Robert, a 27-year-old married nurse from your hospital, is referred to your emergency department for an urgent evaluation by his supervisor. In the past 2 weeks, he has been noted to be increasingly distressed while at work, with occasional tearfulness, distractibility, and irritability.
During the initial assessment, Robert reveals that there is a specific reason that he has been so preoccupied. He indicates that 2 weeks ago he was jailed for operating a vehicle while intoxicated and that he feels ashamed. He is afraid that his coworkers have read about it in the newspaper, although no one on his floor has indicated that this is the case. This is his first legal infraction of any kind and he describes it as humiliating.
On further questioning, Robert indicates that he uses alcohol regularly. While it has not overtly affected his work as far as he can tell, it has caused significant marital strife. He reports that his pattern is to stop by the bar on the way home from work to "relax and let go of the hospital stuff that I worry about." He typically drinks three beers and then drives home, where he continues to drink beer throughout the evening. He notes that his wife and kids complain that he is emotionally absent and even irritable with them, but he says that his family simply doesn't understand the stress of the workplace and his need to "forget about it for a few hours." He and his wife have started arguing lately about his alcohol use, especially since the driving charge. He takes special exception to her stating that he is an "alcoholic."
As you take the history, Robert begins to be more guarded in his responses and more restricted in his affect. Suddenly, he blurts out, "I don't think I'm an alcoholic, but I don't want you to put anything in my record about any of this stuff! And I want you to tell my supervisor that there are some personal problems going on at home and that I'll be fine in a few days."
Question 26.2.1 Which of the following statements is TRUE about your obligation with regard to documentation in the chart?
A) You are obligated to document the visit as it occurred so far as the medical facts are concerned, including the concern about alcohol abuse.
B) You can enter incorrect information into the chart in order to protect the patient.
C) You are under no obligation to document anything said and can withhold information from the chart at the patient's request.
D) Hospital administration or legal counsel should be involved if information is going to be purposefully left out of the chart.
E) You can lie in the medical record … we're pretty sure perjury, liable, and slander don't apply to doctors.
Answer 26.2.1 The correct answer is "A." The ethical principles of beneficence, nonmaleficence, and justice drive the decision here. A patient may legitimately ask for nonactive medical problems (e.g., distant history of sexual abuse) to be withheld from current documentation of an active problem (e.g., allergic rhinitis—by the way, kudos on your detailed history-taking). However, a patient cannot legitimately ask to have information withheld from the record if that information is pertinent to an ongoing condition currently being evaluated and treated. In this case, Robert is receiving care simply by virtue of being seen in the emergency department and disclosing the chief complaint and its associated variables. It is important for you to be forthcoming in explaining why the information may not be withheld from the medical record and also in reassuring him that nonrelevant medical information will be omitted from the record if he feels that this is necessary. For example, the specifics of the argument with a wife need not be detailed beyond the comment that there is nonviolent marital conflict over the patient's alcohol use—important because it supports an alcohol abuse disorder. Furthermore, many institutions have specific policies on managing sensitive medical information and there may be a formal mechanism for increasing the security of the patient's medical record.
Question 26.2.2 Why is protection of confidentiality important in medical practice?
A) It shows respect for patient autonomy.
B) It helps prevent stigmatization and discrimination against patients based on private medical issues.
C) It helps solidify trust within the physician–patient relationship.
D) It helps establish a boundary between the physician–patient relationship and the rest of the medical system.
Answer 26.2.2 The correct answer is "E." The physician–patient relationship is a long-honored tradition in medicine that is increasingly fragile in a medical system with numerous competing obligations. Nevertheless, it is prudent to remember the aspect of the Hippocratic Oath, which states, "What I may see or hear in the course of the treatment … which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about." This is not only important to the tradition of medicine itself but also to the physician–patient relationship. There is no doubt that loss of confidentiality may cause harm to the patient when others are in possession of confidential medical information. Such harms may be as overt as denying medical coverage for certain genetic conditions or as subtle as devaluing a person seen waiting to see the psychiatrist.
