Patient Confidentiality Issues Research Articles

When to Operate on Colleagues? An Unspoken Ethical Dilemma among Aesthetic Plastic Surgeons.

As the demand for aesthetic surgery increases, one must consider the distinct ethical challenges that surgeons face in performing such interventions. Furthermore, the practice of plastic surgeons operating on their own relatives may raise notable concerns, including breach of confidentiality, objective decision-making, patient autonomy, and liability. According to the American Medical Association’s Code of Medical Ethics, “physicians generally should not treat themselves or members of their immediate families” except in cases of emergency, due to the potential “influence [on] his or her professional medical judgment and interference with the care being delivered.”1 While the American Medical Association’s Code of Ethics advises against operating on family, there are no clear guidelines on whether operating on colleagues and subordinates (e.g., medical students and residents) is justifiable. The purpose of this article is to discuss considerations for performing aesthetic procedures on colleagues. Several studies have affirmed that aesthetic surgeons are comfortable with operating on their own families. In fact, Slavin et al. conducted a survey on 465 aesthetic surgeons and determined that 88 percent reported they would operate on a spouse or relative.2 Although surgeons achieved low complication rates and favorable aesthetic results, there are additional considerations that may confound the mere decision to operate. A key concern involves the risk of compromising professional objectivity, which can be detrimental to overall patient care. Another concern lies in the mismanagement of the protocol of informed consent, which may preclude discussion of potential complications and poor clinical outcomes. The situation may, in fact, grow more complex when surgeons consider operating on their colleagues, such as fellow attendings, residents, or medical students. In addition to the aforementioned issues, surgeons may face greater scrutiny when operating on other medical professionals.3 Furthermore, given the professional exposure to surgeons’ skills, medical professionals may be more cognizant and critical of aesthetic and functional results. The Hippocratic Oath states, “To reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required.”4 However, appreciating a teacher or offering assistance does not equate to providing aesthetic surgical care to colleagues.5 This ultimately leaves the discussion open to debate in today’s medical world. We contend that the decision to operate on one’s colleagues is a personal one but requires multiple considerations (Table 1). Furthermore, given our positive experience when treating colleagues and trainees, we provide a series of recommendations that can help the plastic surgeon navigate the decision to operate on a colleague or trainee (Table 1). In relaying this information, we aim to spark an open discussion on this topic to resolve this dilemma. Table 1. - Recommendations for Determining How to Approach Operating on a Medical Colleague Dos Do Nots Intervene if the colleague-physician relationship is considered to be only professional, meaning that it conforms to the expected technical and ethical standards of the medical profession (taking into consideration the principles of informed consent, patient autonomy, and objectivity).Treat the colleague like a lay patient. Intervene if the colleague-physician relationship is considered to be more than professional. Treat the colleague in a preferential manner. Establish a professional boundary and discuss treatment management, concerns, and ethical and financial issues early. Feel pressured to accept every colleague’s request for treatment. Refer the colleague to someone else if you decline to provide treatment.Connect medical professionals with opportunities to gain second opinions for the procedure. Leave the patient without a referral if you decline to provide treatment. Provide medical professionals with the equivalent materials/instruction for the operation, preoperative and postoperative course, and so on. Perform the procedure of informed consent as you would do for any other patient and respect the patient’s final decision regarding the procedure. Carry out an objective history and physical examination in order to ensure the best care possible for the patient. Follow the well-established scheduled clinical visit time course (from preoperative to postoperative timepoints), as you would do for any other patient. In conclusion, performing procedures on colleagues and trainees presents a unique set of challenges for plastic surgeons. In considering the important issues of patient confidentiality, autonomy, objectivity, and liability, we propose a series of recommendations for aesthetic surgeons to guide decisions on how to pursue operating on colleagues. Future studies should elucidate the prevalence of such arrangements and assess the clinical outcomes and satisfaction conferred by such procedures. DISCLOSURE The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.

