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Vol. 54, No. 6, June 2008, pp.834 - 835
Copyright © 2008 by The College of Family Physicians of Canada
Commentary |
Breaching confidentiality and destroying trust
The harm to adolescents on physicians’ rosters
Dan R. Reilly, MD FRCSC MHScPractises obstetrics and gynecology in the rural communities of Centre and North Wellington, Ont. He is an Assistant Clinical Professor in the Department of Obstetrics and Gynecology at McMaster University in Hamilton, Ont
Correspondence to: Dr Reilly, 205 Queen St E, Fergus, ON N1M 1L1; telephone 519 787-7418; fax 519 787-7420; e-maildreilly{at}mcmaster.ca
Fear and embarrassment washed over her. How did he know? Dr Jones had told her that no one would need to know. While Laura struggled to find a lie that would safely answer Dr Smith’s accusing question, she decided she would never trust a doctor’s promise again.
Laura had visited Dr Jones at the high school clinic because she needed contraception. Because her family doctor, Dr Smith, and her parents were good friends, she did not want Dr Smith to know she had become sexually active. Dr Jones had reassured Laura that neither Dr Smith nor her parents would know about the visit; however, he did not know that, 5 years earlier, Laura (by her parents’ consent) and her family had been "rostered" by Dr Smith.
When Laura became part of Dr Smith’s roster, it meant that his group of family doctors agreed to provide her with 24-hour care and the government health plan paid Dr Smith monthly for having Laura on his patient roster. If Laura visited a primary care doctor who was not part of Dr Smith’s group, the government health plan would deduct the amount for that visit from Dr Smith’s monthly payment.
From his monthly payment report, Dr Smith became aware of Laura’s visit with Dr Jones; however, he did not know the purpose for that visit. When Dr Smith asked Laura why she had seen another physician, her still-forming trust in doctors was shattered. She made sure to tell all her friends not to trust Dr Jones.
Laura’s need to tell a lie and her future mistrust in doctors could have been avoided if her province’s health plan had not informed Dr Smith of her visit with Dr Jones. To avoid breaches in the confidentiality of adolescents, all provincial health plans must exempt adolescents who are on doctors’ rosters from the cost-recovery provisions of their patient enrolment systems.
Patient enrolment
Because of patient care reform, patient enrolment systems are becoming increasingly common in Canadian primary care, with all provinces either considering or implementing some form of patient enrolment.1 Ontario is a leading province in the implementation of patient enrolment systems. In 2006, half of the people who qualified for public health insurance in Ontario were on the rosters of primary care physicians2 and the number of enrolled patients had doubled from 2005.3
When a patient enrols with a primary care physician, he or she join that physician’s roster. By consenting to join the roster, patients also allow the Ministry of Health to disclose the existence of any visits to other primary care physicians. Patients are voluntarily surrendering a measure of confidentiality to obtain the benefits of being on the rosters of family physicians.
Points of confidentiality
Rules of confidentiality have been common in codes of ethics since the Hippocratic oath.4 The CMA Code of Ethics devotes 7 articles to privacy and confidentiality.5 Without an expectation of privacy, patients might not fully disclose their health histories or permit full examinations and investigations, limiting their physicians’ abilities to accurately diagnose and treat. Patients might also avoid seeking care if they are reluctant to trust their physicians.
Some argue that respect for patient autonomy means patients should be allowed to determine who can access their health information. Others argue that confidentiality means if physicians implicitly (ie, through a code of ethics) or explicitly promise confidentiality, then they are bound by that promise.4
Threat to adolescents
The problem with adolescent patients is that their parents might have enrolled them in physicians’ rosters when they were too young to consent. Adolescents remain on physicians’ rosters long after reaching sufficient maturity to competently refuse disclosure of health care information, but as long as they remain on rosters, they are denied the option of refusal.
Some argue that parents should be aware of the health care adolescents receive.6 If one accepts this argument, disclosure should be based on adolescents’ age, immaturity, or relationship to caregivers. But basing disclosure on method of family physician payment means some adolescents’ confidentiality rights are diminished compared with other adolescents. This is only appropriate if they consent.
