Physician attitudes toward confidential care for adolescents

From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine--Part II: Challenges in the emergency department

Part I of this article reviewed the concepts of privacy and confidentiality and described the moral and legal foundations and limits of these values in health care. Part II highlights specific privacy and confidentiality issues encountered in the emergency department (ED). Discussed first are physical privacy issues in the ED, including problems of ED design and crowding, issues of patient and staff safety, the presence of visitors, law enforcement officers, students, and other observers, and filming activities. The article then examines confidentiality issues in the ED, including protecting medical records, the duty to warn, reportable conditions, telephone inquiries, media requests, communication among health care professionals, habitual patient files, the use of patient images, electronic communication, and information about minor patients.

The right of minors to confidentiality and informed consent

Doctor-patient confidentiality is a precept of adolescent medicine. In general, physicians honor the privacy of adolescents unless there is evidence that the youngster is engaging in dangerous activities. An otherwise healthy 16 year old was referred for headache evaluation. During the portion of the interview conducted outside the presence of his mother, the patient revealed using marijuana and cocaine regularly and LSD (lysergic acid diethylamide), hallucinogenic mushrooms, and "Ecstasy" (3,4-methylenedioxymethamphetamine) occasionally. Given this information, and as allowed by North Carolina's General Statutes, the patient was offered confidential treatment for illegal substance abuse; he declined the offer. He also turned down the request to forgo his right to privacy so that his parents could be made aware of his addiction. As a result of the patient's drug use and disregard of its consequences, it was determined that notification of a parent was essential to his life or health; thus, confidentiality was breached. Although substance abuse is a behavior that threatens the abuser's health and life, state and federal laws vary regarding the rights of minors to confidential evaluation and treatment. For this article, laws that govern minors' rights to consent to confidential treatment for illegal substance abuse were reviewed. The aforementioned case is used as a catalyst for discussion.

Physician knowledge and attitudes of Minnesota laws concerning adolescent health care

STUDY OBJECTIVE

To determine physicians' knowledge and attitudes of medico-legal issues affecting adolescent health care.

DESIGN, SETTING, PARTICIPANTS

A cross-sectional, mailed survey was distributed to 900 randomly selected primary care physicians in Minnesota, and all eligible physicians in Olmsted County.

INTERVENTIONS

Physicians were mailed a survey with questions concerning Minnesota consent and confidentiality laws.

MAIN OUTCOME MEASURES

Physician knowledge and attitudes of consent and confidentiality laws.

RESULTS

A total of 317 (26%) surveys were returned. Olmsted county physicians achieved a median score of 37.5% and non-Olmsted physicians achieved a median score of 50% correct on a test of knowledge. Using a scoring scale where -1 signified "a bad law," 0 signified "neither a good nor bad law," and +1 signified "a good law," attitude regarding the laws was a median of +0.5 for both groups. In all, 41.1% of Olmsted physicians and 51.7% of non-Olmsted physicians felt that the laws had affected them or their practice. Olmsted physicians were compared to a cohort of Olmsted parents previously reported, with statistically significant differences noted.

CONCLUSIONS

Results suggest that primary care physicians are not knowledgeable of Minnesota laws affecting adolescent health care. Opinion of these laws was positive, with notable exceptions. Physicians lack a sense of impact of laws affecting adolescent health care. Physicians were more knowledgeable and felt more positively about the laws than did parents of adolescents. Lack of knowledge and the presence of certain attitudes identify areas where physicians could benefit from greater understanding.

Adolescent substance abuse. Confidentiality and consent

Although all states have laws that allow minors to consent to substance abuse treatment, there is variability from state to state. Health care providers need to be aware of laws within their states. When providing health care to adolescents, many situations arise in which the provider must make a determination of the patient's competence to consent and whether parental notification would be in the patient's best interest. Confidentiality should be honored when possible, with limitations of the extent of confidentiality explained. Adolescents are able to consent for alcohol and drug treatment in most states, but involvement of the family is optimal in most cases. Physicians and other medical care providers also need to manage confidentiality issues in drug testing, billing of services, and medical records and need to work with clinical administrative staff to clarify and implement policies to maintain confidentiality. Proposed changes to medical privacy regulations may compromise confidentiality for medical care of adolescents. Medical providers should continue to work with their professional societies and legislators to ensure that appropriate consent and confidentiality statues exist to provide optimal health care to adolescents.

Adolescents' interpretations of conditional confidentiality assurances

PURPOSE

To improve physicians' discussions of confidentiality policies with adolescent patients.

METHOD

Fifty-three students completed private semistructured interviews designed to explore adolescents' interpretations of a statement explaining both the protections and limitations of confidentiality.

RESULTS

Results suggest strategies for explaining conditional confidentiality in a way adolescents' understand and trust.

