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Controversies in Management: Access should be denied
H Lavender,
general practitioner a
http://www.bmj.com/cgi/content/full/313/7052/286
a
Falmouth Road Group Practice, London SE1 4JW
"Patients have a right to expect that you will not disclose
any personal information which you learn during the course of
your professional duties, unless they give you permission.
Without assurances about confidentiality, patients may be
reluctant to give doctors the information they need in
order to provide good care."--General Medical Council,
Duties of a Doctor.1
I
believe that when doctors reveal information to insurance
companies they destroy the trust that is essential for good
medical care. When I receive a request from an insurance
company for information about a patient, I feel
uncomfortable. I know that the patient has given written
consent, but does the patient have any choice? In order
to buy a home, most of us need a mortgage and life
insurance is usually a requirement for this. Is the
patient really in a position to refuse to apply for life insurance?
When an insurance company requests information from a doctor,
these are the kinds of questions that are asked
*
Do the patient's records indicate any clinically important
family history?
*
Has your patient ever been advised that any aspect of their
lifestyle could have an adverse effect on their health? If so,
please give dates and details
*
Has your patient sought consultation or treatment for AIDS
or for a suspected acquired immune deficiency syndrome, or has
an HIV infection been established? If yes, please give details
*
Has the daily alcohol consumption been recorded? If so, please
advise dates and amounts
*
Has your patient ever sought advice or treatment for any sexually
transmitted disease? If so, please give dates and details
(Abbey Life, 1995)
*
Have there been any suicidal tendencies or actual suicide
attempts? (Black Horse Financial Services, 1994).
Lack of confidentiality means patients do not confide
A
patient recently said to me, "Doctor, I poured out my heart
to you, and now you have to tell the insurance company." This
patient says that he wishes that he had gone elsewhere for
help. Indeed, many patients will go to extremes rather
than ask the help of their general practitioner. For
example, patients in southeast England travel to the
anonymity of the genitourinary clinic at my local
teaching hospital rather than seek help from their
general practitioner (J P Watson, personal communication).
Many general practitioners admit to sending patients with
possible sexually transmitted diseases to their local
genitourinary clinic, and so avoid making a note in the
patients' records.
Beware the patient who confides a mental health problem. Up
to half of people attending general practice may have
depressive symptoms,2
of whom about 5% will have major depression.3
4
5
6
7
8 In the "Defeat depression" campaign general
practitioners are encouraged to be better at detecting
and treating depression. However, if a mental health
problem is entered in a patient's notes then there is a
chance that an insurance company will penalise the
patient and the stigma of mental illness will be
reinforced, as occurred recently with one of my patients.
As part of health promotion, we are required to note patients'
smoking and drinking habits, yet this information can be used
against a patient's interests. So, what often happens is that
patients censor what they say and their doctor censors what
is put in their records. Does this make for good medical care?
When information from general practitioners' notes is entered
on to an insurance company computer, who else in the world has
access? It is well known that information held on computers
is not safe and can be a "target for data thieves,
blackmailers and others with less than altruistic
motives."9
In order to regain the confidence of our patients, the
medical profession needs to think seriously about
confidentiality, and this may mean drastic action with
possible financial consequences for our patients,
ourselves, and the insurance industry.
Medical records should be for patient care only
I
propose that if a patient wishes to have life, private medical,
or disability insurance, the insurance company should conduct
its investigations with the patient rather than seeking
information from the patient's doctor. The patient could
be sent a questionnaire, and if help was needed in
filling it out the patient could make an appointment with
the general practitioner or other health professional.
The patient is then more in control of what information
is given out. A doctor employed by the insurance company would
carry out the examination and investigations. The
investigations could be comprehensive and reveal a lot of
useful information, both for the company and for the
patient, who should be informed of the findings. The
following investigations could reveal a great deal: HIV
and hepatitis B testing, carbon monoxide levels, renal
and liver function tests, haemoglobin A1c, full blood
count, drug screening, urine analysis, resting and exercise
pulse rates, and electrocardiography. If any adverse findings
were openly discussed with the patient the insurance medical
could even be an incentive to the patient to change his or her
lifestyle.
If a patient was suspected by the insurance company of having
lied or withheld information at the initial application, then
the insurance company could ask the patient's consent for
access to his or her records; if the patient refused or
was dead the company could apply through the courts for
access.
Patients need to regain control of personal information. To
do this, we need legislation to clarify and separate rights
and obligations between insurance companies and their clients,
and between patients and their doctors. I propose that the
medical profession take action to ensure the medical
records are absolutely confidential and for patient care
only, so that patients no longer need say, "Please don't
write this down, Doctor."
1.
General Medical Council. Duties of a doctor.
London:
GMC, 1995.
2.
Freeling P, Tylee A. Depression in general practice. In: Paykel ES.
Handbook of affective disorders. 2nd ed.
Edinburgh:
Churchill Livingstone, 1992.
3.
Hodiament P, Peer N, Syben N. Epidemiological aspects of psychiatric
disorder in a Dutch health area. Psychol Med 1987;17:495-506.
4.
Bebbington P, Hurry J, Tennant C, Sturt E, Wing J. Epidemiology of
mental disorders in Camberwell. Psychol Med 1981;11:561-81.
5.
Vazquez Barquero J, Munoz P, Madoz Jauregui V. The interaction
between physical illness and neurotic morbidity in the community.
Br J Psychiatry 1981;139:328-35.
6.
Vasquez Barquero J, Diez-Manrique JF, Pena C, Aldama J, Samaniego-Rodriguez
C, Menendez-Arango J. A community mental health survey in Cantabria:
a general description of morbidity. Psychol Med
1987;17:227-41.
7.
Regier D, Boyd J, Burke J, Rae D, Myers J, Kramer M, et al.
One-month prevalence of mental disorders in the United States.
Arch Gen Psychiatry 1988;45:977-85.
8.
Weissman MM, Myers JK. Affective disorders in a
US
urban community. Arch Gen Psychiatry 1978;35:1304-11.
9.
Anderson R. NHS-wide networking and patient confidentiality. BMJ
1995;311:5-6.
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