Friday ethics coffee klatsch

Mmmmm....crema
There was a time, you may remember, when I was off caffeine.  It was horrible. Those times are past, and lately, I’ve been favoring espresso over American coffee.   I usually pop out of bed about seven, hop in the shower, get dressed, and wake up PalKid. She’s been a delight lately—I wake her up out of a sound sleep, and yet she’s cheerful, cuddly, and ready to start her day.

Most of which she does without me.

I set her up with breakfast, and I’m out the door.  Depending on traffic patterns,  I stop at one of two coffee shops, both of them chains, unfortunately, but good chains.  I order a doppio in a real cup, stand at the bar and enjoy it briefly, and I’m on my way.


From there, I fight traffic to my office, stamp out disease, and then head over to my hospital’s resident clinic to stamp out more disease.  One of the great things about working at a teaching institution is the ability to bounce ideas off each other.  We share clinical conundrums, and often enough, ethical ones.
I love ethics discussions.  I always imagine them taking place over coffee, with my brilliant colleagues explaining to me how in this case my definition of beneficence is not congruent with my patient’s. That’s not always the way it goes.
Many ethical discussions involve problems that are very real, and that are temporally constrained.  A patient laying in the ICU may need the care team and doctors to come up with a solution immediately.  And the various parties are emotionally tied to their firmly held opinions.  Consequently, ethical discussions are sometimes a bit of a, well, you can imagine, I think.  This is where tools like ethics committees can be very helpful.

In medicine, ethics discussions are very real.  They deal with real people in need if real guidance.  Let me share a (somewhat constructed) case with you.  But first, a favor. Pour yourself a cup of your favorite beverage, place yourself in the position of both parties, and give me some feedback.

Case

A young woman comes to see you in the office.  She has been having some depression and anxiety.  She also has some pain on urination and a change in her normal vaginal secretions.  As a good doctor, you take a thorough history, paying special attention to the patient’s chief complaints, trying to tease out connections to other problems and thinking of possible causes .  In the standard format of a medical chart note, you complete the HPI (history of present illness).  You move on to past medical history, family history, allergies, medications, and social history.  Social is a catch-all category for living situation, employment, habits, etc.  She is married with a teenage son.  She works full time. The patient tells you that she smokes cigarettes on the weekend when he goes to the bar, and that last week at the bar she met a man with whom he had unprotected sex.

As you continue the exam, you are thinking about her chief complaints.  Is she anxious because of the sexual encounter?  Was the encounter consensual? Is she worried about being pregnant or having an STD?  Is this a simple urinary tract infection? The sexual encounter is the piece of the history that ties everything together.

The patient stops.  She says, “Doctor, look, I need you to not write that down—the stuff about the guy.  You know my husband and I have been having problems, and we’re working on it.  I can’t risk him finding out.  You can’t write it down.”

Well, yes, I can.  The medical record is my record of observations, formulations, and plans.  I own it. I need it to be complete  in order to make intelligent decisions.  In some states, patients may addend their medical record to get in “their side”, but from a practical standpoint, the chart is a tool the doctor uses to care for a patient and to fulfill certain legal requirements regarding documentation.

I need to use the information about her sexual encounter.  She may very well have an STI,  and without the complete sexual history, the visit doesn’t make sense. But must I include this information?  What are my obligations to myself, the patient, the law, and my profession?

When something like this happens, it’s important to set down the pen or the keyboard and focus on the patient.  Can she tell me more about why she wants this left out of the chart?  Is she afraid her husband may get access to it?  Or is it more of a personal privacy concern?

Privacy

Medical records are a type of information known as PHI (protected health information).  The law (specifically HIPAA) protects PHI from inappropriate disclosure. But this information can be legally shared with the insurance company and can be shared for other medical uses, usually if needed to benefit the patient.  In this case, the husband may be the actual holder of the insurance policy, and the bills and EOBs (explanation of benefit forms) may come right to him.  In addition, any lab bills may list the labs I ordered and the diagnosis justifying the lab.  I have no idea how likely this actually is, and that’s part of the problem—I cannot reassure my patient of her privacy.

Deception

I cannot lie in the chart.  I can, I suppose, choose not to include everything I know, and I can word things carefully, but I cannot lie.  If the patient tells me she has had three sexual partners in the last year, I cannot write, “the patient has been sexually active only with her husband in the last year.”   I can fail to explicitly write the sexual history, but any other doctor (or lawyer) reading the chart would wonder why I left out a sexual history when someone clearly has a suspected STD.  If I fail to mention the sexual encounter, and a test  for chlamydia comes back positive, someone may assume that the husband was sleeping around and gave the patient chlamydia—which may or may not be true, but the implication is quite different than if a proper history had been noted.

Trust

I should not add the information to the chart without telling her.  Transparency encourages trust, deception destroys it.  And if she cannot trust me to include her in decisions about her data, she is less likely to share important data with me in the future.  On the other hand, I may be less likely to trust a patient who asks me to treat her without proper documentation.  Poor documentation leaves me open to potential liability.

Quality of care

I see many, many patients.  I cannot remember everything about every patient. What is written in their charts strongly influences my decision-making.  If I  fail to note this fact, I (or another physician) may fail to include important diagnoses in our future thinking.

