I heard the other day about an old lady who had been upset by her doctor. The story was that her habitual consumption of one Campari and soda each evening had resulted in a collection of empty bottles by the back door, which her doctor noticed when he called to see her. Attending surgery some time later she was distressed to find that as a result of this her medical record had been flagged to suggest she was a problem drinker. She explained that this was certainly not the case and asked that the record, which she could see on the computer screen, be amended. The doctor refused.
His refusal upset her. She can't bear the thought of a false slur remaining on her record, or the fact that her doctor didn't put her interests and the confidentiality of their relationship first.
The collection of bottles by my back door at the moment would certainly provide equally good grounds for a warning flag, as I suspect many of yours would as well. But now that total abstention from alcohol is known to constitute risky behaviour, the thing I am anxious that the world should not discover from my medical records is that my private life really is as dull and unadventurous as it appears to be. Which rather snookers those who argue that people with nothing to hide have nothing to fear from this sort of thing. For, in spite of my cupboard being so depressingly bare of skeletons (so far, so far …), I find it a substantial disincentive to my visiting an NHS doctor to know that nothing that I say there can be recorded at all, except on what is effectively the public record, permanently impossible to delete.
Another thing I heard recently was that private agencies are being employed by GPs to produce computer summaries from the old Lloyd-George cards and the vacuous wadges of printout from the computer systems of previous practices. The big advantage to the doctor who was telling me this was that these commissioned summaries made it so much easier for him to provide reports to third parties.
Dear, oh dear, oh dear — didn't that just bring back memories of things that used to worry me in practice! That survey I did that showed that the great majority of patients, for whom these reports are requested, have no idea that the signature they have been required to give (if they want the insurance, that is, which surprisingly enough they invariably do) has given their permission for this intrusion. And who asked the previous doctors if they minded hirelings sifting through the confidences entrusted in them by their former patients? And who asked the patients? And why didn't the doctor telling me about this think of mentioning some way in which the new summaries were of clinical use as well?
My legal patients used to agree with my concerns. Because they knew better than most what was going on. One solicitor told me that it was invariable practice among her colleagues to withhold sensitive information from their doctors because they knew how impossible it would be to prevent subsequent disclosure. And that was in the days when we still had paper records and before the Google phenomenon had awakened the world to the previously unimaginable and still barely-believable speed, power and selectivity of computerised information retrieval.
I have some expertise in this area, having been one of the two GPs on the Caldicott Commission, which reported in 1997. I believe that easy talk about patient confidentiality disguises an accelerating departure from traditional standards — standards that are nonetheless still taken for granted by many patients. The assumption that certain things you say to the doctor will remain confidential between the two of you has deep roots; we may be about to discover how much of the standing of general practice depends upon that assumption. Not so many years ago some GPs destroyed their records when they retired from practice. Perhaps the time has come to contemplate the possibility that such doctors were not self-centred and benighted dinosaurs, but wise and experienced professionals with great integrity. Perhaps the time has come to contemplate the possibility that the way we have chosen to employ information technology in general practice, as well as delivering unquestionable benefits, has at the same time created a kind of monster.
In the Back Pages, July...
Jenny Wilson, on family breakdown; Amanda Wood on multilevel modelling; Dorothy Crowther, a short story; David Watson on Quentin Tarantino; and more!
- © British Journal of General Practice, 2004.
