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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