Virtual Mentor. October 2005, Volume 7, Number 10.

Clinical Cases

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The Wayward Husband

Physicians should understand the limits of patient confidentiality and the importance of taking a thorough sexual history in the diagnosis and management of a patient with an STD.

Commentary by Dave Cundiff, MD, MPH

Tom Covington arrived for an appointment with his primary physician, Dr Tony Charon. Tom explained that for the last week he had felt some burning when he urinated. Dr Charon asked some detailed questions; Tom’s answers seemed vague and nonspecific.

Dr Charon ordered a series of tests, including a urinalysis and STD screening and placed Tom on presumptive antibiotic treatment. A few days later the tests came back positive for gonorrhea. Dr Charon called Tom back to the office to review the results. After Tom learned that he had gonorrhea, he explained sheepishly that he’d recently gone away on a business trip and confessed to a brief affair. He begged Dr Charon not to tell his wife about the infection. Dr Charon was conflicted about what to do, especially since he was also the primary physician for Tom’s wife, Ann. He wondered whether he should maintain confidentiality or whether doing so would place Ann at risk.

Later that afternoon Dr Charon noticed that Ann had an urgent care appointment scheduled for the next day. “She may be coming in with similar symptoms,” Dr Charon thought, “then I could legitimately test her for STDs.” The next day Ann arrived for her appointment and explained that she had concerns about a sinus infection. She had had congestion, facial pain, and a mild fever for a few days. Dr Charon conducted an extensive review of symptoms. When asked about genitourinary symptoms, Ann answered “no” to all those suggestive of a STD. Dr Charon was unsure about the appropriate course of action.

Commentary

Dr Charon had good intentions throughout this episode, and he has done several things right. However, his implicit promise not to reveal Tom's diagnosis to anyone is a promise that he cannot keep, either ethically or legally. Dr Charon should not pursue this issue with Ann during this visit. He must use other means to protect both his patients, and an unknown number of people who were their sexual contacts, from an infection with serious consequences. He must act quickly.

Tom appeared embarrassed about sexual issues, giving "vague and nonspecific" responses in the initial interview. Dr Charon didn't succeed in resolving this vagueness. It isn't clear whether the missing data affected the accuracy of the presumptive diagnosis.

After a specific diagnosis was made, Tom recounted "a brief affair." Apparently the timing was consistent with gonorrhea's incubation period. Dr Charon allowed Tom to believe that they could keep this a secret from Ann. We don't know whether Tom had intercourse with Ann after the "affair," but Dr Charon thought Ann was at risk. He wanted to help Ann, but he didn't know how.

When Ann scheduled an appointment on her own, Dr Charon hoped he could address Ann's sexually transmitted infection (STI) risk without revealing Tom's secret. By the end of Ann's interview, it was clear that this strategy would not work.

Dr Charon must do something different and he knows he must do it soon, but he doesn't know what it is. He may have thought of questions like these:

1. Can the physician avoid full disclosure by treating Ann for gonorrhea, under the guise of treating her sinus symptoms?
2. Must physicians always preserve the patient's secrets?
3. Can other professionals help evaluate and treat patients with STIs appropriately?
4. What should be done next for Ann and Tom?
5. How difficult and time-consuming will this problem become?
6. How could STI issues be handled better next time?

Q. May the physician avoid full disclosure by treating Ann for gonorrhea, under the guise of treating her sinus symptoms?
A. No. This paternalistic deception would violate the AMA Code of Medical Ethics, which states:

The patient’s right of self-decision can be effectively exercised only if the patient possesses enough information to enable an intelligent choice…. The physician’s obligation is to present the medical facts accurately to the patient or to the individual responsible for the patient’s care and to make recommendations for management in accordance with good medical practice [1].

The Code also counsels: "… a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions” [2].

Deceiving Ann would postpone embarrassment for Dr Charon and for Tom at the expense of depriving Ann of the information she needs and deserves. Ann must discuss her recent sexual history and name any partners, so that all potentially infected persons can be diagnosed and treated. Why would she do that without knowing why a sexual history is being taken? Ann should report symptoms related to her diagnosis. How can she do that without knowing what the diagnosis is? Ann needs follow-up testing. How can Dr Charon collect genitourinary specimens if Ann believes he is treating a sinus problem?

