A crisis of confidence
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39521.625486.59 (Published 20 March 2008) Cite this as: BMJ 2008;336:639
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I am delighted Mr Keegan from the GMC has issued a response. I must confess, however, that I would not be terribly reassured if I were a practising clinician. The crucial question remains: How can clinicians who interact with dozens of patients each day ‘make sure that patients are aware that personal information about them [patients] will be shared within the health care team, unless they object, and of the reasons for this’? or, in the words of Mr Keegan, ‘how can clinicians “explain even the basics to new patients” in a manner that is not burdensome, time- consuming and counter-productive?
The non-inclusion of the sentence referred to by Mr Keegan was certainly not intended to mislead the reader. Here is the relevant paragraph, in its entirety, from the GMC’s booklet on confidentiality:
‘Most people understand and accept that information must be shared within the health care team in order to provide their care. You should make sure that patients are aware that personal information about them will be shared within the health care team, unless they object, and of the reasons for this. It is particularly important to check that patients understand what will be disclosed if you need to share identifiable information with anyone employed by another organisation or agency who is contributing to their care. You must respect the wishes of any patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm.’ (available online: http://www.gmc- uk.org/guidance/current/library/confidentiality.asp)
My questions for Mr Keegan and his colleagues at the GMC are this: will the above paragraph, in particular the second sentence, remain in the next edition of the booklet? If so, how can its continued inclusion be justified and how will they deal with the thousands of doctors who presumably violate it on a daily basis? The disciplinary committees could get very busy...
The GMC’s Standards and Ethics team have a difficult task and, in my opinion, do an excellent job. I hope they will not misinterpret my concerns with one section as a denigration of their laudable work.
Competing interests: I am the author of the article
Competing interests: No competing interests
Dr Sokol suggests (BMJ 22 March 2008) that patients are well aware that their personal information will be shared among the healthcare team. We agree. Our guidance says ‘most people understand and accept that information must be shared within the healthcare team in order to provide their care’, a part of the guidance Dr Sokol conveniently overlooks.
Dr Sokol suggests that patients will know this from observing practice in hospitals, and watching medical dramas on television; to ask doctors to provide leaflets explaining how information will be used, or to explain face to face, would be too tedious and time-consuming for doctors.
Most young people’s expectation is that doctors will share their information with parents, social services, the police and others. Many older people’s formative experience of healthcare is that of the single- handed general practitioner, whose notes serve only as personal aide memiore. And a significant number of patients will have had little or no experience of Western healthcare (or less-than-accurate depictions of healthcare from soap operas) to inform their expectations. We would like patients to get their information from more reliable sources than urban myths and medical dramas.
Of course there is a balance to be found between informing patients (through a variety of media) about the uses to which their personal information might be put, so that they can exercise their legal rights, and overburdening them with details they have no desire to know. Our guidance makes clear that. But failing to explain even the basics to new patients – or to improve everyone’s understanding with posters, leaflets and occasional verbal checks or reminders – can only serve to undermine confidence in the profession when unexpected disclosures are made. Providing information need not be unreasonably time-consuming or burdensome to doctors or patients.
Competing interests: None declared
Competing interests: No competing interests
Daniel Sokol is correct - the guidelines on confidentiality may be unhelpful, unnecessary and excessive. It seems abundantly clear that most patients expect healthcare professionals to share information to the extent and in a fashion that is necessary for their comprehensive care. This is similar to the unstated expectation that their doctor won't abuse them. It is taken "as read" and is an important component of the bond of trust bteween patient and physician. To spell this out before each contact with the patient would be absurd and produce a barrier to effective communication which depends heavily upon that trust. There may be occasions when to spell it out would be of benefit, but I cannot imagine that overall adverse affects would not be the predominant consequence. I'm sure this is why in practice we do not follow the guidance. It is indeed a time for a re-think.
Perhaps what is needed is an honest appraisal of times when confidentiality is being unecessarily breached and steps to improve our professionalism in dealing sensitively with patient's stories.
Competing interests: None declared
Competing interests: No competing interests
Daniel Sokol's article on assuring patient confidentiality in a deliverable way in the new millenium is timely, balanced and important.
Electronic patient records, including details of psychiatric illnesses, and electronic transfer of images through PACS, present new challenges for which failsafe methods have yet to be comprehensively enforced and monitored.
The author's experience of his own scan being reviewed by a "friend working in a different part of the hospital" is not unique. While such activity may in the author's case have been well intentioned, access to electronic healthcare data of a colleague may be motivated in other instances by curiousity or even malice. Currently healthcare personnel are especially vulnerable to confidentiality breaches due to their profile in the workplace and the ease of inappropriate browsing by others in the organisation. As sharing of healthcare information through ever wider networks increases , so too does the vulnerability.
Legislation, guidance, local rules and the GMC's "Good Medical Practice" are not enough.
Each day a healthcare professional logs on for the first time , a reminder should appear that he/she should only access data/images of a patient when he/she can, if challenged, justify his/her role in the patient's care and the need for such access.
It should be made clear that such access is monitored, inappropriate access will be investigated and if justified disciplinary action will follow.
Specific external audit of access to records and images of healthcare staff should occur. Such a strategy is necessary to ensure healthcare staff do not delay seeking diagnosis and treatment for illness because of fear of job security etc through current potentially porous and unmonitored access to their data. Such delay could compromise patient safety as well as their own wellbeing.
The need for anonymisation of patient images in lectures and publications including the internet, is well established.The confidentiality needs of individual patients needs to be factored into the considerable benefits in training that can be achieved through access to patients images for teaching in small groups.
Competing interests: None declared
Competing interests: No competing interests
Confidentiality
Daniel Sokol opens up a useful discussion here. The problem is the term "confidentiality." In the dictionary confidentiality is all about "keeping matters private." The Catholic priests use the word correctly.
In medicine we collect lots of information and data to care for our patients. We work in teams. We communicate with others. We could not care properly for our patients if we did not do this.
Would it be better if we went to a concept of "fair and legitimate uses of medical data" and defined the rules clearly on who can access what medical data for what purposes?
Refs. 1. Daniel K Sokol A crisis of confidence BMJ 2008; 336: 639 [Full text] 2. Davies, P Who are we kidding on confidentiality? Hoolet 41 Summer 2004 http://www.hoolet.org.uk/41hoolet/kidding
Competing interests: None declared
Competing interests: No competing interests