Putting some of this into the language of medical ethics, how can I balance beneficence, non-maleficence, autonomy, and privacy/dignity?

Some ethical problems (most, really) do not have a clean answer.  I want to properly diagnose this patient’s problem while maintaining her trust.  I want to avoid harming her by potentially exposing her private information.  And I want her to feel she has some control over herself and her information.

But as always, it’s a balance.  I would tell her directly that I understand her concerns, and share some of them, but that failing to document properly may lead to other problems.  She engaged in a perfectly legal behavior that she wishes to remain private, but that may have led to a serious medical problem.  I can’t change that, and she is left with no perfect choices.  I don’t want her to avoid treatment in order to avoid having her problem documented, but I have to decide as a clinician whether I’m willing to leave out that information (a very tough call.  Also, no cheats here.  We are assuming there is no way for her to obtain confidential/unidentified testing and treatment elsewhere).

So, go refill your cup, sit down, and tell me what you think.

(Dr. FreeRide is an invaluable resource for me when I’m confused about how to approach ethical problems.  She rocks.)

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64 Comments

  1. In your experience, does utter transparency with the patient work? What I mean is, if you explain your obligation to keep the information, how it is ultimately in her best interest (along with everyone else’s) that this process is adhered to (although in this specific instance it sucks to be her), does it carry any weight against the immediate concern of privacy in this case?

    Yes, I know I am ducking addressing the actual issue, but I had a question.

    (apropos of nothing, I also want to take this opportunity to express my admiration of both you and Dr. FreeRide. While I don’t want to go out on a limb and say I have enjoyed every single word of yours I have read, I cannot recall any contrary cases at the moment. For either of you.)

    • Can you re-word the question a wee bit? I’m used to thinking of these things a certain way, so it takes a few tries sometimes for me to get a different view.

      • I mean, in your experience (I have none, myself), if patients are given the “big picture”, which includes the good to both themselves and others (frankly, if the big picture does not include both of these, then the justification does not exist), does that balance out the “immediate picture” which is painted, frankly, fairly miserably for them? Or does the short-term view predominate?

        (I apologize if my question seemed complex; it is, I think, a fairly simple question borne of utter ignorance on my part. If there is a simpler interpretation and a more complex one, I think you are safe assuming the simpler one.)

        • In my experience people are variable, but generally speaking, anxiety drives short term thinking and goal setting, and logic does not help things overmuch.

  2. I believe that there is substantial societal good that comes of people being able to seek and obtain completely anonymous acute medical care in relation to possible STDs. Most importantly, this enables people to obtain preventive treatment without fear of disclosure instead of just doing nothing and praying they aren’t infected, and thus reduces the likelihood of innocent third parties themselves getting infected.

    • The HIV pandemic introduced us to truly anonymous testing, as in by random number, not associable to any name.

      This has fallen off as the pandemic and our society have matured.

      The availability of clinics to obtain anonymous testing is frightfully limited. I’d argue that we should be able to do it right from the office.

  3. Karen

     /  October 8, 2010

    Wouldn’t you test for pregnancy and sexually transmitted diseases any sexually active woman of childbearing age presenting with those symptoms, regardless of her number of sexual partners? In this case, I don’t see the value of recording her indiscretions. (That being said, she needs a strongly worded reminder not to have unprotected sex with men she meets in a bar.)

    Seems to me your primary obligation is to your patient, not to your colleagues or to her husband.

    • Interesting point. There’s not that much advantage to the patient, i’d imagine, if, say, she has not had sex with her husband in several months, it would look “suspicious” either way.

      Your last sentence is true but not relevant. I have no obligation to either. Accurate record keeping helps the patient in the future. If, for example, she goes to a new doctor, the new doc must be able to make sense of my records.

      If she tests positive for an STD, I have an obligation to try to convince her to notify her partner in one way or another, but I must not violate her privacy to do it myself.

      The public health dept may not have the same constraints, and may choose to become involved.

      • Isabel

         /  October 9, 2010

        ‘In this case, I don’t see the value of recording her indiscretions. ‘

        Great comment Karen! And a good idea to regularly screen sexually active people!

        Yes wtf is all this importance to recording your patient’s specific indiscretions? Really? What are you the fucking FBI? Just treat her and counsel her about safe sex and about notifying partners.

        “If, for example, she goes to a new doctor, the new doc must be able to make sense of my records.”

        Why does the new doctor need fucking details either?

        From the OP: “You move on to past medical history, family history, allergies, medications, and social history. Social is a catch-all category for living situation, employment, habits, etc. ”

        WTF? Social history? What about her fucking symptoms??? She CAME IN complaining of std symptoms.

        “I need to use the information about her sexual encounter. She may very well have an STI, and without the complete sexual history, the visit doesn’t make sense.”

        Dear or dear, a sexually active person walked into your office with symptoms of an STI. Makes perfect sense to me.

        Maybe you can legitimately ask if she had unprotected sex. This would admittedly be useful (in anonymous form) for public health concerns. But what difference does it make if it was a guy in a bar or her husband? Because her husband is cheating on her, or having unprotected sex with hookers etc. WHY do YOU need to know?