Confidentiality at the interface of an adolescent psychotherapy service

AimsAims included to explore how, within a London trust, staff at the interface between patients, relatives and access to services view their understanding of confidentiality, and to determine ways to improve knowledge if needed.BackgroundConfidentiality is essential to the trust and development of clinician-patient relationships. National policies set guidance on how confidential information should be recorded, secured and shared. However, confidentiality breaches are reportedly common within health professions. Working with adolescent patient groups brings additional issues regarding confidentiality. Care-givers who contact services, often desiring containment, may experience a sense of uncertainty when confidentiality policy prevents details being shared about a young person's clinical experience.MethodStakeholders were identified from the multidisciplinary team, with a collaborative rather than ‘top-down’ approach. Administrators in patient-facing roles were surveyed to ascertain current understanding and frequency of involvement in confidentiality issues. Based on feedback, a flowchart prompt was designed, ensuring it reflected best practice. Qualitative and quantitive data were collected before and after a two month implementation period.ResultAll respondents (n = 10) dealt with confidentiality issues at work, with 50% experiencing issues daily. 33% respondents did not feel confident dealing with confidentiality queries at work. The majority (60%) had received confidentiality training, but all respondents thought extra information would be useful. Of possible interventions, 70% supported a flowchart. Following an implementation period, 100% respondents re-surveyed agreed they felt confident dealing with issues related to confidentiality at work. The majority of respondents had used the flowchart and found it useful (83%). Qualitative data gathered suggested rolling-out the project elsewhere.ConclusionA lack of confidence surrounding issues with confidentiality, including information sharing, was identified. This can negatively impact patient engagement and delivery of care. The introduction of the confidentiality flowchart demonstrated improved understanding of, and confidence in, patient confidentiality issues. The small sample size means there are limitations in extrapolating findings to wider contexts. However, it is likely that more confidentiality training and practical information for NHS staff at the interface between patients, clinicians and services would reduce the risk of confidentiality breaches and reinforce positive relationships with services.

Carer involvement in compulsory out-patient psychiatric care in England

BackgroundThere is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process.MethodWe conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements.ResultsWe found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers' involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers’ knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such ‘proxy’ for patient decision, ‘gatekeeper’ to services, ‘mother’ or ‘expert carer’, however, conflict with one another and make the overall role unclear.ConclusionsThere is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.

A Case Suspended in Time: The Educational Value of Case Reports.

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.

Confidentiality protections versus collaborative care in the treatment of substance use disorders.

Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients’ primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.

It's time for alltrials registered and reported.

AllTrials The Cochrane Collaboration has become a lead partner in the AllTrials initiative (AllTrials.net), a campaign to ensure that all clinical trials are registered and the results reported, for all treatments in current use. Cochrane joins Sense About Science, Bad Science, the BMJ, the James Lind Initiative, and the Centre for Evidence Based Medicine in leading this international campaign, which has already signed up over 200 research bodies, regulators, and patient groups, and nearly 50,000 individuals. This, though, is just a beginning. Everyone involved in medical research knows that we only see parts of the picture of how treatments work and in whom. There are ‘known unknowns’: studies not yet conducted and comparisons not yet made, for example. We can press for the funds and motivation to do them. There are ‘unknown unknowns’: limits to our current understanding that we can only guess at, such as the extent to which epigenetics might sweep away working assumptions about how we respond to drug treatments. But medical research is suffering from something far less explicable: ‘unknown knowns’. Trials are run and data are gathered, but what many of them found is kept a secret. Researchers, doctors, and patients cannot benefit from knowledge that they are unable to obtain. Around half of all the clinical trials that have been conducted have not yet been published, and trials with positive results are twice as likely to be published as others.[1] The problem of failure to report the outcomes of trials exists for industry and non‐industry trials, internationally, and at all stages of drug development. A cross‐sectional analysis of trials registered and completed on the FDA‐run registry ClinicalTrials.gov between 1999 and 2007 found that 56% of industry‐sponsored trials and 40% of non‐industry, non‐government‐sponsored trials had been published.[2] Compared to all the other challenges of medicine, the missing information about clinical trials is a routine barrier to knowledge, and its solution is a simple matter of communication about what is known. It is strange that we have lived so long with a problem that can be fixed relatively easily. It is unfair to patients and trial participants, it is frustrating to researchers and medical practitioners, and it is completely unnecessary. One of the reasons that the problem of missing trials has not been addressed is that discussions have taken place behind closed doors, amid promises that “it is being fixed”. Behind those closed doors, arguments to slow and complicate the path to improvement can thrive. These arguments have been redeployed against the AllTrials initiative. The problem is fixed. It shouldn't be discussed in public because it undermines trust in medicine. Publishing research results causes scare stories. The regulator has what it needs, and we should be content with that. Patients are alarmed that their information might be shared. It wastes resources. The problem is being exaggerated. And so on. These are not, though, the arguments of people with greater insight into the problems of clinical trial reporting. They are the arguments of people who don't want change. The problem is not fixed. We have seen a slow improvement in registration compliance and reporting rates, but the medicines that are currently prescribed for patients already have marketing authorisation. This is why AllTrials is calling for retrospective publication of trials relating to treatments in current use. Talking only about the conduct of future trials is just kicking the ball further up the street, which is what has happened since Iain Chalmers first sounded the alert on the problem of non‐reporting 20 years ago.[3] Registering protocols and reporting outcomes do not present insurmountable patient confidentiality issues. GlaxoSmithKline, the first pharmaceutical company to sign up to AllTrials, has agreed to publish the results of all trials going back to its formation as a company, which shows it can be done. Under the glare of the public spotlight now on this issue, the arguments against communicating trial results disappear into the shadows. AllTrials is an opportunity for us to come together to ensure that this public spotlight continues to shine on the dark corners of missing trials until there is change. There are no new arguments here. Patients have expected and continue to expect their treatments to be based on the best available evidence.[4] Clinical trial participants expect to be contributing to knowledge about their disease and future treatments. Policy‐makers expect to be able to make decisions about effective and efficient health care. We all expect researchers to know what is known and to be free to analyse it. All of this underlines the valuable and necessary role of The Cochrane Collaboration in this essential campaign. Please sign up and urge other individuals and organisations to do the same at AllTrials.net. This editorial is also available as a podcast.