Question 26.2.3 Which of the following are legally protected exceptions to the rule of maintaining patient confidentiality?
A) Reporting tuberculosis to public officials without patient consent.
B) Warning a third party at risk of imminent and serious bodily harm from the patient without patient consent.
C) Reporting a patient's alcohol abuse to a work supervisor without the patient's consent.
Answer 26.2.3 The correct answer is "D." Under current national and state laws, physicians are mandatory reporters of some infectious diseases and of intent to harm another. In most other cases, provision of medical information without the patient's written consent is not legally protected, although there may be cases in which it is felt to be morally justifiable. Physicians need to weigh violations of patient confidentiality very carefully, even when legally sanctioned. Ethicists typically agree that if a physician is going to compromise a patient's confidentiality for an overwhelming moral obligation that, in respect for patient autonomy, the patient needs to be notified. In many situations in which a physician hopes to communicate confidential information to a third party even when the patient is unwilling, a process of education and negotiation with the patient occurs such that respect for autonomy is acknowledged while simultaneously making the patient aware of competing moral obligations.
Having a faxed, e-mailed, or mailed report containing a patient's confidential medical information misdirected to an unintended recipient is not legally protected. Be cautious about transmission of patient information.
Question 26.2.4 Which of the following interferes with protecting patient confidentiality in the medical structure?
A) Involvement of managed care organizations in patient care and medical payments.
B) Electronic records and transmissions.
C) Group practices and/or teaching hospitals with multiple care providers.
Answer 26.2.4 The correct answer is "E." While individual physicians and patients continue to prize the tradition of respect for confidentiality, the multiple players in health care make it nearly impossible to restrict all information to the dyad of physician and patient. Insurance companies will not provide payment without, at least, information about the diagnosis, and notably, insurance companies are not legally bound by the same codes of conduct that apply to physicians regarding patient privacy. Electronic records and transmissions by e-mail, cellular phones, faxes, and other means are much more easily accessed by the curious or unintended recipients who have no reason to have confidential information. Open waiting rooms and multiple providers of care mean that larger and larger numbers of the community are aware that a patient is being seen in certain clinics for certain purposes. While patient records are not often considered a confidentiality issue, the reality is that once information is in written form, it is more difficult to control who might, either now or in the future, have access to the details of the report. For this reason, some physicians try to err on documenting only that which is considered absolutely necessary to patient care, although the distinction between the "absolutely necessary" and unnecessary can be a difficult line to draw in the sand, especially without the ability to appreciate how multiple variables may play out in the patient's future medical care.
Back to the patient at hand … Robert is asking you to be deliberately deceptive with the supervisor. You disagree with this.
Question 26.2.5 Which of the following is FALSE?
A) Trust in the physician–patient relationship depends on allowing the patient to make such a directive about communication with outside persons.
B) A physician who establishes a precedent for deception may be expected to practice deception in a future situation in which the harms greatly outweigh the benefits.
C) A physician who deceives may undermine general trust in the profession.
Answer 26.2.5 The correct answer is "A." Another way of phrasing the question is, "What drives a physician to be honest even when what the patient really wants is not honesty?" Will the patient trust you more if you are deceptive for him? Will this help him (aside from allowing him to keep his job)?
The physician–patient relationship is generally not considered an adequate reason to lie to a third party about the nature of a patient's illness and treatment. There has been concern that a physician who deceives a third party, even in the immediate interest of the patient's confidentiality or other concerns, establishes himself or herself as a physician who may not be trustworthy in other matters. A patient may not consider this at the time a deception is requested. These kinds of ripple effects from the decisions of an individual physician can affect the profession in general, ultimately producing fears that physicians will take the self-serving path rather than the higher moral ground.