Ann and Tom would benefit from a shared understanding of, and a shared plan for, their marriage and family. Dr Charon cannot force this dialogue to occur, but he must refrain from deceptive actions that would harm this process.

Q. Must physicians always preserve the patient's secrets?
A. Physicians must understand the limits to confidentiality and must never promise more confidentiality than can be given.

The AMA's “Principles of Medical Ethics” provide that "[a] physician…shall safeguard patient confidences and privacy within the constraints of the law” [3]. When does the law require disclosure of confidential information without the patient's express or implied consent?

Laws and ethics require disclosure of information in certain dangerous situations. Evidence of child abuse or neglect and abuse or neglect of a vulnerable adult must be reported whenever required by law [4]. Evidence of a crime must be reported if the law requires. Physicians must also report a credible threat of injury to others [5].

Laws require reporting of public health concerns to public health authorities. Ethics require compliance with those reporting laws. Physicians must report gonorrhea in every US state.

Q. Can other professionals help evaluate and treat patients with STIs appropriately?
A. Public health authorities classically use "contact tracing" methods to bring STI contacts to evaluation and treatment without violating confidentiality. Persons reported to have STIs are interviewed promptly by public health disease investigators. These investigators are generally not licensed clinicians. They are trained in interviewing techniques, STI epidemiology, and how to maintain confidentiality while finding and protecting partners. Interviewing each confirmed patient, they take histories of all sexual experience relevant to the particular STI and determine how to locate the patient's recent sexual contacts. Contacts are told that they may have been exposed, without disclosing the index patient's identity, and are urged to seek examination and treatment. Some jurisdictions follow up with each contact as needed until medical evaluation is completed. Other jurisdictions are notified of out-of-area contacts if feasible.

The scope of this service varies greatly in different jurisdictions. Some departments use contact tracing for all gonorrhea cases. Other departments reserve contact tracing for a few selected situations or diagnoses. Because traditional partner notification is not always available or successful, public health researchers are exploring alternative strategies for promoting treatment of partners exposed to STIs [6].

Q. What should be done next for Ann and Tom?
A. Dr Charon should treat Ann appropriately for her sinus symptoms, answer her questions, and end the visit as he normally would. He must then make sure that Tom's gonorrhea has been reported to the appropriate health department.

Dr Charon must talk with Tom again, preferably that day. Dr Charon must inform Tom that his right to confidentiality is not absolute. He must tell Tom that his illness has been reported to the health department as required by law. He should assure Tom that the health department will not reveal his name to others.

If Ann finds out about this situation from anyone but Tom, or if she is harmed by Tom's delay in telling her, the marital and legal consequences are likely to be much more severe than if Tom discloses promptly. Tom should be reminded of the potential harm from untreated gonorrhea. Whether or not Tom wants to stay married to Ann, he should be reminded that he has a legal obligation not to harm her. It is in Tom's long-term interest to treat Ann and other known partners with respect and to help each one to stay safe.

It may be best for Tom to reveal the situation to Ann himself. An objective third party (such as Dr Charon, if his schedule permits) may help Ann and Tom to process initial emotions. He should offer to refer the couple to one or more qualified marriage counselors if he thinks that is appropriate.

To protect her from additional risk, Ann must be notified immediately. If Tom will notify Ann outside the office, Dr Charon should know how and when Tom will discuss this. If either partner's history suggests a possibility of violence, a safe environment must be assured. In case Tom fails to notify Ann as agreed, Dr Charon should request permission to discuss Tom's diagnosis with Ann the next day. He should also urge Tom to notify his other partner if possible.

If Tom will notify Ann in the office, Dr Charon can influence the likelihood of success. Child care must be arranged if needed. There should be enough time to talk with both partners together. Ann must have time to speak privately with Dr Charon. She will probably want Tom to be out of the room when she is examined. If Ann has received antibiotics that might lead to a false-negative culture, at least one of Ann's diagnostic tests should be a DNA-based test. All patients with STIs should be encouraged to obtain appropriate tests for other STIs, including HIV.

