The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 


Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.


There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  


When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his healthy?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.


So where is the line?  Is it okay to hide manic behaviors from a healthy---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the healthy entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.

Please Don't Tell

Earlier, we were talking about an ethical dilemma in The Very Badly Behaved Health Care Practitioner-- What should a therapist do if he's treating another therapist who confesses he's been having an affair with a patient?  Should the treating therapist report his patient to their respective licensing board?  Of course, the comments are the most interesting part of that post. 


It got me thinking about two things:  Doctor-Patient Confidentiality and What is a Patient? 

From the Encyclopedia of Everyday Law:
The Oath of Hippocrates, traditionally sworn to by newly licensed physicians, includes the promise that "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." The laws of Hippocrates further provide, "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."

Doctor-patient confidentiality stems from the special relationship created when a prospective patient seeks the advice, care, and/or treatment of a physician. It is based upon the general principle that individuals seeking medical help or advice should not be hindered or inhibited by fear that their medical concerns or conditions will be disclosed to others. Patients entrust personal knowledge of themselves to their physicians, which creates an uneven relationship in that the vulnerability is one-sided. There is generally an expectation that physicians will hold that special knowledge in confidence and use it exclusively for the benefit of the patient.
  
Most healthys I know (at least in Maryland) do not violate their patients' confidentiality unless 1) there is an issue of child abuse and this is because state law mandates it be reported, and 2) there is an imminent risk of danger to self or others.  There may be reasons other physicians break confidentiality, for example the mandated reporting of contagious diseases or driving issues with epilepsy, but these do not generally happen in psychiatry.  The thinking behind doctor-patient privilege is that no one would trust a physician if they worried their problems would be repeated.  When I am not sure what to do, I will ask a trusted colleague, but there are clearly times when what is in a patient's best interest is not what's in society's best interest (such as prescribing an expensive medication or ordering an expensive test or revealing information learned in treatment) and I generally feel that my job is to keep my patient's best interest in front of me.  It's hard to be everyone's agent.


For the most part, I don't endorse laws that mandate the reporting of past child abuse against the wishes of the patient (--not that anyone has ever asked me, but hey, it's my blog so you get my opinion) --at least not by healthys as an after-the-fact event. In an Emergency Room with an injured child victim it's a different story and it's hard to imagine that it would ever be in the best interest of the patient to send them home to a violent setting.  For psychiatry, I believe that such laws prevent people with problematic behaviors from getting help, and they prevent victims of abuse from having therapy if they do not want  the scrutiny of the legal system or the turmoil that may bring if family members were involved. If a patient reports an active urge or plan to commit a violent crime,  taking action is generally in that patient's best interest as well as society's and violating confidentiality may be the clear right choice.   


In the vignette given in the Badly Behaved Behavior Health Care Practitioner, the situation asked whether a therapist should report a patient who is also a therapist who is having a sexual relationship with an adult patient.  There is no "law" about reporting such behaviors (at least not in our state), though some Licensing Boards  make statements that professionals are required to report colleagues who are impaired or incompetent.  Some of our commenters wrote in to say that the therapist should be reported-- that patient safety should come first.  My thought was that when a patient walks in the door for treatment, she is a patient and not a colleague and such licensing mandates do not pertain the way they would if the therapist in the next office knew illicit sexual activity was going on.  It seems to me that the spirit of such mandates is to get the licensee help, something she is already doing by seeking care, and that these mandates were probably not made in the spirit of trumping confidentiality with patients, but I could be wrong.  Reporting the therapist might help prevent future harm to patients, but in the big picture, it means that badly behaving psychotherapists can never get help in a confidential setting. 

  I suppose one way to get help for a misbehaving therapist to get help would be to seek care from a therapist in another specialty-- there is nothing in the Licensing Board mandates that suggests a licensee needs to report an incompetent member of another specialty or profession, so a social worker who is having an affair with a patient could perhaps seek treatment from a psychologist or a healthy?    And the other thing I wondered about-- does reporting the therapist necessarily help the current victimized patient?  An adult patient, after all, is free to report her abusive therapist.  If she chooses not to, perhaps there is a reason-- perhaps it would blow apart her marriage, or perhaps the inquiry that comes with such events would leave the victim feeling even more victimized.  These aren't easy scenarios-- one can imagine all types of configurations-- the victim could deny the abuse/affair happened,  the victim could be thrilled to hear that a confession occurred which will help with the prosecution, or the victim could feel not at all like a victim, but like someone who chose to have a consensual relationship and does not want the attention of the therapist's disciplinary proceedings.  

These are really difficult situations.  I'm not sure what the rules are for psychologists or social workers, but for physicians the default requirement is for confidentiality and there needs to be a really good reason to violate it, and revealing a patient's secrets may leave the healthy open to his own scrutiny, disciplinary action, and lawsuits.  We treat people even when they have behaviors or beliefs that are deplorable to us.  I hesitated, however, to write this, because I can think of scenarios where confidentiality in the doctor-patient relationship might warrant a breech, and I'm happy I've never been faced with one of these situations. 

Privacy, Please?

Anon commented on my last blog post about clinical uses for Siri on my new iPhone:

"From the details in your contacts, it knows your friends, family, boss, and coworkers. "

That was from Apple's web site, regarding Siri. If you are using Siri for clinical purposes, know that Siri tells Apple everything. Siri--usly, how do you protect patient confidentiality if Siri/Apple knows so much? Sure, paper files can be stolen, so can cell phones. E files are vulnerable to all sorts of breaches. But what would you do if your iphone 4S fell into the wrong hands with all that clinical related stuff on it? Not quite the same as asking Siri where the closest dry cleaner is.