        Treat her, counsel her about unprotected sex and tell her she needs to let her partner/partners know, and you’ve covered all the “ethical” bases.

        • JJM

           /  October 9, 2010

          @Isabel wrote “Yes wtf is all this importance to recording your patient’s specific indiscretions?” … “Dear or [sic] dear, a sexually active person walked into your office with symptoms of an STI.

          It is clearly spelled-out, there needs to be documentation that a person is sexually active. One cannot assume that a married person is. Moreover, if the husband has not had extramarital sex he is an unlikely source for an STI. Either way, if she has an STI it would be clear to the husband that she must have gotten it from someone else.

          @Isabel wrote “Why does the new doctor need fucking details either?

          That is also clear, small details often play an important role in diagnosis. Full medical background info expedites the process when a new doctor is consulted.

          • Isabel

             /  October 9, 2010

            As far as I understood she objected to the MD recording the information about the affair, not the information that she was sexually active. You have not explained why PalMD needs to know who got it from who before he can make sense of the situation, and move forward to diagnosis and treatment.

            ” She says, “Doctor, look, I need you to not write that down—the stuff about the guy. ”

            Why not assume everyone is sexually active instead of asking intrusive questions about their social situation, personal life. Is it too expensive to run the tests or something? (Maybe this is a good time to discuss how money fits into this picture). Anyway, I already said I would even tentatively accept asking (perhaps “optionally”) about unprotected sex. But why this obsession with getting out a detailed description of the sexual activity before you can start diagnosing the person?

            “there needs to be documentation that a person is sexually active”

            Please explain why you need to document this (preferably in explicit Peyton Place level detail) along with the fact that she is a married woman with a teenage son who smokes cigarettes and goes to bars on the weekends etc. before you can proceed to diagnose the issue, even though the patient walked into your office complaining of urinary pain and vaginal discharge.

          • Because in medicine, facts matter. Sure, I can tell if someone is having a heart attack, but knowing why is pretty important in deciding how to treat and prevent disease. It’s not just a matter of how much “all the tests” cost. When a patient comes in with certain symptoms, our best tools for diagnosing them are our history and physical exam.

            Believe it or not, doctors aren’t passive health vending machines.

          • Dianne

             /  October 9, 2010

            Please explain why you need to document this (preferably in explicit Peyton Place level detail) along with the fact that she is a married woman with a teenage son who smokes cigarettes and goes to bars on the weekends etc.

            Non-comprehensive list of why these are issues that could matter to her medical care:

            The patient’s age is not given but she is described as “young”. Nonetheless, she has a teenage child. This could mean that she was sexually active at a very young age, possibly under 18. If so, she may be vulnerable to a number of sexually related traumas and is probably at increased risk of HPV infection and related diseases. Even if the child was born when she was in her 20s, his existence indicates that she is or has been sexually active, is fertile, and had un- or inadequately protected sex at least once. All of which change her risk for a number of diseases (some up, some down). Finally, suppose her urinary complaints are due to a vesico-colonic fistula which occurred because of a late stage colon cancer. In that case, it would be imperative to counsel her on risks to her first degree relatives and knowing she has a son reinforces the importance of genetic counseling.

            Do I really need to explain why it’s important to know that she smokes cigarettes? Anyone not living under a rock has surely heard by now that cigarettes increase the risk for a number of serious diseases including multiple types of cancer, heart disease, and osteoporosis. Less obviously, the amount she smokes may give a hint as to which diseases she is most at risk for. An occasional smoker is, for example, very unlikely to get small cell lung cancer but at moderate risk for non-small cell.

            She goes to bars and, at least once, picked up a man there. This might mean nothing-but it might mean a lot of things. How much does she drink when she goes to bars? Does she black out and not remember what she did? Did she drink an unusual amount this time or have only one drink but not remember how she ended up in bed with this man (which might suggest she was drugged)? Alcohol consumption can be anything from good for your health to deadly, depending on the amount and frequency of consumption. It’s important to know whether she drinks a glass of wine at a bar on weekends or binges every night-or something in between. Finally, if she lives in an area without a smoking ban, if she spends a lot of time in bars she probably has a significant second hand smoking history and is at increased risk regardless of personal history.

          • Isabel

             /  October 10, 2010

            And if she wrote about even a tiny percentage of this on Facebook or emails you would say she was a fool and counsel her to only put something in an email or Fb that you don’t want the whole world to see. But when it come to the medical profession, just keep answering the endless questions as the technician dutifully types every detail into the database, where it will exist for evermore.

            If you object, why, you’re holding back the profession! Don’t ask questions. Just answer them!

          • Dianne

             /  October 9, 2010

            Is it too expensive to run the tests or something?

            Cost is not the only issue involved in testing considerations. Some tests can be dangerous. And even if the test is benign, a false positive could lead to unnecessary treatment.

          • JJM

             /  October 10, 2010

            Isabel wrote “… You have not explained why PalMD needs to know who got it from who before he can make sense of the situation, and move forward to diagnosis and treatment.

