Uncomfortable subjects in the age of electronic health records

DEAR DR. ROACH » As a physician, with the advent of electronic health records, I can see a reluctance of both the educated patient and the physician to be forthcoming about sexually related matters. Do you have any suggestions on how to circumvent this problem? — R.V., M.D.

DEAR READER » My advice to colleagues is to be aware of any discomfort in your patient in discussing intimate details. If a patient seems reluctant to discuss them, you can offer not to write the information into the chart. Personally, I tell my patients in these situations that although their information is kept confidential, there are limits to that confidentiality (including disclosure by mistake, which unfortunately has happened), and anything that they don’t want in the chart will be left out. In the case of sexual matters, I will write something like “I discussed issues of sexual health and gave suggestions on reducing risk” in the chart. There are other areas in which I act similarly on request: Illicit drug use is one.

My advice to readers is that you should discuss these matters with your clinician. If concerns about it being in your medical record are keeping you from bringing it up, ask that it not be put in. There are limits to patient confidentiality, however: Some sexually transmitted infections must be reported to the local health department, which may pursue (anonymous) partner notification. Physicians also must disclose records in case of a subpoena. There are a few other exceptions to patient confidentiality.

In an ideal world, patient medical records would be used only for communication among health care professionals, and sexual health, drug use and many other personal details may be important for the entire team to know about. However, for those people who are very concerned about confidentiality, I feel it’s better to get the information, even if I have to promise not to write it in the chart. (I solicit permission to tell consultants the information verbally, if necessary).

DEAR DR. ROACH » When doctors overtreat patients, is it because of concern about being sued or is it about the money? It seems to me it’s both. — G.C.

DEAR READER » The term “overtreatment” refers to any treatment — especially pharmaceuticals, but also surgery and over-the-counter medicines or supplements — that would not be expected to benefit a patient. Overtreatment can be done by mistake, but I think you are referring to a physician (or other health professional) deliberately prescribing a treatment they know is unnecessary.

I’d first point out that this behavior is unethical. Physicians are obliged to put the needs of the patients above their own needs, so knowingly prescribing a treatment (or even ordering a test) that the patient doesn’t need fails this test. If it’s about money, physicians would be enriching themselves at the expense of their patients, insurance providers and ultimately society. If it’s about fear of being sued, it’s still unethical and probably counterproductive, since it is more likely to lead to harm than to benefit.

I wish I could say that physicians ordering unnecessary tests or procedures for financial gain never happens, but I know it does. There are laws to deter this behavior, and the medical community has a duty to police itself to identify and correct bad behavior. We don’t do as well at it as we should.

Better education and communication, for both physicians and patients, can help reduce ordering unnecessary testing that may be done out of fear of being sued.