its meaning once someone else must rely on it.

“I know what I meant” works only when the writer stands beside everyone who will ever read the sentence. As we know, medicine does not work that way. A covering physician may read the note at 2 a.m. A nurse may use it during a handoff. Another psychiatrist may encounter it months later. A patient may read it through an electronic portal. Years later, a lawyer, expert witness, judge, or jury may encounter the same words. None can access the clinician’s intention; they have only the documented words. The courtroom does not create the communication problem; it exposes it.

For generations, clinicians have been warned: “Document as though your note will someday be read by a lawyer.” I have never particularly liked that advice. Fear of litigation should not drive clinical documentation. The primary audience for a medical record is the people caring for the patient.

Clinicians often have only minutes to evaluate a patient, review records, formulate a differential diagnosis, make decisions, discuss treatment, enter orders, answer questions, and document everything. Lawyers may later spend enormous amounts of time analyzing a single sentence from that encounter. Expecting every clinical note to anticipate every future litigation question is unrealistic.

So, forget the courtroom for a moment. Instead, imagine another psychiatrist must determine whether the patient exhibited a possible symptom of mania: “Not hyper, pressured speech.” Why leave room for interpretation? “Not hyperactive; no pressured speech” requires only a few additional keystrokes. The objective is not defensive documentation. It is unambiguous clinical communication.

This communication failure persisted in the courtroom. When Reddington challenged Tufts’ interpretation, Tufts’ response of, “I don’t care what it says. I know what I meant” risked sounding dismissive. Testimony is important. Even a perfectly competent physician can be poorly prepared for cross-examination. The greater problem may not have been the shorthand itself but Tuft’s preparation for the legal environment.

Physicians are trained to defend diagnoses. We are rarely trained to defend commas. Perhaps we should be trained to do both — not because punctuation is medicine, but because credibility can hinge on how calmly we explain the limitations of documentation from months or years earlier.

The Clancy exchange offers a deceptively simple lesson. Medical documentation need not be literary. It need not anticipate every hostile interpretation by a lawyer. And an awkward sentence does not establish negligent care. But words matter. Because someday the person who wrote them may not be there to explain: “I know what I meant.” And even when that person is there, as this courtroom demonstrated, what we meant and what we wrote are not always the same.