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September 22, 2003

By Dr Rita Pal

The name is God, Dr God...

" All I that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal " The Hippocratic Oath

The requirement for confidentiality, recognised as far back as the 5th century BC, was restated in the Declaration of Geneva in 1947.

Recent revelations of medical secrets have shaken trust and stirred the public image. Doctors are 'confidants' likened to the priest or the 'agony aunt'. The vision in the mind's eye is one of " trustworthiness, problem solver, miracle worker and perhaps God?" The time of the 'paternalistic entourage' parading through the wards introducing himself as God - all knowing, all seeing of the medical condition but revealing only small truths has been overtaken by demands of accessible patient information.

A life history at a touch of a key:
but whose eyes are on your medical secrets?

We all hold secrets in our lives not to be known by those around us: our employers, our friends and acquaintances, for fear of the consequences or prejudices. The knowledge accumulated during a long-term doctor-patient relationship is phenomenal -how many affairs the spouse has had, what the daughter's contraception status is, whether the son is gay or not -all may be detrimental in wrong hands. With the advancement of technology, particularly the Internet, how do we know who is spying on our secrets? Computerised systems recording patient data are easily available and demanded by the increasing patient numbers and the wealth of information from advancing technology. Gone are the days of little cream coloured notes bulging out of the envelope taped together by the irritated GP. A click of the computer key brings the data to full view.

Taboo subjects like drug addiction, alcoholism and HIV are personal concerns, which are revealed on commencing employer/employee partnership. Other subjects like impotence and infidelity may endanger the patient's reputation and ruin a family life.

Secret files of Medical Legislation

Medicine has essentially been a closed-door network, much like the secret service; there are many aspects of medicine that are simply not discussed with patients, merely by convention. Patients of today demand knowledge of their health: the ability to take control and own their life decisions. Patient autonomy spells out the advent of the Human Rights Act 1998.

Routine practices in today's health service fail to perform the function of adequate data protection breaching the Data Protection Act 1998.

Health Authorities and social services have access to medical records through Patient Information systems. Clinical audits or studies carried out by researchers gain access to variable amounts of data, often without the patient's consent. Professional discussions about patients between the doctor and a social worker may mention every known detail. There are no rules governing such interchange of personal or medical data. An informal conversation with any health professionals may have a severe impact on your life. The patient still has limited control over their personal medical data in the health system of today.

Is our role as doctors to protect our patients
from adverse events that are reasonably foreseeable?

A different slant may be considered in medical neglect issues to protect public interest. Battered wife syndrome, child abuse, patients at risk are all matters where a GP has to balance the 'safety of the patient' to 'confidentiality'. Increasing concerns about the problems in the National Health Service which are ignored by Institutions, can result in a doctor having no alternative but to breach confidentiality -for the sake of improved healthcare. Thus, a doctor must always balance the 'public interest' to patient confidentiality. To prove mistreatment of a patient, a doctor must provide detailed accounts of that patient to several 'non-health professional' superiors including Managers, Health Authorities and the General Medical Council. Given that the system protects itself, how far does one go in the search of justice and how many authorities does one breach confidentiality to?

Patient safety is imperative and medical errors must be limited. The current climate of litigation propels Trust authorities into self-protection that is virtually watertight. Dissatisfaction with the complaints systems and on-going litigation encourages many more people being party to all the information. It is not unknown for a Member of Parliament to intervene and for their medical data to be passed from the general practitioner to the MP.

Driving Directives and Detectives

Although issues such as insurance, which has been hotly debated in the context of HIV status as affecting a person's life, other areas having equal devastation remain neglected, particularly surrounding the Fitness to drive. The Driving Association (DVLA) is where a doctor has substantial power to " make or break " an application should your health affect your ability to drive. There is no legal duty to inform the patient of the details of the letter sent although there are directives by the GMC. More often patients find themselves with their license revoked, without warning. If a full license is revoked there is no availability of a future provisional license to prove your driving ability. An informed decision involving the patient is therefore vital. A patient that may need time and assistance to comprehend, such as following brain damage or a psychiatric problem, may react adversely to the sudden removal of their license. The person's health and welfare must be taken into account in order to ascertain how best to write to the DVLA or insurance companies. Often this is not done, leaving the patient to flounder, denying a voice in consent.