You tell Robert that he has alcohol dependence and then provide education about the diagnosis and treatment options. You recommend outpatient treatment in Alcoholics Anonymous (AA) and a chemical dependency program. Robert agrees, more for the sake of his family stability rather than because of any true insight into the severity of his problem. You then arrange for follow-up with one of your partners (you've been selected as a contestant on the next Survivor and get to escape to a tropical island).
At the next appointment, Robert meets his new physician, Dr. Pincus. At this appointment, Robert indicates that he did attend two AA meetings but was very uncomfortable with the aspect of the 12-step program that requires acknowledging a "higher power." Robert indicates that he is an atheist and secular humanist, believing that the locus of self-control comes from within the individual human spirit. He has refused to continue in AA due to his rejection of its theistic foundation. He has had no further legal problems and reports that work is still going fine, with diminished irritability once he resolved in his mind that his coworkers were unaware of his previous driving violation. However, he continues to drink six to nine alcoholic beverages per night and admits that he occasionally needs a shot of whisky in the morning to "make sure I don't lose it with all the work stress" (this is where his self-control theory really comes together). He also works a night shift about once per week and does use approximately the same amount of alcohol before beginning the night shift, although he denies being intoxicated while on the job on these nights ("six beers just get me started"). He doesn't think this is a problem because "things are quiet at night and everyone just helps each other keep the patients comfortable." He reports that his family is satisfied with the decrease in consumption and that he considers the matter of alcohol abuse resolved.
Dr. Pincus has had her own problems with alcohol in the past. She has had a rocky course over the past many years but found AA to be very helpful. She has become very active in her Jewish synagogue and community, where she receives support and is accountable to her friends. Her own alcohol history has been marked by difficulty with alcohol bingeing, such that when she starts to drink, she drinks to intoxication. Only with aggressive honesty at a professional-group AA, as well as a substance abuse protocol through the state board of medical examiners, does she feel that she's been able to remain completely abstinent for the last 4 years.
Dr. Pincus is considering revealing to Robert some of her own struggles as a health-care professional with a substance abuse disorder. She believes that this will help him reevaluate the role of AA in sobriety and the importance of very tight control of alcohol consumption to prevent relapsing illness.
Question 26.2.6 Self-disclosure is best described as involving the ethical issues of:
A) Deception and nondisclosure.
B) Privacy and boundaries.
Answer 26.2.6 The correct answer is "B." There are explicit and implicit boundaries that exist between a physician's private experiences and the physician–patient relationship. One of these boundaries has to do with preventing physician needs and private matters from encroaching into the visit in a way that is not therapeutic to the patient and does not respect the physician's boundaries. While it would appear that Dr. Pincus has therapeutic reasons—for Robert, not for herself—for crossing the boundary of self-disclosure, both physician motivation for self-disclosure and the immediate and potential effects of the self-disclosure need to be weighed very seriously before private matters are revealed. If there is even a potential of harm, crossing the boundary in this way should be considered a violation of professional norms.
Question 26.2.7 How could Dr. Pincus appropriately respond to Robert's refusal to participate in AA on the basis of his religious impulse?
A) "AA is still shown the best intervention for preventing relapsing alcohol use. I hope you can go and get something out of it without acknowledging your acceptance of the 'higher power' explicitly."
B) "AA has important group support from others who understand how difficult it is to stop using alcohol. It is not meant to be religious, but rather a community of care."
C) "I have found both AA and a theistic world-view to be very helpful in understanding my own powerlessness to control some of my behaviors. Would it be helpful to you to hear more about this?"
D) "I understand how the religious aspect of AA is inconsistent with your own philosophy. Would you be willing to investigate non-religious group meetings for alcohol abusers?"
Answer 26.2.7 The correct answer is "D." AA is an example of a prescribed treatment that involves an active theological component. AA's first step involves acknowledgment of a higher power, traditionally invoking a specific monotheistic conception of the divine as a necessity to surrendering the illusion of control. In the interest of respecting a patient's religious rights in a diverse community, and of optimizing treatment options, it would be disrespectful and ineffective to have the patient participate in AA, while ignoring the first step of the program and the foundational philosophy of AA. While there are fewer studies about the efficacy of nonreligious alcohol treatment groups, it is appropriate to respect Robert's beliefs by investigating nonreligious alternatives. As to option "A," the Cochrane database concludes, "No experimental studies unequivocally demonstrated the effectiveness of AA."