Access to regulatory data from the European Medicines Agency: the times they are a-changing

Systematic reviewers are increasingly trying to obtain regulatory clinical study reports (CSRs) to correct for publication bias. For instance, our organization, the Institute for Quality and Efficiency in Health Care, routinely asks drug manufacturers to provide full CSRs of studies considered in health technology assessments. However, since cooperation is voluntary, CSRs are available only for a subset of studies analysed. In the case of the inhaled insulin Exubera, the manufacturer refused to cooperate and in 2007 we asked the European Medicines Agency (EMA) to provide the relevant CSRs, but EMA denied access. Other researchers have reported similar experiences.In 2010 EMA introduced a new policy on access to regulatory documents, including CSRs, and has also undertaken further steps. The new policy has already borne fruit: in 2011, by providing additional sections of relevant CSRs, EMA made an important contribution to a review of oseltamivir (Tamiflu).Unfortunately, speedy implementation of the new policy may be endangered. We define a CSR following the International Conference on Harmonisation (ICH) E3 guideline. Although this guideline requires individual patient data listings, it does not necessarily require that these listings be made available in a computer-readable format, as proposed by some regulators from EMA and other agencies. However, access to raw data in a computer-readable format poses additional problems; merging this issue with that of access to CSRs could hamper the relatively simple implementation of the EMA policy. Moreover, EMA plans to release CSRs only on request; we suggest making these documents routinely available on the EMA website.Public access to regulatory data also carries potential risks. In our view, the issue of patient confidentiality has been largely resolved by current European legislation. The risk of other problems, such as conflicts of interest (CoIs) of independent researchers or quality issues can be reduced by transparency measures, such as the implementation of processes to evaluate CoIs and the publication of methods and protocols.In conclusion, regulatory data are an indispensable source for systematic reviews. Because of EMA’s policy change, a milestone for data transparency in clinical research is within reach; let’s hope it is not unnecessarily delayed.

Integrating information on substance use disorders into electronic health record systems

For reasons of safety and effectiveness, many forces in health care, especially the Affordable Care Act of 2010, are pressing for improved identification and management of substance use disorders within mainstream health care. Thus, standard information about patient substance use will have to be collected and used by providers within electronic health record systems (EHRS). Although there are many important technical, legal, and patient confidentiality issues that must be dealt with to achieve integration, this article focuses upon efforts by the National Institute on Drug Abuse and other federal agencies to develop a common set of core questions to screen, diagnose, and initiate treatment for substance use disorders as part of national EHRS. This article discusses the background and rationale for these efforts and presents the work to date to identify the questions and to promote information sharing among health care providers.