The phenomenon of " talking shop" or defamation.

Doctors love talking to doctors about their favourite subject which is medicine!

" Why do you think Mrs X looks so young?
Did you know Mrs X is having an affair with a younger man half her age."
" Wow, lucky her "
" Yes, she told me today in surgery"
" She asked me for HRT as well "
" Good stuff HRT, remind me to take some myself, I am feeling a hundred after my patient list today!"
(a GP meeting 1997)

The general practitioner may then tell his wife, the wife may tell her friends at the next garden tea party. The domino effect of Chinese whispers results in catastrophic consequences e.g. violence in the home or even attempted suicide by the innocent party.

Other instances are when GP's will share information about patients they consider to be " problem patients ".

" She is mad you know, she told me she wanted to see another specialist. This would be the 10th one. I think it's all psychological anyway.
She threatened to sue".
" I know, I have patients like that, they drive me mad"
" Make sure you don't take the Mrs X on, she is a nightmare, she wants to change to you apparently, that's what she said to the secretary today "
" Definitely not taking her on mate, I have enough patients like that " (brotherly hug)
(Taken from a GP meeting 1998)

The lady found it impossible to obtain a general practitioner. She was blacklisted as her details provided to prejudice another GPs opinion. Blacklisting is common practice and, in essence, it comes out of respect for the medical brotherhood.

Dare we question this form of conversation? Is it detracting from providing fairness in patient confidentiality and retaining their dignity? Are self-prejudicial judgements smothering our patients? As doctors, are we here to solve the problems a patient may have? Prevention of small talk may curtail the despair and discrimination often suffered at the hands of their own doctor. Certainly, there are unreasonable patients but there is usually an underlying reason or right of a second opinion.

Dilemma of a Doctor's despair

What happens when doctors become patients themselves? Rising problems in alcoholism, drug addiction and marital problems are reported in all walks of the medical profession. Sooner or later we find ourselves in a waiting room tapping our fingers and reading last year's edition of Woman's Own, wondering why the doctor is taking so long! The medical fraternity live in a close knit community. By virtue of our vocation, we have an inquisitive nature, and doctors are therefore blacklisted from the profession through their 'Chinese whispers'. Doctor's ailments are more likely to penetrate to their employers at speed. The General Medical Council directs a practitioner to report any doctor who is unfit to work with or without their consent. This is particularly true in psychiatric cases. Reporting doctors in this way may indeed affect and worsen their psychiatric state and compound suicidal ideation, particularly knowing the loss of future earning ability or status. Again the balance of the welfare of future patients against reporting a doctor who is not working needs debate. More often, during the acute illness, a very sick patient will be forced through rigorous panels of medical professionals to ascertain his ability to work, rather than assessment during convalescence. This adds trauma to an ill doctor, and interferes with the process of healing. The GMC obtains their valuable report but do they consider the future professional life of that doctor? Emotionally traumatising a doctor in this way results in catastrophic consequences - limited future earning potential, pension rights, disinterest in life, family stress, loss of professional friends who all know about his confidential health predicament.

Pandora's box of Medical Secrets

The future lies in respecting confidentiality, balanced with public interest, in a world that is constantly changing with respect to public expectation. Your medical secrets are not for the world to know. Today's doctors should respect patient autonomy. With the advent of the Human Rights Act 1998, doctors and patients should work in equal partnership to ensure a high standard of service towards confidentiality, encompassing the protection of their fundamental Human Rights.

"A physician shall use great caution in divulging discoveries or new techniques or treatment through non-professional channels" International Code of Medical Ethics 1983

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