Confidentiality

Possible stations

Think about what you would say or do before expanding the boxes!

A patient has a blood-borne disease and does not want this disclosed in a referral letter to the hospital because they know people who work there

• You do not have to disclose this (for procedures, every patient should be treated as if they have a blood-borne illness)
• However, you need to explain why it would be in their best interests for the hospital to know; and how you can help ensure confidentiality

  • Your illness may mean certain drugs will be handled differently by your body and may be dangerous
  • You may be given drugs which interact with your current medications
  • Highlight that every medical professional has a duty of confidentiality, which is taken very seriously
  • Only those directly involved in your care will know

A patient thinks their partner (another one of your patients) has an STI and wants to know why they came to see you last week

• You cannot give them any information about their partner
• You can give them a full STI check

A patient wants treatment for an STI from the GP surgery but does not want this put on record because their partner knows one of the other GPs

• If a treatment is prescribed at the surgery, this must be put in the records
• Reassure them that all GPs have a duty of confidentiality which is taken very seriously
• Advise them they can go to the sexual health clinic confidentially, where records are kept separately from GP records

A patient has contracted an STI from a prostitute and does not want to tell their partner, with whom they have since had condomless sex

• • As a doctor, you can generally break confidentiality if the patient has a blood-borne STI (e.g. HIV) and their partner is at significant risk and the patient refuses to tell them (but generally not for non-blood borne STIs). Breaking confidentiality would only be done as a last resort by a senior clinician (e.g. consultant).

• • You have a duty to try to persuade the patient to tell their partner

    • • Their partner is at risk
    • • If their partner is not treated early, they may suffer irreversible complications (such as infertility for Chlamydia)
    • • It is likely to be better to tell their partner now than have them find out later

• • Help with possible ways to tell them

    • • They could both come in together and talk to you
    • • The sexual health clinic can send an anonymous letter

• • If asked, you can not treat the patient’s partner without the partner’s consent!

An inpatient has become unconscious and unresponsive. The relatives have been told and have come in to see you. They did not know their relative was in hospital and want to know what has happened.

• If a patient lacks capacity, you can speak to relatives with regards to their health unless you strongly suspect the patient would object
• Try to disclose only as much as is necessary
• You must be sensitive to the relatives’ feelings and concerns

Aims of the station

• Know the rules surrounding confidentiality and do not breach confidentiality
• Show that you can be firm but also sympathetic, non-judgemental and helpful
• Empathise with the patient and do not attack their motives
• Address their concerns and pick up on cues
• Address confidentiality (what is it; why it is in place; explain why it is in the best interests of all patients)
• Offer what help you can

The rules

• You can only breach confidentiality when ‘another person is at significant risk of harm’ (General Medical Council) – it is not black and white and would only generally be done by a consultant as a last resort
• If a patient’s partner is at significant risk, you must take all measures to persuade them to tell their partner before breaching confidentiality (this may require multiple consultations)
• ‘You must respect the wishes of any patient who objects to any information being shared with others providing care, except where they would put others at risk of death or significant harm.’ (General Medical Council)
• You have a duty to warn patients if their behaviour puts others at risk, and to explain any implications of that risk (e.g. complications of an STI remaining untreated)
• If a patient lacks capacity, you can speak to relatives about their health unless you strongly suspect the patient would object

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Now try a full OSCE station

1. Patient concerns
2. We have loads of stations here!