Table of Contents

AbstractBattle Lines Drawn Over Patient Confidentiality IssuesOklahoma Counselors Could Gain Delay in Loss of Payment for Therapy ServicesTechnology and Consent Can CoexistHow to Cooperate With 2010 Census and Preserve ConfidentialityCombined Deductible Benefits PatientsAATOD Calls for OTPs to Report Patient DeathsBriefly NotedState NewsCall for ApplicationsComing up

Families' Experience With Seeking Treatment for Recent-Onset Psychosis

Families' Experience With Seeking Treatment for Recent-Onset Psychosis

Pharmacists' Role in Depression Care: A Survey of Attitudes, Current Practices, and Barriers

Pharmacists may be well placed to take up a role in depression care, complementing the role of general practitioners. However, depression care is a relatively new role for pharmacists, and little is known of their attitudes, current practices, and barriers toward it. A random sample of 200 community pharmacists in Belgium was surveyed about the care of patients with depression in comparison with patients with other, physical conditions. The 69 pharmacists who responded to the survey generally endorsed a very positive attitude toward their potential role in depression care. This willingness was, however, not reflected in current practice, and fulfilling this role appeared to be more difficult with patients with depression in comparison with patients with other, physical conditions. A lack of training in mental health issues was the most important barrier reported. Cooperation with general practitioners in depression care was desired, but the current level of cooperation was rather low. For pharmacists to effectively take up depression care, perceived barriers need to be addressed through specific training programs and increased cooperation with general practitioners.

Pharmacists' Role in Depression Care: A Survey of Attitudes, Current Practices, and Barriers

Pharmacists' Role in Depression Care: A Survey of Attitudes, Current Practices, and Barriers

Litigation and Doctor-Patient Confidentiality.

When a patient sues a healthcare practitioner with regard to their care, the healthcare records are an important part of the evidence used in the case. Litigation is usually heard in open court in the presence of the public and information contained within the records can be aired in that public forum. The issue of patient confidentiality and litigation arose in the case of Kadian v Richards [2004] NSWSC 382, which forms the basis for this report. The decision in Kadian preserves the right of patients to confidentiality of their medical records other than when a patient sues a practitioner for negligence in the delivery of health care; the loss of confidentiality is limited to what is necessary to enable the defendant doctor to prepare an adequate defence; and patient-doctor confidentiality with subsequent treating doctors is preserved unless it becomes inconsistent for the plaintiff patient to press on with litigation while continuing to maintain a full obligation of confidentiality with those doctors.

Using a standardized patient walk-through to improve implementation of clinical trials

This report describes a standardized patient (SP) walk-through to facilitate implementation of a clinical trial within the National Drug Abuse Treatment Clinical Trials Network (CTN). SPs are actors trained to portray a set of symptoms consistently across interactions with multiple clinicians. The Oregon/Hawaii Node of the CTN employed one SP to pilot participant screening processes in a study testing a combined pharmacological and behavioral therapy for women and men dependent on prescription opioid analgesics. The SP mimicked an individual seeking treatment and “walked” through study intake processes. Findings such as study staff members' inadequacy in describing issues of patient confidentiality and problems explaining the Health Insurance Portability and Accountability Act led to modifications to the clinical implementation of the study. Research coordinators and the staff found the use of an SP to be highly effective. The node is now making routine use of SPs in the implementation of CTN protocols.

The use of OsiriX® software and 3d Reconstructions from diagnostic images as an aid to cadaver dissection and surgical planning.

