It was Friday of the seventh week of my family medicine clerkship. I was tired. Tired from the day and, honestly, tired from the clerkship. I was ready for a change of pace. The next patient was Mr. S., a 30-year-old male, here for an establish care visit. I did not recognize the name. I reviewed his chart before the encounter, two visits in the system, both to the ER for cocaine-induced angina. I stereotyped him immediately. Not that this was right, but I did. I think everyone does. After I gathered my notes, I walked to the room. I stood outside for a second and took a deep breath to help me clear the bias from my head, I knocked and entered.
The next moment literally froze me in my tracks. I was lost for words. How could this be? This person can’t do cocaine. This person can’t have a drug problem. Not because they’re not allowed, but because this person interacts with my five-year-old daughter every day. He is a member of our church. As I know him, he is a hard-working family man that volunteers countless hours towards improving the lives of the children at church. When something is broken, Mr. S. fixes it. When the kids need new play equipment, Mr. S. builds it. When the kids need a chaperone, Mr. S. volunteers. He is regularly mentioned and thanked for his service in the church newsletter … and he is addicted to cocaine.
He didn’t recognize me. I panicked and excused myself from the room without getting the H&P. I reconvened with the resident and explained the situation. He understood and said I didn’t need to complete the encounter with him. However, after a few minutes my head cleared and I reentered the room with the resident. Mr. S. went on to admit he was an addict, but had not used in over a year. His chest pain had diminished. He revealed financial and family concerns that had contributed to his drug and alcohol use. Halfway through the visit, his wife and children enter the room. She recognizes me instantly and then Mr. S. did. She gave me a hug and he shook my hand. It is a small, tight-knit congregation. The visit was over.
That night, my mind raced. What do I do? Can I do anything? Does his wife know? Does the church know? Should they? Can I allow my daughter to have continued contact? This is protected information, but it impacts my family, the single most important thing in the world to me. I would face Hell’s fury for eternity to protect them, but now I’m handcuffed.
This was my first ethical dilemma and I’m sure I’ll have many more to come. I learned more about ethics, patient care and myself in that one event that I have in all of medical school. Of the lessons I learned that day, ranging from the power of stereotypes, to the idea that all people have secrets and stresses (even good ones), the most important was that patient confidentiality is the backbone of quality care. If we don’t keep this information protected, all trust is lost and then treatment is futile. If we don’t know our patient’s struggles then we don’t know the patient. We have to know our patient’s deepest, darkest secrets or we can’t treat them effectively. We have to know about the substance abuse, the suicidal thoughts, and the high risk sexual behavior. It is our job and duty. And we will not be privy to that information without trust. Patient confidentiality is everything.
With all that said, in the end I did nothing. I wanted to confirm that he’d never used at work; I didn’t. I wanted to talk to my wife about it; I didn’t. I did nothing. I protected his confidentiality. I think the kids are safe, I think my daughter is safe, but I don’t know that for sure. He’s never shown any type of inappropriate behavior before. But what if he does and what if the kids aren’t safe? Should I have done something? I guess this is the burden I will carry, like all physicians and healthcare providers, because without trust everything is lost. I never imagined that upholding my duties as a physician would be so gray — that by protecting my patient’s confidentiality, I would feel like I am betraying my family. That, no matter what I do or do not do in such a situation, I will never feel good about it. I wonder if I will feel the same the next time, because there is definitely going to be a next time.
Author’s note: All patient identifiers have been modified to protect patient privacy.
Contributing Writer Emeritus
University of Kansas Medical Center
I am a MD/PhD student that recently graduated from the University of Kansas Medical Center. My PhD research was focused on the role of sensory neuron insulin signaling in the pathogenesis of diabetic neuropathy. I matched into orthopedic surgery at my home institution.