            Assuming it is an STI it matters because the doctor needs to know who else may need to be treated. If she hasn’t had sex with her husband in a while, she needs to make sure she doesn’t give it to him. If they have been active, he may need treatment, too, in order not to re-infect her after she has been cured (also, so he does not suffer from the STI).

          • Isabel

             /  October 10, 2010

            Um yeah, we get all that. BUT WHY DOES PALMD NEED TO KNOW THE DETAILS? I keep explaining he can counsel her without extracting a single detail. The two are completely unrelated!! He tells her “Everyone you have had sex with (or unprotected sex or whatever) MUST come in for an examination etc etc etc…” Why the fuck does he need to know who needs to be treated? Can he do anything about it anyway? The names and details are useless. I think the patient knows who needs to be told. This is paternalism at its worst, imo.

          • @isabel, I don’t recall asking for names. I also don’t recall asking for prurient details, although it can be very important whether there was oral/anal/genital contact and with what.

          • Isabel

             /  October 10, 2010

            Oh come on. You know what I was referring to. Why do you need to write everything down? So now you need to put in her chart, which nowadays means it will go on the computer and be accessible to others over the internet, and to insurance companies etc, that the women works full time and has a teenage son and cheats on her husband and smokes on the weekend and picked up a guy in a bar and gave him a blow job in the parking lot before you can treat the poor woman?

  4. shasta

     /  October 8, 2010

    Inform her of her options with regard to the fact that insurance or labs may come back to her husband if he is the primary insurance holder. She may opt to go to Planned Parenthood for those tests and pay cash for those tests instead when she realizes that .

    There is probably a way to word it in her chart that she is a married woman “with history of other, past sexual partners ” or “married with history of other sexual partners at some point in her past”. to where it’s vague enough that time lines won’t be deduced.

    Idea: since it’s your record, that you use to remember stuff and make the right decisions, why not use a code–one that you know what it means, but is specifically generic should outside eyes get a look at it they won’t have any idea what you’re referring to.

    also, I didn’t hear you mention, that you would suggest some therapy or counseling to her.

    • I guess I’m a stickler for accuracy in the chart. Yes, I can choose to make vague statements, but in medicine, small details often make a difference, sometimes a difference that wasn’t predicted.

      As to therapy, if she wishes to continue marriage counseling or some such, fine, but infidelity per se is certainly no reason to suggest therapy.,

  5. Isabel

     /  October 9, 2010

    “I believe that there is substantial societal good that comes of people being able to seek and obtain completely anonymous acute medical care in relation to possible STDs.”

    Anonymous and free.

  6. SurgPA

     /  October 9, 2010

    I empathize with your patient, but she is asking you to participate in her deception of her husband by omitting from her chart information that is key to your presumed diagnosis. To my thinking, you must chart the pertinent social history if you are going to pursue the diagnosis of an STI; it would be dishonest not to and could complicate her future care (as you note). You should, of course inform her of this. My concern is that if you simply accede to her request, you and she will both know you committed a lie of omission for her, and this will damage your relationship going forward, setting precedent should you and she have future differences of opinions.

    I think this can be managed with good communication, though. She is not obliged to accept your care for this issue. I think you can ethically inform her of your clinical suspicion and the reason the social history is an important detail. You can also inform her that insurance billing may divulge her secret to her husband. You can further inform her of her option to utilize a free-standing clinic (planned parenthood, “doc-in-a-box” or other) in a cash transaction that would preserve her relative anonymity. She is then free to choose her option and is not coerced by a lack of viable options. This preserves your integrity while providing her the means to access appropriate care.

  7. Dianne

     /  October 9, 2010

    In principle, you should be able to reassure the patient that her medical records are confidential and can only be viewed by you, her, and someone with a court order. But that’s not always the reality. Suppose your patient’s name was Michelle Obama? Could you reassure her that no reporter would ever get the records without her consent? More prosaically, someone at the clinic might be friends with her husband, see the chart, and tell him what was in it. Or the microbiologist that runs the test might know the couple. If you use EMR, there’s always the chance of someone hacking into the records for whatever reason as well. The records are by no means perfectly protected, despite our best efforts.

    That being so, how would you feel about using an ambiguous statement in the chart? Say, writing something like, “Patient is concerned these symptoms could indicate an STD”. One might read that statement to mean that she had had extramarital sex-or that she feared her husband might have. Or that she was worried about reactivation of an old infection. (Some STDs can be asymptomatic, so it might be vaguely plausible to consider that she might have had, say, chlamydia from an encounter years in the past.)

    This may all be irrelevant since, as you pointed out, the bill can be revealing and is not confidential.

    My impulse is to say that the best initial route would be a frank discussion with the patient about the risks, benefits, and alternatives of getting tested immediately, i.e. going to Planned Parenthood or similar clinic. If she has access to one and the time to get there. And the cash to pay for it. And doesn’t convince herself that it’s all her imagination before she goes.

    It would also be important to ask more about her problems with her husband. Has he been abusive? Does she suspect him of cheating? Does she feel safe at home? What does she fear might happen if her husband found out about the encounter?

    Sorry, this comment is a bit disorganized.

  8. Necandum

     /  October 9, 2010

    Would a compromise be possible?