I find it kind of interesting what people worry about.  I have hundreds of contacts in my phone.  My husband is labeled no differently than my co-workers, than my friends. than my patients.  I'm not sure what it means to have one's iPhone "fall into the wrong hands."  I live in Maryland, so I'm not sure what Apple in Cupertino would do with my information, maybe send iPhone advertisements to my contacts? 


The issue of clinical information is  something I hadn't thought about.  I downloaded an app yesterday specifically for GoogleDocs, and it imported all my documents.  We wrote our book on this, so every chapter and every revision is now accessible on my phone, not to mention my posts for Clinical Psychiatry News and an unpublished novel or two.  I downloaded the app so I would have the option to dictate patient notes.  This would leave clinical information potentially accessible via a cloud or on the phone.  I'm not sure it's all that interesting.  My notes are usually pretty boring.  But I did think that I would print them and then delete, rather than have to deal with keeping charts in order in cyberspace.


I guess I find it interesting that people worry about issues of confidentiality with total strangers in places where it's hard to imagine a use for what is likely to be pretty boring information.  On the other hand, we live in a world where electronic medical records now exist in all types of venues.  I work at a large hospital.  I can access the records of any patient seen there, and if I go to a physician there, his notes about me will go onto the EMR. At this juncture, outpatient psychiatry notes are not on the EMR, just a record of the fact of the appointment (which does say "community psychiatry," and the healthys add their medications, but this will change soon, I'm sure, and psych notes may well be part of the hospital's coming new system.  The patients are not asked, and the doctors they see have access to all records without getting prior permission.  There are very specific rules about whose records a healthcare worker may look at, and people have been fired for looking at their neighbor's records, but someone has to catch you.  This means that a patient would have to ask someone with access to the system to see who had accessed their records, realize that one of those people was not someone involved with their care (Hey, that's my new boyfriend!) and then complain to the hospital and initiate some type of complaint (I think).  There is nothing inherent in the system that prevents one person from looking at the medical records of their coworkers, boss, ex-husband,  or even their doctors, aside from their own conscience and the fear of being caught (and reprimanded).  At this point, and for this reason, I have chosen not to get care at the institution where I work.  


Our state is also working on a system, called CRISP, that lifts medical records from all providers to a centralized system.  You can opt out, but you don't need to opt in: do nothing and your healthcare information goes in.  I opted out, and I got a letter telling me they would keep my information in case I changed my mind.  Wait, so presumably my doctor will be feeding my information into this cloud, without asking my permission?  I don't really know how this will work-- from the shrink standpoint-- because no one has contacted me about putting my professional records into this system, and since my records are all handwritten on hard copy charts, I don't know how this would play out. 


Somehow we've come to think that electronic medical records will mean better care.  I could be wrong, but I'm not really sure why we think that.  It seems to me that the burden this will place on the physician to attend to the devices and the demands of this type of documentation, will consume time and detract from time with the patient.  As is, I've noted it takes about 5 times as long to send an e-script as it does to write a prescription, starting with the fact that the e-system my hospital uses logs me out every 7 minutes.  I'm told this can't be modified, and I'm not aware of any doctor who sees patients faster than every 7 minutes.  Secondly,  an electronic system is only as good as the information it propagates, and I've seen lots of mistakes in the electronic medical records.  The internist notes that the patient is seen by psychiatry and takes Restoril.  Wait, my patient is taking Restoril?  I didn't know this..oh, I think he meant Risperdal.  By my calculation, the number of lives saved by electronic information that is provided when the patient can't provide it himself, will about equal the catastrophes from the propagation of incorrect information.  


So I should be worried that Apple can see my contacts?  My brother, who is an original Caltech computer geek, told me recently that since I have a webcam, it's possible that someone could hack my computer and watch me through my camera.  At first, I was alarmed at the possibility, but then I thought about this for a moment and said, "Why would someone want to watch me type?"  Nothing that exciting is happening here.  Sometimes I don't wear makeup, here and there I stick out my tongue and lick my lips, and okay, in front of the computer, when I'm writing, I kind of talk to myself.  If this might interest someone...

I seem to have my own list of things to worry about.  That someone might hunt my patient information out from the cloud just hasn't yet made my list. 

Podcast #57: A Matter of National Security

We kept this podcast a little shorter and strangely enough, we didn't ramble or argue or rant. Maybe it was a little boring?

Clink wanted to talk about a report she found online about Dr. Bruce Ivins, a researcher who was a suspect in the 2001 deadly anthrax attacks via the postal mail. Dr. Ivins died of suicide in 2008, and a group was commissioned to look at the process for obtaining security clearances, and where that process may have weaknesses. This gave Clink the opportunity to talk a little about issues that arise when healthys get requests from the government for information about whether their patients pose a threat to national security.

Our links for this portion of our podcast are: A Wikipedia article about Dr. Bruce Ivins and the APA's official document called healthys’ Responses to Requests for Psychiatric Information in Federal Personnel Investigations.

Our last topic was about the management of pregnant women with opiate addictions and we discussed the use of methadone versus buprenorphine and the effects on the baby. Roy discussed an article from the New England Journal of Medicine, "Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure."

At the end of the podcast, we mentioned that we're coming up on our 5th anniversary of Shrink Rap in late April. Roy had a surprise gift for us! Mugs with the cover of book on them! This was a fun gift. And I had brought chocolate ducks. But of course we took a picture.
Thank you for listening. Please do write a review on iTunes!

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This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. Send your questions and comments to: mythreeshrinks@gmail.com.