Patient Privacy

For patients who seek treatment in an academic hospital setting, they are often seen by multiple people in varying levels of medical training - medical students, interns, residents, fellows, attendings. It can be a daunting experience especially for those who prefer to maintain their privacy. In those instances, patient privacy becomes a difficult issue to deal with in a teaching hospital where everyone is there to learn from the patients.

Introduction and Question
While I was on my gyn rotation, we had a number of patient encounters that involved similar issues as this case. On one occasion, we found out that a patient was positive for a sexually transmitted infection while we were rounding, and the patient received this information with a gaggle of med students and residents standing around in her room. Since it made ME uncomfortable, I’m fairly sure the patient was as well. I know I would want these discussions to at least seem as private as possible if it was me, but even in non-teaching institutions the patient’s complaint may be known by the nurse and other necessary personnel. Since being discreet, sensitive and understanding were major points made in the case, how do you reconcile the needs of providing medical education and sharing information with staff with establishing trust and making the patient feel comfortable?

Discussion
I think that it's important in such a case to (a) limit the # of medical students in the room to 1-2 max, out of respect to the patient and the sensitive nature of the encounter and (b) absolutely ask the patient's permission for even those 1-2 students to be present.

While I was on my urology rotation we had a patient come in with severe HPV. The attending told us that "you will probably never see a case this bad again in your career" (away from the patient of course). There were two residents, the intern, the attending, and two medical students who went down to see the consult in the ED. Some members of the team had already seen the lesions. The patient said "are all these people coming in?" The attending then explained that it is a teaching hospital but offered the patient the option of having only three people present and the patient chose that option.

The attending, one resident, and one medical student went in to the exam room. I was the medical student who did not go and at first I was disappointed. If he did not want medical students why did he come to an academic institution? After reflecting for a second I had to remind myself that these are not diseases, they are people. And as much as we have to learn, they need to feel comfortable with the medicine we provide.

Respecting the patient is just as important as providing proper treatment.

The role that the nurses play in this scenario is also really important to providing the best care for patients. I feel like time is a constant pressure in family medicine and can make a physician who wants to be thorough really frustrated. To have nurses or other staff members that have the time, training and knowledge to go over things like STDs with a patient like Tammy would really round out, and allow for comprehensive care and ensure patient understanding. In practices where this is not a reality what are some alternatives to feeling that you have really addressed the patients concerns and questions in the best way possible?

There are also few other points that seem important to emphasize from the video that may contribute to patient ease and comfort:
 * 1) explaining procedures before the patient is on the exam table, perhaps feeling vulnerable and exposed.
 * 2) Making sure you know the best way to contact a patient with test results etc. since a teenager like Tammy would probably not want the office to call her home. This helps to reinforce patient trust in her doctor.
 * 3) Importance of providing patients with material to take home and read with web addresses for further information. It may be a lot to take in at one appointment so having a resource is helpful.

This was a really interesting case. I'd just like to comment on the importance of asking the patient what their preferences are as far as who is in the room, especially during a visit that explores sexual practices. Patients should have the option of having one, two, three, or NO people in the room, teaching hospital or not! I was appalled by the example of the patient with HPV who was given the option of THREE or MANY people in the room, even after a previous sensitive exam with many people in the room. My heart really goes out to this patient. To insist on a minimum of three people after the patient has made it clear that they are uncomfortable is absolutely ridiculous.

I like the proposed solution to the teaching hospital dilemma - if the case is really that interesting and teachable, bring it up in conference where the patient is spared the embarrassment of multiple well-attended exams.

Links to Cases
Back to Tammy or Case studies.