    That is, you write down the full history in your own records, but add a line indicating that this particular piece of information should not be divulged to anyone outside your office (other doctors, insurance company, clinic ect.) without her explicit consent?

    That way, you’ll still have the information for making decisions in the future, but no one else need know, unless they manage to hack your computer system.

    • The entire medical record is supposed to be that way. It has not secret caves.

      • Vicki

         /  October 11, 2010

        I thought that HIPAA’s list of who my medical information can be shared with included the insurance company (in my case, selected by my employer: I had the options of insurance or no insurance, but not a choice between insurance companies within that); is it impossible (legally or practically) to annotate something as “do not share with insurance company” if the patient opts not to have tests, or to pay for them out of pocket so the insurer won’t see a bill?

  9. Barquentine

     /  October 9, 2010

    I don’t really see an ethical problem here.

    First, contemporary doctors in most countries are forced to practice “defensive medicine”, i.e. they are trying to protect themselves against possible lawsuits. The most important thing is to have impeccable documentation.
    After explaining to the patient that a doctor cannot lie in the chart and after informing her/him of their other possible options, they are free to choose what to do.

    Second, I can’t really sympathize with such patients because what they are trying to do is shift the responsibility for their own medical problems and their consequences solely onto their doctors (not only for STDs, but even for the running nose of their children). This is not how the doctor-patient teamwork should function.

    Third, if a patient doesn’t want to to disclose a piece of sensitive information, he/she is not obliged to but once it’s on the table, there is little they can do about it.

    • All of those thoughts are quite common, but as a whole, the comment goes very much against most of our basic medical ethics.

      • Barquentine

         /  October 9, 2010

        Yes, I agree it’s hardly an original idea. I am wondering though, what part of my opinion goes against most of the basic medical ethics.
        Are you, personally, really willing to take the risk of not writing down this important piece of information, putting at risk your job or medical license? Just wondering.

  10. Isabel

     /  October 10, 2010

    Another concern – all my life I have heard that many STD’s can initially have vague or no symptoms, and given that we know cheaters and young people (i.e. those most at risk) are likely to be less than honest about their sexual activities, why are we only testing when we have clear symptoms and detailed, conclusive personal activity info? I’d like to hear more about this angle. I really liked Karen’s idea about testing all sexually active people regularly, or at least automatically if they have any symptoms.

    • ginger

       /  October 11, 2010

      Back in the day I volunteered at my local Planned Parenthood, and the policy was exactly that, Isabel – female clients in a given age group were asked whether they were sexually active in the past X months, whether they’d had any new partners in that period, how many partners they’d had, and so forth, and were offered testing for STIs whether they reported symptoms or not. Of course, everyone who reported symptoms was also offered testing, and if a client was in for a pregnancy test, she was offered testing.

      The algorithm questions were asked of everyone, the same way – the idea was that using the algorithm removed the value judgment from the situation. Instead of deciding that this person was promiscuous or that person was “clean” or some other bullshit of that sort, the fundamentals were dictated by the literature risk factors related to transmission behavior – partner change in a certain timeframe, total number of partners, etc. instead of marital status or religion or education, personal factors that would lend themselves to making a personal judgment rather than a clinical one. (Yes, there are correlations between each of those things and population STI rates – but that is largely because they proxy individual and network behavior.)

      (The reason age group was considered was twofold: the degree of partner change in the population was higher in younger age groups, and young women were thought more vulnerable to ascending pelvic infection because of the histology of the cervical os.)

      • And much of that is information that some commenters seem to think irrelevant.

        • Isabel

           /  October 11, 2010

          Ginger,
          So you ran some algorythym and decided who to test for what? Why not just test for the six most common STD’s or something? Your system still sounds judgmental in a way, as PalMD points out, and likely to not always get honest results. Plus a lot of patients won’t match the expected probabilities, but won’t get tested for something they may have. I’m curious to know which tests are risky, and are the others expensive or something?

          • Isabel

             /  October 11, 2010

            Sorry, *algorithm*, lol. I forgot to spell check.

  11. Isabel

     /  October 10, 2010

    Oh and I don’t mean mandatory testing of course. I mean during regular check-ups, and when they come in with symptoms that might point to STDs. And making it a low-stress experience, and free to those without insurance. Obviously many carriers could be discovered this way, for starters. And many also suggest the benefits of anonymous testing, although I’d like to think that wouldn’t be so necessary if visits to primary caregivers weren’t so intrusive.

  12. How does the patient know her husband is leading a virtuous life free of marital infidelity? Granted, she’s got STI symptoms which led her to the present debacle, but other things could be at play. If it really had to be kept off the record, I would suggest going to the county health department or Planned Parenthood, where you can pay in cash on a sliding scale.

  13. So, Isabel, you think a thorough history is unimportant, right? Because there is no way this could go wrong, right? We try to note every piece of evidence we can, because we don’t know what the future brings. We don’t see a single patient for a single moment and then move on. Anything may turn out to be important, even if you don’t think so.

    You seem to have this vending machine fantasy of medicine, where nothing is every inconvenient and the patient simply gets whatever they want no matter what.

    So, if a patient says they have cancer and want medical cannabis, should I simply leave it at that and write the rx without asking some more questions?

