Confidentiality & Professionalism

Confidentiality: the default, and HIPAA

Confidentiality is the default. Protect all patient information, because patients disclose honestly only when they trust it will stay private. Confidentiality persists after the patient's death. It applies even to a spouse or other family, who receive information only with the patient's consent. Avoid discussing patients in elevators, hallways, or other public spaces.

HIPAA basics. HIPAA protects individually identifiable health information:

• Disclose only the minimum necessary for the purpose (this limit does not restrict clinician-to-clinician sharing for treatment).
• Disclosures for Treatment, Payment, and health-care Operations need no separate authorization; most other disclosures need written authorization.
• Patients have the right to access and obtain copies of their own records and to request amendments. Access cannot be withheld because of an unpaid bill, and only a reasonable, cost-based copying fee may be charged.

When a family member calls asking about an adult patient, the answer is to obtain the patient's permission first, not to share "just the basics."

When confidentiality yields

The general rule. Confidentiality gives way when an identifiable third party or the public faces serious, foreseeable harm, or when the law mandates reporting. Even then, disclose only the minimum necessary, and only to the appropriate party.

Tarasoff (Tarasoff v. Regents, 1976). When a patient makes a credible threat against an identifiable person, the clinician's duty to protect overrides confidentiality. The duty attaches to a specific, identifiable target, not a vague or generalized threat.

Waiting until an act occurs, merely documenting the threat, or only raising the antipsychotic dose all fail the duty to protect.

Reportable diseases. After diagnosing active tuberculosis, syphilis, or HIV, report to public health yourself; the patient's permission is not required. Encourage the patient to inform partners too, but you do not phone contacts personally.

Impaired colleagues and professional accountability

Report impairment. A physician who suspects a colleague is impaired (substance use, illness, cognitive decline) or incompetent must report it to a supervisor or department chief, the physician health program, or the licensing board. Patient safety outweighs loyalty to colleagues. Reporting can route the colleague to a physician health program for help and monitoring, not only discipline.

Smelling alcohol on a colleague before rounds, or suspecting a surgeon is operating while impaired by opioids, calls for a prompt report. Ignoring it, covering their patients quietly, warning only the nurses, confronting them publicly, or waiting for a complication are all wrong.

Core professional duties. Professionalism means:

• Honesty with patients, including disclosure of medical errors
• Maintaining competence
• Respecting patients and colleagues
• Avoiding conflicts of interest
• On social media, never posting identifiable patient information, even without names

Boundaries, conflicts of interest, and gifts

Boundaries. Sexual or romantic relationships with a current patient are unethical, and relationships with former patients are unethical when they exploit trust or knowledge from the clinical relationship. If a patient makes advances, set a clear, professional boundary and use a chaperone. Avoid treating yourself, family, or close friends, because objectivity is impaired and the history is incomplete. Offer chaperones for sensitive exams; they protect both the patient and the physician.