Attitudes and practices of Israeli physicians toward adolescent health care: a national survey

PURPOSE

To assess practices and attitudes of Israeli physicians with regard to adolescent health.

METHODS

Questionnaires were sent to a sample of 1050 Israeli physicians specializing in pediatrics (P) family practice (FP), and internal medicine (IM). They were requested to report their experience, perceived skills, and desire for further training regarding 16 adolescent health items grouped under four topics: medical, sexuality, risk behavior, and psychosocial problems. A scoring system was applied to assess their report. Attitudes toward confidentiality in the same topics were also surveyed.

RESULTS

Questionnaires were received from 306 (29%) physicians, of whom 42% were P, 35% were FP, and 29% were IM. The majority (96%) of respondents included adolescents in their practice, and adolescents comprised 33%, 17%, and 11% of the registered patient population of the P, FP, and IM, respectively. The mean scores for practice, perceived skills, and desire for further training were generally low. Analysis of variance revealed significant differences among the three physicians groups in all surveyed topics, resulting from the low scores of the IM group. A diversity regarding confidentiality was noted, in that younger FP were most willing to keep health issues confidential.

CONCLUSIONS

Physicians in Israel have limited experience and perceive themselves to be underskilled in dealing with adolescent health issues. Training programs in adolescent health need to be developed to meet the needs of physicians in Israel.

Parental knowledge and attitudes of Minnesota laws concerning adolescent medical care

OBJECTIVE

To determine parents' knowledge and attitudes of medicolegal issues affecting adolescent medical care.

DESIGN

An anonymous, mailed survey with 16 questions concerning Minnesota consent and confidentiality laws that affect adolescents' medical care.

SETTING

A community of >70 000 in rural, southeastern Minnesota.

PARTICIPANTS

Parents of 600 randomly selected 7th- through 12th-grade public school students.

RESULTS

Two hundred eighty-eight (48%) parents returned the surveys. Parents achieved a median score of 18.8% (range, 0%-93.8%) correct on a test of knowledge. Opinion was a median of +0.3 on a scale where -1 signified "a bad law," 0 signified "neither a good nor bad law," and +1 signified "a good law." Four questions, however, generated a more intense response. Seventy-seven percent of parents reported that, as a whole, the laws in the survey had no effect on them and/or their children.

CONCLUSIONS

These results suggest that parents are not knowledgeable of Minnesota laws that affect adolescent medical care. Overall opinion of these laws was mildly positive, with notable exceptions. Parents also lack a sense of impact of laws affecting adolescent medical care. Lack of knowledge and the presence of certain attitudes allow for identification of issues that clinicians should address by incorporating medicolegal education into the care of adolescents and their families. These results are especially timely in light of the Parental Rights and Responsibilities Act under consideration in Congress, which would provide parents greater authority over their children's medical care.

Pediatricians' views of access to health services for adolescents

PURPOSE

The American Academy of Pediatrics (AAP) carried out a member survey to measure pediatricians' views of parental permission and notification for selected health services for two age groups of adolescents, the 13 to 15 year olds and the 16 to 17 year olds.

METHODS

Through an AAP Periodic Survey, a sample of 1000 members of the AAP were sent questionnaires to fill out and return. The response rate was 77%.

RESULTS

The majority of pediatricians in all groups examined believed parental permission and notification were important for general medical and surgical care. But for most other types of care delineated, related to substance abuse and sexuality, most pediatricians did not believe parental permission should be required, except for requests for abortion for 13-15 year olds. For several types of care most pediatricians believed parental notification should be required for 13-15 year olds. Older pediatricians, male pediatricians, and self-employed pediatricians were more apt to support both parental permission and notification for all types of care. When age, gender and self versus not self-employed were introduced together through a logistic regression procedure differences in views were accounted for by self versus not self-employed, and age and gender had no additional impact.

CONCLUSIONS

Most pediatricians supported the right of minors to seek care without parental permission for care related to substance abuse and sexuality. The majority were less likely to grant confidentiality to adolescents, particularly those 13 to 15 years.

Exploration for physicians of the mature minor doctrine

The "mature minor doctrine" is the common-law rule that allows an adolescent who is mature to give consent for medical care. Ethical decisions regarding consent and confidentiality should be distinguished from legal requirements. Recent court decisions have altered the law, especially in regard to consent for refusal of life-sustaining treatment. There are statutory exceptions to the rule of parental consent regarding emergency care, sexually transmitted diseases, drug treatment, mental health care, pregnancy, contraception, and emancipation. A detailed analysis of the mature minor exception is presented, utilizing court case vignettes. There is minimal legal risk in allowing adolescents older than 14 years of age to give consent for treatments entailing small degrees of risk, when they can make adultlike decisions and demonstrate signs of maturity.