    • Isabel

       /  October 11, 2010

      I have no idea what you are talking about. I am merely suggesting that you do not need to know, or to permanently record, that your patient had an extramarital affair with a man she met in a bar in order to treat her successfully, and ethically, for an STD.

      It is impossible to go to any doctor with any symptom nowadays without ending up in the lab donating multiple vials of blood for analysis, thus regularly traumatizing the 10% or more of the population that is needle-phobic. Unfortunately, doctors can no longer diagnose anything with having the results of these tests to refer to.

      But for some reason we are very reluctant to test for STDs, despite the potentially far greater public health benefits.

      • Dianne

         /  October 11, 2010

        I am merely suggesting that you do not need to know, or to permanently record, that your patient had an extramarital affair with a man she met in a bar in order to treat her successfully, and ethically, for an STD.

        If you go back to the original case, you might notice that the presenting complaints were those of an uncomplicated UTI. It was only after the social history, including the sexual history, was taken that the issue of STDs came up. (It’s still most likely a UTI.) If I were to go to the doctor with UTI sx and s/he demanded that I get full STD screening, I’d probably say, “Huh? Why? I’ve been monogamous since the 20th century.” It would be a waste of time and resources and an unnecessary, awkward exam.

        Writing something in the medical record is in no way the equivalent of posting it on facebook. The protections aren’t perfect-they never were and they never will be-but legally it is protected. If the IT department is competent, the EMR can’t be accessed from outside except on a registered computer and with a rotating strong password. The bill, OTOH, is pretty much public knowledge and not asking about or writing down details of social history won’t stop the patient’s husband from seeing that she had STD testing if he reads the bill. And if he is the primary payer then the bill “belongs” to him. If the doctor had NOT asked about sexual contacts but simply done the testing as you propose, the husband would get a bill which included line items for testing for chlamydia and, if he were suspicious, had his suspicions confirmed. It is only because the issue was explicitly addressed that the option of getting tested anonymously came into play.

        • Isabel

           /  October 11, 2010

          Okay, now you are losing site of the topic. What is making patients uncomfortable and possibly not coming in for treatment? Or driving them to anonymous clinics, so that their primary physician now not only doesn’t know every detail of the patient’s sex life, he/she doesn’t know what is going on with their basic medical care. That is what we are discussing.

          You are also deliberately misreading my comments, which is why the internet is so fucking annoying. Okay maybe the internet is not unique in this. But I KEEP SAYING it is reasonable to ask

          1) are you sexually active
          2) have you had unprotected sex

          The patient objected to details about the affair being recorded.

          Okay I am officially exhausted from repeating myself. Really people is it so hard to follow a thread?? No hope of getting anywhere as usual.

          • Yeah, that set of questions is still going to give unacceptable answers to my patient. She’s not gonna want that written down.

          • Dianne

             /  October 11, 2010

            The goalposts are scuttling off into the distance…earlier you claimed that it was not necessary to document whether the patient was sexually active at all! (See comment Oct 9 at 8:51.) Now you’re saying it’s ok to ask if the patient was sexually active but not to explore issues like whether she has a new partner recently, whether all her recent sexual activity was cosentual or whether she is at risk for being abused by one or more of her partners.

          • Isabel

             /  October 11, 2010

            Have fun “exploring” Diane. I think I will consider the anonymous labs from now on. You remind me that I have noticed the paternalistic probing for signs of abuse in relationships etc also in recent years. This may be welcomed by some, perhaps necessary with very young people in some cases, but not by others.

            I have made my position clear from the start. The patient said she didn’t want the Doc to “write about the guy”.

            “She’s not gonna want that written down.”

            Then clearly she needs to go to an anonymous clinic, but now you are assuming something about her that was not clear in your OP. I also said the second question could be optional. Maybe you could ask if she feels she should be tested for STDs. She’s not at confession, and she is an adult.

            What is the point of driving people away with your nosiness? Well have fun! (I can see some wounded egos here. awww)

          • Vicki

             /  October 12, 2010

            The group of patients who may be abused is not limited to the young and naive. I have a friend whose ex-husband was abusive.

            She’s a white, middle-class professional who was in her 40s at the time.

            One of the reasons that doctors ask questions like that is because so many people still assume that abuse is something that happens to “them,” and is done by the “wrong” sort of person: the image is of a poor or nonwhite or non-Christian or immigrant household, not a well-to-do doctor in the suburbs, or a police officer from a “solid family.”

            You’ve noted elsewhere in this thread that a monogamous person cannot be sure that her husband doesn’t have other partners, and that her doctor has to take that into account if the patient has STI symptoms. Given that, why is it “paternalistic” for a doctor to worry that some of her/his patients may be suffering abuse, a problem whose pattern includes concealment and denial.

        • Isabel

           /  October 11, 2010

          Also your comment here and many on this thread are paternalistic in the sense that they assume the patient is powerless to figure any of this out on her own.

          • I don’t know PalMD other than by his blogging, but my impression is that the only person he is paternalistic to is his child, for whom paternalistic actions are appropriate because he is, in fact, her parent. It is not paternalistic to want to provide the best possible medical care. It is wanting to be the best health care provider that one can be.