Adolescent patients seek temporary care from physicians other than their family doctors for various reasons. An adolescent might be uncomfortable with the family’s primary care doctor knowing about medical issues related to puberty and sexuality.7,8 Adolescents might find it more convenient to visit medical clinics in or near their schools, and they might avoid visiting their family doctors for fear of their parents learning about the visits.9
Adolescents also visit other physicians because they specifically do not want their family doctors to know about health concerns. When a family doctor knows about a visit to another physician, despite the promise of confidentiality, an adolescent’s trust in the confidentiality of the medical system is threatened. A lack of trust in physicians can prevent adolescents from seeking care or from fully disclosing health information.
Open discussions
Until provincial health ministries exempt rostered adolescents from the cost-recovery mechanisms of patient enrolment systems, family physicians will need to manage any possible breaches in confidentiality for their adolescent patients.
If you are a family physician participating in a patient enrolment system, discuss what it means to be on your roster with your adolescent patients as soon as they are mature enough to give informed consent. Adolescents who refuse to consent to disclosure of visits to other doctors must be removed from your roster.
When you become aware, by the cost-recovery mechanism, of a visit to another physician by a competent adolescent who is rostered but has not consented to being so, you must handle the situation with great care. The most prudent approach is to ignore the visit, and thus not affect the adolescent’s trust in the confidentiality of the health care system.
If you must disclose knowledge of the adolescent visiting another doctor, you should minimize the harm caused by that disclosure. Discuss the visit alone with the adolescent. To protect the adolescent’s trust in the other doctor, explain to the adolescent that the other doctor is not responsible for disclosing the visit. Then proceed with a discussion about informed consent or refusal of enrolment in your roster.
Footnotes
Cet article se trouve aussi en français à la page 838.
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
References
- Canadian Medical Association, Primary care reform—a national overview. Primary care reform. Reshaping health care in Canada. Ottawa, ON: Canadian Medical Association; 2005. p. 22-31. Available from: www.cma.ca/Multimedia/CMA/Content_Images/Inside_cma/WhatWePublish/LeadershipSeries/English/national_overview.pdf. Accessed 2008 Feb 16.
- Health Canada. Canada Health Act annual report 2005–2006. Ottawa, ON: Health Canada; 2006. p. 77-84. Available from: www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/2005-cha-lcs-ar-ra/index_e.html. Accessed 2008 May 1.
- Health Canada. Canada Health Act annual report 2004–2005. Ottawa, ON: Health Canada; 2005. p. 95-104. Available from: www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/2004-cha-lcs-ar-ra/index_e.html. Accessed 2008 May 1.
- Beauchamp TL, Childress JF. Principles of biomedical ethics. 5 ed. New York, NY: Oxford University Press; 2001.
- Canadian Medical Association. CMA code of ethics. Update 2004. Ottawa, ON: Canadian Medical Association; 2004. Available from: http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 2008 May 1.
- Ross LF. Adolescent sexuality and public policy: a liberal response. Politics Life Sci 1996;15(1):13-21.[Medline]
- Guttmacher Institute. Into a new world: young women’s sexual and reproductive lives. New York, NY: Guttmacher Institute; 1998. Available from: www.guttmacher.org/pubs/new_world_engl.html. Accessed 2008 Feb 16.
- Wilson KW, Klein JD. Opportunities for appropriate care: health care and contraceptive use among adolescents reporting unwanted sexual intercourse. Arch Pediatr Adolesc Med 2002;156(4):341-4.
[Abstract/Free Full Text] - Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA 2002;288(6):710-4.
[Abstract/Free Full Text]
Related articles in CFP:
- Playing the part
- Diane Kelsall
CFP 2008 54: 827.[Full Text] - Trahir la confidentialité et détruire la confiance: Préjudices aux adolescents inscrits sur les listes de médecins
- Dan R. Reilly
CFP 2008 54: 838-839.[Full Text]
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