Dr Charon should seek consultation if he needs it. Public health physicians are trained in a team approach to disease prevention and control. Dr Charon should request assistance if he is not qualified to handle the epidemiologic and emotional complexities of a case, if he lacks the time to address these complexities quickly and thoroughly, or if he is uncomfortable about the progress of the case. This consultation is available from the public health physician or other expert responsible for STI control in the city, county, or state. Public health consultation is not a violation of confidentiality.

Q. How difficult and time-consuming will this problem become?
A. Many things must be done quickly. Counseling, interviewing, and full sexual histories can be difficult or impossible in a short appointment. Locating Tom’s sex partner and, possibly, that person’s sex partner(s), interviewing and counseling, and convincing them to seek treatment involve skills and time beyond that of the office setting. Barriers to interviewing, testing, and treatment can involve mistrust of interviewers or authority figures; disbelief or denial; excessive anger or fear; lack of knowledge about STI's; or financial, language, and transportation concerns.

Sexual networks are often complex. Tom's sexual network includes Tom and Ann plus the presumed source case for Tom's infection. This person may or may not be the source and may live in another area. That person has a sexual network of her or his own. She or he may have asymptomatic gonorrhea.

Will Tom contact this partner immediately? In light of his attempt to hide his behavior from both his physician and his wife, one wonders. Others are at risk besides Ann. Timely support from well-trained specialists, such as health department disease investigators, can be crucial.

Q. How could STI problems be handled better next time?
A. After resolving this episode, Dr Charon should have a working relationship with his public health department and its STI services. He should know whom to call for STI consultation, epidemiologic analysis, and disease control interventions.

When the crisis has passed, Dr Charon should learn to take a good sexual history. A skillful introduction can help assure the patient that the physician is comfortable discussing sexual topics, that all information will be held in confidence within the constraints of the law, and that the information will help the physician to provide better care. A more effective sexual history might have resulted in faster diagnosis, more appropriate treatment, and better protection against spread of the infection.

References

1. American Medical Association. Opinion 8.08. Informed consent. AMA Code of Medical Ethics. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browsedoc=policyfiles/HnE/E-8.08.HTMs_t=st_p=nth=1prev_pol=policyfiles/HnE/E-7.05.HTMnxt_pol=policyfiles/HnE/E-8.01.HTM. Accessed August 12, 2005.
2. American Medical Association. Opinion 8.12. Patient information. AMA Code of Medical Ethics. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browsedoc=policyfiles/HnE/E-8.12.HTMs_t=st_p=nth=1prev_pol=policyfiles/HnE/E-7.05.HTMnxt_pol=policyfiles/HnE/E-8.01.HTM. Accessed August 12, 2005.
3. American Medical Association. Principles of medical ethics. Principle IV. AMA Code of Medical Ethics. Available at: http://www.ama-assn.org/ama/pub/category/2512.html. Accessed August 12, 2005.
4. American Medical Association. Opinion 2.02. Abuse of spouses, children, elderly persons, and others at risk. AMA Code of Medical Ethics. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browsedoc=policyfiles/HnE/E-2.02.HTMs_t=st_p=nth=1prev_pol=policyfiles/HnE/E-1.02.HTMnxt_pol=policyfiles/HnE/E-2.01.HTM. Accessed August 12, 2005.
5. American Medical Association. Opinion 5.05. Confidentiality. AMA Code of Medical Ethics. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browsedoc=policyfiles/HnE/E-5.05.HTMs_t=st_p=nth=1prev_pol=policyfiles/HnE/E-4.07.HTMnxt_pol=policyfiles/HnE/E-5.01.HTM. Accessed August 12, 2005.
6. Golden MR. Expedited partner therapy for sexually transmitted diseases. Clin Inf Dis. 2005;41:630-633.

Dave Cundiff, MD, MPH, is secretary of the American Association of Public Health Physicians. He is a self-employed locum tenens physician practicing primary care and public health medicine in the Western states. He lives in Olympia, Washington.

Acknowledgement
The author thanks Joel L. Nitzkin, MD, MPH, DPA, and Kevin M. Sherin, MD, MPH, for manuscript review and helpful comments.