            My perception of the issue is not that the patient doesn’t trust PalMD, she willingly told him. She doesn’t trust the security of the medical record. PalMD isn’t asking these questions and writing down the answers to satisfy his prurient instincts, but as data to do a differential diagnosis.

            Some patients (and some clinicians) do have boundary issues. I don’t think the issues that PalMD raised have to do with his boundary issues.

            The patient’s request that data not be recorded is her telling PalMD how he is to do his job. There is a saying among lawyers that the lawyer who represents himself has a fool for a client. The same is true of health care providers. I think he was interpreting her request as “data” to be understood and not as an order to be followed (or not). He is the expert in his job, not her, just as she is the expert in the symptoms she is having, not him. They need to exchange information to achieve optimal health care for her, which is PalMD’s job.

            He can’t just order tests because no test is 100% reliable. There are false positives as well as false negatives. The patient is in clear distress and is depressed. Is she suicidal? Would she become suicidal if she got a positive STI test? A false positive STI test? A positive pregnancy test? Is it soon enough for her to take something that would prevent pregnancy? Does she want something that will?

            How serious are the “problems” she and her husband are having? Is she being battered? Would she be battered if her husband found out she had an STI? Was unfaithful? Was pregnant? How long have they been married? Is the husband the father of her teenager? Is the teenager at risk? Are there guns in the home? Does she need protective services? Does she know everything that she might need depending on how this situation plays out?

            I don’t know the answers to any of these, but the answers are important and can’t be figured out without more information. It is not paternalistic for a health care provider to want to know the answers to these questions to provide her with information she may need to make decisions that will optimize her health. If PalMD was female, would it be paternalistic for her to be asking these questions? The gender of the health care provider isn’t what confers “paternalistic behavior”, it is infantalizing behavior on the part of the clinician. It is the clinician deciding what is “best” for the patient for things which are and should be the patient’s decision. Being a resource for the patient is not being paternalistic.

          • Isabel

             /  October 12, 2010

            Okay, I am totally wrong in my perceptions. You are all totally correct, and know the right way to proceed. Problem solved!

            My perceptions and suggestions, as a patient who, as I explained early on, is naturally open with medical professionals but in recent visits have found myself responding as Pal’s patient did, are useless, and I must be beaten down until I agree.

            Okay I agree. Let’s move on then.

          • Isabel, it is certainly not my intent to beat anyone down, and it should also not be anyone’s intent to beat PalMD down. This exercise in ethics is a complex situation, and there may be no unambiguously “correct” answer.

            No one has assumed this woman was unable to figure out any of this stuff on her own. She decided that she didn’t want to figure it out and deal with it on her own and so she came to PalMD. In the context of this exercise, we are still suspended in the moment of time just after she told PalMD to not write stuff down and PalMD is thinking to himself “they are my records, I can write in them what ever I want to” while pondering what he should actually do and say. We still don’t know why she is upset, and won’t know without further investigation. If she is upset over something that PalMD can fix (and he can only know that after he knows what is upsetting her), then once he finds out what it is, he can help. If he can’t help, then she is no worse off than she is now. There may even be things that he can fix that she doesn’t even know are wrong.

            It is paternalistic to assume for the patient what questions she should or should not be asked. Probing about abuse may be perceived as “paternalistic” by those who don’t need it. Such people should be grateful they don’t need it, and be grateful that their health care provider still asks the questions even when some patients get snarky about the health care provider being “paternalistic” for asking about abuse, as if just asking the question implies there is something “bad” or “wrong”, or “broken” with the patient. The reason they ask is because they can’t tell unless they do ask. It is my understanding that health care providers today ask more questions but are actually less paternalistic than health care providers in the “good old days”.

            Being paternalistic is about taking away patient autonomy, not about going through a list of questions. In the anonymous clinic they go through an even bigger list of questions. Why is the anonymous clinic perceived to be less paternalistic even though they ask more questions?

            Let me add that I really don’t like how replies get narrowed down so much.

        • Isabel

           /  October 11, 2010

          “with UTI sx and s/he demanded that I get full STD screening, I’d probably say, “Huh? Why? I’ve been monogamous since the 20th century.” It would be a waste of time and resources and an unnecessary, awkward exam. ”

          Your husband may not be faithful and practicing safe sex. I would test you first for UTI based on your protestation, but if that was not positive, or treatment did not clear up your symptoms, I would again suggest other tests. We cannot assume anything about your partners’ behavior. Right?

  14. drugmonkey

     /  October 11, 2010

    Dude. Pal. It is completely and utterly irrelevant if a patient has, say, a history of dependence on marijuana when you assess their claim. Just write them up for MMJ, man. Run Tests. Write Scripts. That’s the job, right?

    • Isabel

       /  October 11, 2010

      If people can afford it, I recommend http://www.stdtestexpress.com/std-testing-faq/ or the like.

    • Isabel

       /  October 11, 2010

      I don’t really get the analogy. No one is talking about barging in insisting on a particular diagnosis and treatment. But the question remains, why can these anonymous clinics, such as planned parenthood have the ability to do the job then? Maybe you ARE over-emphasizing your role. That’s the whole point of the paternalism charge.

