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Academy News: November 2005 Patient confidentiality: are we doing enough? It is a busy inpatient consult month with several new consults per day. A new allergy fellow, pockets overflowing with consult forms, goes to see a consult for sulfa allergy. It is for a patient with AIDS who was admitted with pulmonary symptoms highly suspicious for pneumocystis carinii pneumonia (PCP). The fellow knocks on the door and finds the patient involved in a lively conversation with two guests. Three sets of eyes turn as the doctor introduces himself and states, “Hello, I am here at the request of your other doctors to find out a little more about your sulfa allergy, would that be alright?” The patient nods as he states, “yes.” After a couple of minutes, the two guests in the room get up to say that they need to be somewhere else and they should also let the doctor finish the interview. The patient, however, convinces the guests to stay. At the end of the interview, the fellow explains that sulfa dose challenge is indicated, and explains the risks and benefits of undergoing the procedure. In the process of explaining the risks and benefits, “PCP” is mentioned since sulfa drugs are superior to the alternatives, and therefore, the benefits outweigh the risks of possible adverse reaction to the dose challenge. There was no mention of HIV or AIDS. The guests leave, and the fellow performs the physical examination. Several hours later, the fellow gets a page from the nursing supervisor stating that the patient has filed a complaint, and his privacy was violated. One of the patient’s friends, present during the interview, is a counselor for patients with HIV/AIDS and understands the implications of “PCP.” Confidentiality is central to the doctor-patient relationship. Further, protecting patient privacy is part of the Hippocratic Oath and one of a physician’s duties. Recently, it has been applied more broadly to hold institutions accountable to help preserve an individual’s medical information. One cannot avoid going to the hospital or medical clinic without being presented with several documents to acknowledge that the institution and the persons within it are in good compliance with preserving patient confidentiality. Documentation is a necessary part of life, but have we come to a point where we are practicing more lip service than real service? The vignette illustrates some of the more subtle difficulties of protecting patient confidentiality. Despite system-wide effort and documentation of compliance, patient confidentiality can still be easily breached. In an ideal world, the physician and the patient should be equally responsible. Yes, the patient could have asked the guests to leave, or could have asked the doctor to come back at another time. It is not clear in this scenario why the patient insisted that the guests remain in the room. Ultimately, it is the physician’s duty to protect the patient’s confidential medical information and therefore, the physician should ensure that the setting in which medical information is exchanged is appropriate. Implicit consent to discuss health information in the presence of a third party should not be assumed in cases where the patient does not ask the other party to leave the room when the doctor enters. There could be instances where the patient feels powerless to ask the other party to leave for fear of suspicion. This barrier to protection could be present between spouses, or a child and his parents. Maybe the best policy would be for the physician to ask the third party to leave. He or she would only let them stay if the patient explicitly requests their presence, even at the risk of alienating the patient’s family members or close friends. However, some difficulties in protecting confidentiality exist due to lack of an appropriate physical setting, such as the presence of “semi-private” rooms in hospitals, where patients only have a thin curtain separating them. There was an instance where a patient wanted to move because he found out that his roommate had been diagnosed with Hepatitis C and HIV. The larger issue was that this was viewed as a customer service problem for the first patient, versus a breach of the other patient’s confidentiality. Breaches in confidentiality can occur easily in today’s medical world, where a patient often has multiple physicians and caregivers. As information technology becomes more sophisticated, physicians and hospitals will continue to face new challenges, such as ensuring that e-mail dissemination of patient information among staff and physicians is adequately protected. Providing a private setting to discuss medical information and addressing appropriateness of third-party presence are small steps that we ought to take to strive to protect patient confidentiality. The Ethics Committee provides these discussions as a way to open a dialogue on the various ethical issues that confront our specialty on a daily basis. These issues are often quite complex and do not have simple “right” or “wrong” solutions. The articles are meant as a way to highlight the various issues that are involved in these ethical dilemmas, they should not be viewed as the Ethics Committee or the Academy’s particular stance on an issue.
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