Modules

Professional challenges

Scenario 2: Professionalism, privacy and feedback

This scenario takes place in a tertiary care hospital ward. It illustrates how a seemingly simple encounter between a resident and staff member can generate ethical and interpersonal difficulties for both parties. Every physician-patient and inter/intraprofessional interaction has implications that we are often unaware of as we go through our busy days as physicians.

In this scenario, there is a deliberate breach of privacy, although with no bad intention. It probably happens more often than we think, either because it is not noticed, or it is ignored. In this case, the breach of privacy is noticed, and the handling of that issue is the subject of this scenario.

MCC role objectives

Collaborator

  • Demonstrate respect for team members without bias (e.g. bias related to gender, ethnicity, cultural background or health care role) (3.3)
  • Recognize and prevent tensions that may lead to conflict (4.1)
  • Seek help and advice when necessary, recognizing personal limitations in conflict resolution (4.3)

Professional

  • Maintain patient confidentiality (2.3)
  • Maintain the highest personal, professional, and legal standards at all times (3.3)
  • Abide by the profession’s rules, regulations, and ethical codes (4.1)
  • Assume responsibility for one’s own actions (4.2)
  • Be respectful of colleagues (4.3)
  • Report a colleague’s actions or behaviours as required or appropriate, using the applicable reporting mechanism (4.4)
  • Be responsive to feedback from colleagues and other team members (5.8)
  • Behave according to the highest standards of integrity, including ethical conduct, honesty, compassion and dedication to the welfare of patients and society (6.1)
  • Be aware of the potential for unconscious bias influencing judgement (6.2.1)
  • Be sensitive to, and do not abuse, the power relationships within the health care system (6.4)

Sentinel habits

  • Demonstrates respect and/or responsibility
  • Seeks out and responds appropriately to feedback

Entrustable professional activities

  • Lead and work within interprofessional health care teams (8)
  • Improve patient safety and the quality of health care at both the individual and systems level (10)

Critical competencies

  • Participates effectively and appropriately in an interprofessional health-care team (13)
  • Demonstrates a commitment to their patients, profession and society through ethical practice (19)
  • Part 1

  • Dr. Bockh: Oh, hi Dr. Johannson.

    Dr. Johannson: Oh, hi.

    Dr. Bockh: Can I help you? Are you here to see someone?

    Dr. Johannson: No no, I just wanted to check this chart … Mrs. Corelli.

    Dr. Bockh: Oh, I didn’t know she was booked for radiology today.

    Dr. Johannson: I don’t know that she is.

    Dr. Bockh: Oh?

    Dr. Johannson: She’s one of my wife’s golfing buddies. She didn’t make tee off this week … and didn’t say why so my wife was worried so when I saw Mrs. Corelli’s name here, I thought I would just check so I could reassure my wife and tell her she’s okay.

    Dr. Bockh: But she’s not your patient?

    Dr. Johannson: Well, I haven’t received a requisition for tests … yet. Do you have a problem with that?

Reflective exercise 1

There are numerous possibilities for breach of patient privacy within the complex system of a modern hospital. A number of various health-care professionals need to access patient records, and communicate patient information to others. Think about the following situations:

  • Although casual conversations about a patient, over coffee or in an elevator occur all the time, we rarely think about the possibility that we might be overheard.
  • During hand-over rounds, a resident, hospitalist or another team sometimes raises their voices to exchange information over a short distance.
  • Administrative employees have access to many patient charts.
  • Front desk receptionists and hospital admitting employees might openly disclose patient information when answering patient-related inquiries.

While the first example might constitute an ethical breach, the others do not, although they do illustrate a breach of privacy.

  • Who “owns” the patient chart? Is it the hospital, the attending physician, the patient?
  • Can a patient insist on seeing their record?
  • Can a family member make such a request? What about if the patient is not competent. Would that make a difference?

Reflect on the following questions and for each question, refer to the MCC role objectives at the beginning of the module to select appropriate objectives.

How should Dr. Bockh respond to the question: “Do you have a problem with that?”?

  • Say “no” and walk away
  • Apologize and walk away
  • Tell Dr. Johannson the patient’s story
  • Say something about the rules regarding patient confidentiality
  • Explore other options around how to discuss the rules and regulations of patient confidentiality with a colleague or chief of staff

Let us imagine the last response and what might happen in the next section.

Part 2

  • Dr. Bockh: I guess I’m just a little confused about hospital rules. We were told not to access files unless we had a patient care reason to do so.

    Dr. Johannson: Yeah, well, I may have a reason in the near future, so don’t get so upset.

    Nurse: He’s always been difficult. Don’t let him get to you.

Reflective exercise 2

Is Dr. Johannson’s response appropriate from an ethical point of view? Consider the reason he gave for accessing the chart in the first place.

If Dr. Bockh is offended by Dr. Johannson’s remark, can she or should she tell him so?

Again, what MCC role objectives are illustrated here? For a complete list of role objectives, visit mcc.ca.

What about the nurse? Do the same professional rules apply to other health care providers?

Dr. Bockh is not sure she should even be upset by her encounter with Dr. Johannson, and does not know if she should take any action. She especially does not want to do anything that could jeopardize her end of term evaluation. Dr. Bockh decides to ask the attending staff physician, Dr. Matheson, for his advice.

