There was an article in the LA Times today about a study underway where patients would get unlimited access to doctor’s notes in their files. While I am normally a big fan of transparency, there are certain relationships where the information exchanged is expected to be private and sacrosanct.
The concept of “privileged communication” is a legal concept that basically says that certain recognized relationships involve the exchange of confidential communication, and that without some over-riding compelling reason, the communications between these parties is not allowed into evidence in a Court of Law. It basically excludes things said or written between the parties to remain confidential The general list of professions and relationships that generally have a right of privileged communication under State law (and this varies between States) often includes:
- Accountant -Client
- Attorney Client
- Physician- Patient
- Clergy -parishioner
- Spousal privilege
- Reporter’s/Journalist’s privilege
- Therapeutic (psychologist/Therapist) Privilege
- Executive Privilege (Governmental)
While there’s an existing Doctor-Patient privilege, this rule causes me to wonder if there’s a Doctor-Doctor privilege as well? While I’m all for people having information about their health, should a patient be constantly evaluating and arm-chair quarterbacking their own care? What happens if a Doctor notes in chart for other physicians in the practice to see that he suspects a patient may be in an abusive relationship, have drug-seeking behavior, or suspects a patient may be lying about their habits or alcohol intake for a variety of reasons (including insurance purposes, etc.) and the patient objects to the Doctor’s noting this information? Is a Doctor liable for accusations of slander for making such remarks to other physicians in a chart?
Moreover, from having chats with doctors I know, there’s a whole bunch of codes in charts such as “FLK” for “funny-looking kid” when a doctor might suspect something could be wrong but isn’t sure; or “2 carbon fragment abuse” as a euphemism for alcoholic; 4F- for fat, forty, female and fair, indicating a pre-disposition for gallbladder disease; CTD for circling the drain and getting close to death, and the like. (You can see a whole list of them here-not all are commonly used and many are crude, but look at it as gallows humor). Also check out an alternative lists here and here, and a more informative list of common terms and abbreviations found on charts here.
I know that doctors need to communicate this information between them. They need to be able to give honest and even, to the public, rude assessments about a patient’s appearance, and that’s not something every patient is going to want to read or hear. It’s easy to imagine times where a doctor makes remarks about a child’s parents or relatives and whether or not they seem like they can handle a patient outside of the hospital. This is vital for the support staff to know, but I’m not sure a patient needs to know their doctor thinks their Mom is crazy or unengaged in their care.
I think as we look for more and more transparency between professionals and their clients/patients, we also have to realize that sometimes, not everything needs to be known. For example, if a Doctor is trying to figure out what’s wrong and is going through a diagnostic tree, and is trying to rule out all sorts of things, I want to make sure that’s documented on the chart. But afterwards, it can look like the Doctor didn’t automatically know what was wrong (like magic) and instead relied on a pathway to diagnosis that may have led to some dead ends, which may lead to patients making assumptions about malpractice, incompetence and the like that may be very far from the truth. And certainly, we don’t want every patient using Web MD to second guess their physician with every medication they are given in the hospital, moment by moment. This sort of transparency may lead to more mistrust than trust, undermining the fundamental reason why people sought professional help in the first place.
In all avenues, we need to let professionals use not only their facts and knowledge, but their experience, intuition and “feelings” about something to get a job done. Having access to information and data on the web does not give us the experience or the host of background knowledge and experience that makes people good at their jobs. We can’t boil down every profession into a simple lists of “to do’s” to be mechanically followed without variance, because people are not machines. We have weird things happen, and we need people to be able to improvise and follow non-logical avenues from time to time, without worry that someone will be up their butt second guessing everything they do afterwards.
I’m finding in this age of too much information, I need to be able to trust certain folks to be professional and do their jobs, and do them well. I may be as jaded as the next guy, but I hire professionals because of their expertise, not in spite of it.
I can’t be a master of all trades, so I need to trust that some things, like my heath care, will need to be “outsourced” to my physician to monitor, and let me know when I really have to worry, and when I should be kept in the dark to avoid too much worry. For example, when a doctor sends a patient with severe headaches for an MRI, the patient probably doesn’t need to know “It might be a brain tumor, but most likely it’s a migraine, hypertension, or another benign cause” because this is simply too much information and worry, especially if there’s a delay in getting the scan, for something that’s statistically likely to be nothing, but they have to rule out the outlying serious complication.
Let’s start to accept that it’s okay of somethings aren’t known and some things stay private. It’s really for our own piece of mind. The hard part of course, is figuring out the parmeters of that “need to know” and I don’t think we’re even close to figuring that out yet.