Whether or not self-disclosure of one's own religious beliefs is appropriate is an important question. As mentioned in the discussion in the question above, it is very important for the physician to measure the intent of the disclosure. Also, physicians need to be exquisitely sensitive to the power differential that exists between a physician and a patient such that strong individual viewpoints might become threatening or coercive in the physician–patient relationship. In certain religious traditions, sharing one's faith is an important step, demonstrating courage and integrity; nevertheless, physicians should be strongly cautioned to pay heed to the virtue of practical wisdom and the unique circumstances of the medical relationship that makes proselytizing most often inappropriate. A better strategy, if a physician feels that a patient might be seeking additional spiritual or philosophical direction, is to ask open-ended questions and then make an appropriate referral to pastoral care or a spiritual counselor who will be sensitive to the issues the patient has raised as relevant.
Question 26.2.8 Which of the following is true about intervening with an "impaired colleague," like Robert?
A) Impairment should be reported only to a state licensing board if the colleague's patients are placed at known and documentable risk.
B) Because alcohol abuse is a confidential matter, it is inappropriate for a treating physician to report a colleague's impairment to a licensing board.
C) Removing a colleague from direct patient care and increasing supervision during patient care are reasonable first-step interventions for a colleague who is actively engaged in substance treatment (e.g., a report has already been made).
D) It is preferable to contact a state licensing board directly as opposed to discussing the matter with the patient or institutional administration. This protects both the reporter and the colleague from unnecessary negative repercussions.
Answer 26.2.8 The correct answer is "C." Legal statutes on reporting impaired colleagues vary from state to state, with some state laws making physicians mandatory reporters of impaired physician colleagues, while others simply recommend reporting. Furthermore, state laws are even less prescriptive with regard to non-physician health professionals with impairments. Any impairment should be treated seriously, preferably with support from the institution's administration. It is imperative to protect patients from harm. While reporting the impaired colleague may result in anger and disappointment from the colleague or even supervisors who are reluctant to tackle such a difficult question, physicians should consider the needs of vulnerable patients and the patients' rights to adequate care.
Confidentiality adds an additional ethical dimension when an impaired colleague reveals his or her impairment to his treating physician. In an effort to respect patient autonomy, physicians will often urge impaired colleagues to report themselves as well as voluntarily engage in treatment protocols. Many states have less-restrictive policies for treatment and monitoring for impaired colleagues who self-report. If a physician intends to report her patient's impairment without the consent of the patient, the physician is obligated to be truthful with the colleague about her intentions and rationale for reporting.
Question 26.2.9 A colleague may be impaired in her practice by all of the following EXCEPT:
E) Barely passing her board examination.
Answer 26.2.9 The correct answer is "E." Well, she "barely passed," and that's what she needs to achieve to be certified. All of the others, whether acute or chronic, may impair a health professional's ability to practice, but none of these automatically imply global impairment in medical practice. Each has its own implications for a colleague's medical practice. Special attention should be given to the colleague's actual and possible consequences in practice, given her specific job requirements and compensatory skills/supports, while assessing the presence and degree of impairment. One might say that dementia is OK in physicians working for insurance companies (or at least it seems so!).
Objectives: Did you learn to…
Identify what items are required for inclusion in the medical record?
Recognize the importance of patient confidentiality and understand when confidentiality might be broken in order to fulfill other ethical obligations?
Recognize obstacles to protecting patient confidentiality?
Describe the importance of individual and societal trust in individual physicians and the medical profession as a whole?
Describe the ethical principles involved in self-disclosure?
Identify an impaired colleague and determine how to best intervene?