My patient's confidentiality became tricky business

As physicians, we know the importance of patient confidentiality—but sometimes it's a tricky business.

A teenage female patient came into my office with her mother to discuss birth control. As always when speaking with pediatric or adolescent patients, I politely asked the mother to leave the room so I could chat with her daughter in private.

After her mother hesitantly obliged, my patient told me in confidence she was sexually active and wanted to go on birth control—but didn’t want her mother to know.

Since my patient requested this be kept confidential, I decided to respect her wishes. Although my patient was a minor, she was protected under HIPAA in my state on such topics as pregnancy and sexual activity, so I was not required to disclose this to the mother.^[]

When her mom pulled me aside to ask if her daughter was sexually active, I told her that I couldn’t divulge this confidential information. If her daughter wished to talk about this, then it was her decision—not mine—to make.

I wasn’t angry or disappointed when the mother berated me in my office hallway. I was proud that I chose to respect my patient's wishes.

Confidentiality and trust

Patient-physician confidentiality is a fundamental principle of medical ethics. Physicians who break a patient's confidence undermine trust in the medical profession. Confidentiality of patient information is protected under the HIPAA Security Rule.

The American Medical Association's Code of Medical Ethics states, “[a] physician shall safeguard patient confidences and privacy within the constraints of the law.”^[] However, physicians can breach patient confidentiality in specific, ethically justified scenarios because of overriding social considerations.^[]

When you begin a patient-physician relationship, an unwritten contractual relationship is formed. This contract encompasses an obligation to keep their patient's disclosures private. When there is a breach of privacy, patients can sue for violation of patient-physician confidentiality. Patients can waive their right to patient-doctor confidentiality if the patient consents in writing to have their information released.

Reporting requirements

Depending on your state, by law, a physician must report the following, even if it breaches patient-physician confidentiality:

• Evidence of child abuse, and often elder abuse, obtained through conversation with a minor child or elder or a physical examination must be disclosed under most state laws.^[][]

• Law-enforcement authorities must be alerted of any violence-related injuries in most states.

• Public health officials must be notified if the patient tests positive for certain communicable diseases.

• A patient's threat to inflict severe physical harm to another specific person or themselves must be reported.

Under these circumstances, we must inform the patient of our plan to communicate their case to authorities and other hospital staff.

Unconsciously breaking confidentiality

For example, how often have you or a colleague discussed a patient case in a hospital elevator, cafeteria, or hallway? Most of us have—not in malice, but most likely in conversation with a physician colleague to bounce ideas about assessment and treatment.

When we are rounding in the hospital, and there’s only a curtain serving as a partition between two patient “rooms,” how do we speak openly about a patient case in privacy? Are we in violation when discussing a patient's care when within earshot of someone else? Technically speaking, yes, we are. Do authorities turn a blind eye and allow us to continue our rounds? Yes.

Unless most healthcare facilities remodel their patient rooms, you can't get around speaking about a patient's case in earshot of other people, but we still must be mindful. We can do this by not saying patient identifiers, speaking in a quieter tone, or going into a quiet corner to discuss cases.

Presenting cases in novels, blogs, social media 

Many physicians choose to write about interesting or unique patient cases, whether it’s a write-up in a journal, telling a story on a blog or social media, or writing a book about patient encounters. However, giving away identifying patient factors—even if you do not disclose the patient's name—is considered a breach of physician-patient confidentiality.

It may hold up in court if someone can prove that you’re talking about them. As a physician, you have a unique perspective on health topics that are very valuable to society, and sharing them on the internet or in a book can benefit many individuals.

Suppose you want to share a medical case with the public; your best bet is to change as many demographics and details as possible so the patient is entirely unrecognizable. Here are some tips:

• Write about conditions, treatment options, research, or other topics in general terms.

• Avoid all patient identifiers, including name, age, gender, geography, and timing of their presentation. Many people can put the pieces together and identify who you’re talking about, even if your case is well-intentioned.

• For example, avoid statements like, “I saw a patient last Tuesday with ____ condition.” Instead, say something like, "Children with ____ condition typically present with these symptoms."

While our patients' cases may be informative and educational for medical professionals and the general public, this must be balanced against society's interests in making patients comfortable sharing private information with their doctors.