Dr. Matheson listens to the story, and tells Dr. Bockh that she is right to be concerned about patient confidentiality, and that it is understandable that she feels uncomfortable addressing the issue with Dr. Johannson. He reassures her that she did the right thing in bringing up the situation with him. Read the following for further information: “Conflict between physicians and what can be done about it.” and “Collegiality promotes safe care.”

Dr. Matheson tells Dr. Bockh that there is a process to follow, and that he will handle it. He also mentions that he will provide relevant feedback.

Part 3

  • Dr. Johannson: Nice to see you Francis. What’s up?

    Dr. Beltan: Well Craig, an issue has come to my attention, and I felt it was important to hear your side of it.

    Dr. Johannson: My side? What do you mean? Did I miss a diagnosis or something?

    Dr. Beltan: Nothing so easy, I’m afraid. Do you know a patient named Mrs. Corelli?

    Dr. Johannson: Yeah … she’s a patient of Chad Matheson’s.

    Dr. Beltan: Correct, and I gather you accessed her chart.

    Dr. Johannson: So what?

    Dr. Beltan: For personal purposes, not involved in her care?

    Dr. Johannson: Oh…that little resident snitched to you about that!

    Dr. Beltan: No, she didn’t. I heard about this from other sources. And, I don’t like language like that, and your previous remarks to her. Craig, this is not the first time I’ve heard you talk like that, and these days, it’s just not right.

    Dr. Johannson: Oh, come on, Francis, is this a gender thing between the two of us? Lighten up.

    Dr. Beltan: This is not about me, a woman, and you, a man. This is about professional behaviour, and a breach of patient confidentiality. Let’s try and keep emotions and personalities out of it.

    What were you doing looking at that chart?

    Dr. Johannson: Oh, good grief! It was just a golf game! My wife was worried about her. It’s all innocent. Nobody got hurt, it’s not like if Mrs. Corelli was the prime minister, and I was going to tell the press.

    Dr. Beltan: I can’t believe you just said that! Since when do we base our ethical behaviour on the worth — the perceived worth — or fame — of the patient?

    Good grief is right! You should read the hospital policies on patient confidentiality, it’s an important issue for this hospital. There are three things I want to come out of this discussion. First, you are not to be involved in any evaluation of Dr. Bockh, and don’t let me hear about you bad-mouthing her. Second, we will follow-up with a meeting in three months to make sure there haven’t been any further breaches, and third, I’m going to ask that our grand rounds next month be on the topic of patient confidentiality. Perhaps we all need a refresher. And you, Craig, are going to lead it.

    Dr. Johannson: Me? You’re not serious!

    Dr. Beltan: Yes, I certainly am!

Commentary

Feedback, either giving or receiving, is one of the most difficult situations we face at work. Feedback is part of the work environment whether we work in a hospital, a fast food outlet, or a corporation. As physicians, we have all received feedback as part of an evaluation during which there is usually a discussion of things done well, and things that need improvement. That kind of feedback is quite different from that in this case.

In this situation, feedback is given by a colleague on a perceived error – a breach of ethical principle. In the self-regulated profession of medicine, this kind of discussion should and does occur all the time. Ideally, each physician self-regulates and recognizes when they have committed an error. Physicians also need to recognize that feedback from colleagues can be beneficial.

Sometimes, depending upon the situation, a report to the provincial/territorial college or other authority should also be made.

In this case, although the error might seem trivial, it points to Dr. Johannson’s lack of insight into his behaviour. Note that Dr. Beltan first asks for Dr. Johannson’s side of the issue. In any instance of feedback, it is important that all parties feel that they have been heard. Does this happen here? Do we get an adequate idea of Dr. Johannson’s view of the issue?

Dr. Beltan further attempts to keep the conversation on a factual, non-emotional level. This is also important in any feedback situation. Which of the MCC Objectives address this point?

Does Dr. Johannson admit his mistake or show any remorse? Defensiveness is common in these situations and can escalate the conflict. Although it might not be possible to obtain an admission during the feedback conversation, one hopes the person will reflect and change their behaviour. Humiliation is not the desired outcome.

Finally, Dr. Beltan suggests that Dr. Johannson read some reference documents to appreciate the seriousness of a breach in confidentiality, and to understand how confidentiality is regulated.

Dr. Johansson is subject to medical employee bylaws on maintaining patient confidentiality and to the possible consequences if they are not followed. Health-care organizations track and audit access to patients’ health-care information. Inappropriately accessing patient information can lead to disciplinary action.

The regulatory authorities in each province and territory have strong statements supporting the confidentiality of patient information. There are also provincial/territorial and federal laws that outline the responsibilities physicians and institutions have regarding respecting and protecting a patient’s health information.

In this case, if it is determined that this incident was an isolated one, that Dr. Johansson appreciates the significance of his actions and takes steps to change his behaviour, then no further action is required. However, asking Dr. Johannson to present the topic of confidentiality during grand rounds generalizes the problem and allows others to benefit. This course of action might also help Dr. Johannson view the conversation in a more positive light. Had Dr. Beltan been concerned about this situation recurring, or if he believed that Dr. Johannson failed to appreciate the significance of this issue, then further action would be required.

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