      • Dianne

         /  October 11, 2010

        But the question remains, why can these anonymous clinics, such as planned parenthood have the ability to do the job then?

        Do you have any idea how anonymous testing actually works? You don’t just go up to the window at McClinic and order a helping of STD tests with a side of HIV screen. If you go to an anonymous clinic, you get assigned a number which you must have available in order to receive the results of testing. You get asked every one of the “invasive” questions you objected to above. You receive counseling on STD and HIV prevention. You pay cash so that the weak link in the anonymity chain, the bill, becomes irrelevant. You receive the results only if you come back with the correct number and you receive further counseling and treatment options (if relevant) at the time.

        • Isabel

           /  October 11, 2010

          “Do you have any idea how anonymous testing actually works? ”

          Yes, I’ve been tested anonymously. What is your point? And really? They ask you about the guy in the bar, and write it all down in your chart before they decide what to test you for? I don’t remember that part.

          And yes, you CAN apparently order up a package deal at the place I linked to. You do not need to justify each test with a litany of “sins” to be permanently recorded on your chart.

  15. Frameshift

     /  October 11, 2010

    Dear PalMD,

    I very much enjoy your blog, and I really have enjoyed this thread. As a future doctor myself, I appreciate hearing how doctors deal with these ethical issues.

    How familiar are you with HIPAA? The Health Insurance Portability and Accountability Act of 1996? I believe that there are plenty of provisions there to protect your patient’s privacy without sacrificing your integrity or her standard of care.

    Peace,
    -Frameshift

  16. I don’t know…I think Isabel has a point. Okay so you know how she contracted the STD, but as others have mentioned, what difference would it have made if it was the patient’s husband who was unfaithful? Yeah it would have made a difference to the patient, and to her husband, but not to how you treat her. Last time I went in they asked if I was sexually active and started telling me I should get tested for chlamydia, then they looked at my chart and saw I was married and said “oh nevermind.” I’m not sure a ring on the finger should really affect their medical judgment. If I’m sexually active, they should probably test me, like they are testing all the other sexually active people, married or not. You could be in a committed relationship or not, it shouldn’t matter. And since you can’t tell the husband about the STD, again I fail to see its relevance. If you could warn him about contracting it, fine. But these all sound like conversations you’d have with the patient AFTER she tested positive, warning her that anyone she has had sex with should come in and get tested, then the ball is in court. It shouldn’t matter she is married, promiscuous, or whatever.

    If Isabel is sick of invasive testing she should go see my doctors lately who are like the reverse WebMD I like to call them. Totally useless but assure you whatever you have is nothing and go away. Are you in pain? Do you want a prescription of Ibuprofen? No thanks, I did not come here for pain meds I came because I wanted to be sure I’m healthy. I guess by looking at me and poking my abdomen we’ve determined that. Next time I’ll put a sign up that says “it’s probably nothing, go buy some ibuprofen” because it’s cheaper than the copay.

  17. This post and the thread are fantastic. Is this going to be a weekly series? If so, it’s one more reason to look forward to fridays.

    I like diane’s response:
    My impulse is to say that the best initial route would be a frank discussion with the patient about the risks, benefits, and alternatives of getting tested immediately, i.e. going to Planned Parenthood or similar clinic. If she has access to one and the time to get there. And the cash to pay for it. And doesn’t convince herself that it’s all her imagination before she goes.

    You noted that her post was clear despite her concern (I agree), but didn’t actually give a response. Is that because you agree?

    • Gah! I can’t find the original comment. Anyway, one of the points I agree with isabel about is being pretty liberal with STD testing (even though I think history is quite relevant in deciding how to proceed and how to counsel—counseling is part of the package, isabel). Given that I am skeptical of an absolute expectation of privacy, I would inform the patient of the existence of PP, but these resources are limited. It would be nice to be able to order anonymous labs from the office, but it’s not available. Anonymous clinics are few and far between and don’t offer the continuity of care and the personal relationship of your own doctor.

      When treating suspected STIs, you often get only one chance. It’s far better, IMO, to test and treat immediately, if practical and if the patient will allow it.

  18. Katherine

     /  October 13, 2010

    If everyone was in the habit of being regularly tested for STDs, married or not, monogamous or not, safe sex or not, long term monogamous married living with your mother so neither of you can have sex while both of you have tracking devices attached so neither of you can cheat while standing on your head or not, then it wouldn’t look suspicious when you actually needed to get tested.

    Doesn’t solve the dilemna though!

  19. PalMD

     /  October 13, 2010

    No, it does not. We can’t test everyone for every known disease regularly because it screws up the test performance significantly.

  20. It’s between you and the patient. Your primary concern should be her welfare. You can be non descript in your sexual history about her concerns.
    With EMR and even with HIPAA (which is pretty meaningless) almost anyone can get into her records (at a h ospital, at another clinic (with health information exchanges and CCR). The danger here is you are worried about everyone else looking over your shoulder and being criticized, etc. In reality there is probably no chance of your being sued here. By whom? Let’s use common sense and not get run over by the dysfunctional parts of medicine and the wannabes directing traffic.

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