Doctor & Patient Relationships: Confidentiality

In order for a patient to receive a proper diagnosis, they need to be honest with their physician about their condition. A doctor can more adequately treat a patient if they know as much as possible about the patients’ ailments, which occasionally means sharing details with your physician that you may be somewhat uncomfortable with. Fortunately, you can rest assured in most cases that anything you share with your doctor is strictly between you and your doctor. While some exceptions exist, a doctor will faithfully keep the details of your medical history and treatment to himself.

If you’ve ever seen House, M.D., you’re probably familiar with this scenario: In the show, a patient will be rushed to the emergency room with some foreign, difficult-to-diagnose illness. The medical team trouble-shoots to figure out what could be causing the patient’s illness, until doctor House finally weasels pertinent, if embarrassing information out of the patient. It just so happens that this minor detail, previously left out, saves the patient’s life. While House, M.D. is a dramatization, it is a great example of why doctors and patients need to depend on confidentiality. If you can trust your doctor, you can be treated more efficiently, getting to the root of the problem without any guesswork.

The Field of Psychology

Psychologists study the mind, and there are a wide variety of types of psychologists for different kinds of patients and their struggles. Some psychologists specialize in child psychology, treating children exclusively with a niche for childhood development, while others specialize in the much broader field of clinical psychology, which delves deeper into science, theory, and clinical knowledge for psychological issues. A psychologist takes the form of a therapist in that they develop a relationship with the patient through verbal assessment in order to determine their psychological needs. There are even sports psychologists, who act as a consultant for athletes in order to keep them not just physically but mentally prepared to be on top of their game.

Given that psychologists develop stronger relationships with their patients than, say, a general doctor, doctor-patient confidentiality is of utmost importance. The relationship between a psychologist and his patient is usually very reliant on communication. If a patient is depressed, for example, the psychologist may urge the patient to discuss his or her feelings about certain events. Discussing such matters helps the psychologist to evaluate his patient and their needs. The doctor can’t treat the patient if they are withdrawn about particular things that may be contributing to the depression.

History of Doctor-Patient Confidentiality

Doctor-patient confidentiality has been built into the healthcare system for centuries. In fact, it was derived from the Roman Hippocratic Oath taken by physicians. The Hippocratic Oath outlines the qualifications of a good physician; one who treats the sick with finesse, is considerate of the patient’s privacy, and shares their wealth of knowledge with future generations of budding physicians. Today, many medical school graduates utter a modernized version of the oath during their graduation ceremonies, with doctor-patient confidentiality still holding true. While many other aspects of the oath are not necessarily taken to heart, such as never giving a woman an “abortive remedy,” doctor-patient confidentiality is still a staple of modern treatment.

Doctor-patient confidentiality laws are complicated. Originally, doctor-patient confidentiality was simply a code of ethics. Now it is usually built into a state’s statutes as common law. In 1996, the Health Insurance Portability and Accountability Act, or HIPAA, came into fruition. The laws were originally conceived because electronic health care transactions were threatening the patients’ privacy. Likewise, the “Principles of Ethics for Emergency Physicians” portion of the Code of Ethics of the American College of Emergency Physicians weighs in on patient confidentiality quite heavily. Confidentiality applies not only to words shared between a patient and doctor, but also every nuance of treatment, including documents and X-rays. Generally, it also must be recognized by any nurse or physician’s aid. Even when a patient has stopped seeing a doctor, the laws should be abided by, with his or her information kept at bay.

Stipulations for Doctor-Patient Confidentiality

In order for doctor-patient confidentiality to exist, there must be a legitimate relationship between the patient and the doctor. In other words, the patient must seek out the physician’s care themselves, with the premise of procuring treatment. Doctor-patient confidentiality should not be expected if a patient is ordered to receive treatment via a third party. For example, if an employer requires an employee to seek rehabilitation for drug abuse, the doctor is allowed to report details of the treatment to the employer. Furthermore, if someone were to meet an acquaintance at a dinner party, find out they were a licensed doctor, and then lay their problems on them, there would be no obligation for confidentiality. Nor should the person consider the doctor’s advice outside of the medical setting to be an actual diagnosis or form of treatment. However, if a person schedules an appointment with a doctor and expresses concerns in the doctor’s presence during the scheduled exam, any verbal exchange between the two should be considered strictly confidential. The patient should not have to request this, as it is already implied and enforced.