OsiriX® software allows the trained user to render a 3 dimensional virtual representation based on images captured during diagnostic CT and MRI scans. OsiriX® software can assign levels of transparency and color to select tonal values and stack each slice relative to its position during the initial scan to create “3D Reconstructions” that can be manipulated and exported as image files. These 3D Reconstructions improve the understanding of anatomic relationships as they exist in the living body. They may be used to supplement anatomy instruction, provide an adjunct to traditional dissection, and improve surgical planning.Traditional dissection often requires the removal, displacement or distortion of superficial anatomy in order to access deeper structures. The non‐destructive and reversible nature of virtual dissections allows a trained user to remove or isolate structures selectively, permitting the visualization of a particular region or tissue. Measurements of distance and volume are also possible. Diagnostic images of both living patients and cadavers destined for dissection can be reconstructed and used to correlate diagnostic images to the actual anatomy of a patient or cadaver.Cost and practical concerns of setting up a 3D workstation, usability of the OsiriX® software, as well as patient confidentiality issues will be discussed. Several case studies will be presented.

Patient confidentiality issues and accuracy of medical images used in publications

Patient confidentiality issues and accuracy of medical images used in publications

Reply to ‘Patient confidentiality issues and accuracy of medical images used in publications’

Reply to ‘Patient confidentiality issues and accuracy of medical images used in publications’

Trauma Video Review: A Valuable Resource: In Reply

In Reply.—Upperman et al make some important observations regarding the use and role of video recording in trauma resuscitation education. It is disappointing indeed that the use of video recording is on the decline in the United States, seemingly as a result of medicolegal concerns and resource issues.1 In contrast, although in December 2001 amended health privacy legislation was enacted in Australia to enhance issues of patient confidentiality, our hospital ethics committee and legal counsel were satisfied with the utility and appropriateness of video recording and approved this project. However, in Australia, video recording is not a routine part of resuscitation review, and medicolegal concerns have contributed to the lack of widespread use. We support the more widespread use of this medium, which provides vital audit information not otherwise available and can detect up to 5 times the errors that medical chart review will find.2Regarding changes made to our trauma team, these were not instituted until after the video-recording project was finished, and the published data refer to the time when a surgical team member was the trauma team leader. Issues of leadership and communication are still present, but there is no longer the confusion of roles when the designated leader is not present at the time of patient arrival.Our trauma team has defined membership and preassigned roles. The trauma paging system at the time required immediate attendance by all members. The videotapes were reviewed by the study personnel but not the treating team, and information from the review was communicated to the team members. It is accepted that best practice from an educational point would involve self-appraisal by team members3; this is planned for our hospital, but resource issues have limited the implementation.The communication issues highlighted by Upperman et al are vitally important to the function of any team. The video recording allows clear and irrefutable information on the team leaders’ instructions and the other members’ responses. We did not specifically analyze this but looked for clear leadership and interaction between the team members and the leader. This could be seen as a limitation of our study, but it provided valuable information that lack of clear team leadership was associated with poor communication in all cases.Our study identified resource issues as a major limiting factor to the ongoing use of video recording as an audit tool. The integration of patient notes to monitor recording of vital signs and video into a single electronic program that can be viewed simultaneously is being developed to allow more timely access to all the necessary data.We join with Upperman et al and encourage trauma centers to continue to use video recording to audit trauma resuscitation management. We believe that patient confidentiality issues are surmountable and that electronic interfaces will minimize the resource requirements.

Legal aspects of continence: disclosure of a medical condition

This article explores the issue of patient confidentiality and the exceptions to that duty. Even if a health professional considers that there would be a public interest in a patient's condition being made known, the patient is entitled to have his confidential information kept secret. There are recognized exceptions in law to the duty of confidentiality, and the guidance issued by the health professional registration bodies should be followed.

People with problematic drug use and HIV/AIDS in European prisons: An issue of patient confidentiality

Research has shown that a key issue for prisoners using healthcare services during their sentence is that of patient confidentiality. Maintaining prisoners’ medical confidentiality has been shown to be difficult in the prison setting as many treatments, especially those considered to be out of the ordinary, are more likely to result in a breach of medical confidence. This can include treating infectious diseases, such as HIV/AIDS, Hepatitis or tuberculosis, which can often include long term and regular contact with healthcare staff, and which, in some cases, may require referrals to specialists outside the prison setting. In addition, institutional factors unique to prisons may impact on healthcare staffs’ ability to maintain prisoners’ confidentiality, such as security or health and safety concerns. Drawing on research carried out by the author on healthcare and people with problematic drug use in prisons in a range of European countries, this paper considers the factors that impact on maintaining prisoners’ medical confidentiality and some of the attempts to address this issue.