AMA Journal of Ethics^®

Brissette I, Gelberg KH, Grey AJ. The effect of message type on physician compliance with disease reporting requirements. Public Health Rep. 2006; 121(6):703-709.

The lecturer stands at the podium presenting his newest and most exciting research findings to a room full of eager medical students. Ten hands shoot into the air, and every mind in the room turns over the ideas that have been put before them. What you will find at medical schools across the country on any given morning—an eagerness to question authority and think beyond what is presented—is a quality that physicians have in common with other human beings, but one that is often more highly rewarded in medical education. The ability to question those who present absolutes before us will be our greatest strength when new discoveries are sought and our greatest weakness when it comes time to contributing to the common body of knowledge by reporting to a disease registry.

When I think about my fellow medical students and myself, I wonder whether our questioning and challenging of everything we are told is motivated by a desire to know as much as possible about specific disease processes or by some implicit understanding that cultivating this skepticism for its own sake will benefit our patients in the long run. In a 2006 article in Public Health Reports, the authors of "The Effect of Message Type on Physician Compliance with Disease Reporting Requirements" looked at the physician's noncompliance with reporting requirements in a similar light. They wanted to know whether it was the expectation of the law's enforcement that drove their reporting habits or their desire to contribute to the collective knowledge about a particular disease. They undertook to answer this question by contacting 368 physicians in New York who had not complied with the state reporting laws [1].

The authors sent study participants one of three types of correspondence regarding each patient for whom a report was outstanding, asking that the report be filed and including report forms that could be submitted via mail or fax. The three types of correspondence, sent between September 2003 and March 2004, framed the request for the delinquent report as a statement about (1) the legal obligation to report occupationally acquired lung disease to the New York State Occupational Lung Disease Registry, (2) public health benefits of reporting, or (3) a combination of rationales (1) and (2) for reporting those specific diagnoses to the proper authorities.

The replies from these correspondents were evaluated on the bases of response rate, timeliness, and completeness of the reports and were compared to the number and completeness of unprompted reports sent in during the same time period by New York physicians who were not part of the study [2]. Just over half of the physicians who were contacted sent in the requested forms. More responses were received from those whose communication informed them of the legal obligation to report than from those whose communication discussed the public health benefits of reporting. No statistically significant difference was seen between the response rates of those in the legal obligation group and those in the group that received information on both the legal and public health aspects of reporting, but the reports received from the latter group were considered on the whole to be more complete and more informative [3]. This evidence convinced the authors of the importance of seeking wider understanding among physicians, not only of the legal requirements of reporting, but also of the public gains to which those who report are contributing.

In looking at these results, we wonder why half of the group that received requests for reports did not reply. They received personalized requests for information on specific patients, and yet they did not supply it. The authors mention this but do not explore in any great depth why it may have occurred. They speculate that physicians might have felt that reporting would be a disservice to their patients, putting them at risk of losing their jobs, but there is no way to know whether this is a valid explanation without asking the specific physicians. The authors hint that their findings may represent the tip of the iceberg when it comes to the concerns many physicians have about jeopardizing patient confidentiality. To understand the phenomenon, it is important to consider the context within which disease is reported.

This study looked at one particular set of reporting conditions, but each specific type of illness and patient population has its own set of ethical concerns and legal ramifications of reporting. To address that topic, the authors bring in two other studies, one in Rhode Island on the reporting of adverse drug reactions [4] and another that looked at the reporting of communicable diseases in Los Angeles County [5]. In these studies the factors that contributed to differences in reporting rates included whether the disease was acquired at work, whether it was an STD, and the demographics of the population most affected by the disease. Constants in physicians' decision to report or not report were their dedication to the relationship with the patient and their commitment to maintaining patient trust.

Physicians are privy to a great deal of personal information, and a good medical interviewer is one who can make patients feel at ease about confiding the most intimate details of their lives. This relationship is what allows physicians to diagnose the conditions that they are then asked to report, making public something that was once very personal, and in many cases very sensitive, information. Some physicians endeavor to put the best interest of their patients ahead of required disease reporting, especially if legal and public health benefits of reporting have not been satisfactorily communicated to them.

As I return to thinking about the future physicians currently sitting in medical school auditoriums across the country, I believe that their aggressive questioning of their instructors may stem from the same factors that motivate ethical physicians to question reporting of disease. The authors of "Effect of Message Type on Physician Compliance" conclude that, to maximize physician reporting, it is critical to present both the legal requirements and the public health benefits of disease reporting [6]. Our desire as students to question and understand everything we are told in the context of what it will mean for each of our future patients is not unlike the desire we will have as physicians to understand where disease reporting fits into the bigger picture of patient care. By making both the legal requirements and the possible public good of disease reporting more transparent to physicians and patients, public health authorities foster physicians' desire to promote the health of the community.