If a doctor is treating multiple members of the same family or various patients with relationships to one another, each case is dealt with individually. The doctor must not confuse information he has garnered from one patient with another, even if they confide similar stories to the doctor. A psychologist treating multiple members of the same family or a couple in a relationship may suggest that the group consider group therapy, which would lessen the strain of confidentiality between everyone involved.

The Four Models of the Doctor-Patient Relationship

Doctor-patient relationships can take four different forms, each having a slight sway on the way doctor-patient confidentiality is enacted. In the paternalistic model, the doctor decides what is right for the patient based on what they believe is in the patient’s best interest. When conducting treatment, they may encourage the patient to agree to a specific course of action or they may firmly inform the patient of the course of action without allowing the patient say in the matter. It is referred to as paternalistic because the physician might as well be acting as the patient’s guardian, making choices for him or her and assuming the patient will be grateful for the results even if they would not have agreed to the treatment otherwise.

In the informative model, the doctor is more considerate of the patient’s wishes. The doctor will present the patient with all relevant information regarding the treatment along with every option and allow the patient to choose what is best for them. The doctor presents the information in a factual way, without room for his own values. The interpretive model takes it a step further, in which the doctor presents the patient with all of the options, allows the patient to decide, but strongly considers the patient’s personal narrative and personal values. The doctor must be somewhat intimately familiar with the patient, perhaps even alluding to values that the patient doesn’t even realize they adopt. The physician should be cognizant of the patient’s goals, aspirations, and character.

Finally, the deliberative model presents the patient with the various courses of treatment, taking only into consideration their health values. Moral implications or are not brought up, nor does the doctor coerce the patient one way or another. The doctor does not evaluate how the treatment would affect other areas of the patient’s life outside of the health realm, but lets the patient factor that part in on their own. When discussing various treatment options, the doctor is more concerned with letting the patient understand the potential risks and side-effects.

Exceptions to the Rule

Once doctor-patient confidentiality is conceived between a doctor and patient, many doctors will enact a doctor-patient legal privilege that exempts them from confidentiality under a couple of unique and limited circumstances. They will often write up a form for the patient to sign that indicates special scenarios in which doctor-patient confidentiality can be waived. As a rule of thumb, doctors try to do everything they can within their patients’ best interests. Sometimes this means breaking confidentiality if they believe that it is absolutely necessary, but the pros and cons are heavily weighed before deciding whether or not it is worth neglecting the patient’s privacy. A doctor that adheres to the paternalistic model of treatment may be more inclined to breach confidentiality, believing they know what is best for the patient, whereas a doctor that uses the informative model will only disregard confidentiality in an extreme instance. The doctor must remember that if a patient feels that their privacy has been unlawfully breached, they may sue the doctor.

Most legal privilege write-ups contain the same basic clauses: If a patient is liable to be a danger to themselves or others, confidentiality may be breached. If they are mentally unstable to a point that they may harm others, doctors don’t have to ask permission from the patient to inform others, particularly those in close contact with the patient. If the patient alludes to the doctor that they are abusing a child or if the patient is an abused child, the doctor has a duty to inform authorities. The same applies to a patient that could potentially spread HIV or AIDS to a partner — the doctor should not be expected to keep quiet about the matter. Confidentiality is also automatically waived if the patient files a lawsuit against a physician for personal injury. Since the patient’s condition needs to be examined in the lawsuit, they cannot dictate that such information will be upheld. Likewise, if the doctor testifies in court and the patient fails to object to what it said about the patient’s condition, confidentiality is waived.

While doctor-patient confidentiality is usually recognized in state court depending on the circumstance, if a patient or doctor gets in serious trouble with the law then doctor-patient confidentiality is a weak argument and isn’t always upheld. For example, doctor-patient confidentiality will not hold up in federal court. Federal Rule of Evidence 501 stipulates that the federal court does not recognize or uphold doctor-patient confidentiality. Thus, when practice between a doctor and patient delves into legal concerns, the rule is no longer binding. In the court case United States versus Bek in 2007, a physician named Bek was dolling out controlled substances to his patients without concerns for key things such as prescription strength in reference to patient weight, medication interactions, and so forth. When he was brought to court and his patients’ documents were exposed, he tried to call upon the rule of doctor-patient confidentiality, but it could not save him in federal court.