What It Means to ‘Keep Inviolate’

Your patients deserve to have their health information protected and respected at all times.
By Stephen M. Perle, DC, MS
“Doctors of chiropractic should preserve and protect the patient's confidential information, except as the patient directs or consents, or the law requires otherwise.” ~ Tenet IV, ACA Code of Ethics   
The oath we took during commencement exercises includes the line, “I will keep inviolate all things revealed to me as a physician.” This is a fancy way of saying you will not tell anyone what patients tell you.
Patient autonomy, the right to control what happens to our own bodies, is a fundamental right. It includes the right to privacy with respect to information about our bodies and our health. Maintaining patient confidence is critical so that patients will share all the information required by their doctors to make appropriate clinical decisions. HIPAA has codified patient privacy into law, but where does the ethical standard go above what the law requires? 
Sign in sheets, for example, are legal under HIPAA, especially if you make certain efforts to limit the exposure of protected health information (PHI). You could limit exposure to PHI by asking only for patients’ names and time of arrival, or by marking through their names periodically during the day.   
However, just because something is legal does not necessarily mean that it is moral. Doctor-patient confidentiality should extend beyond a sign-in sheet to the mere fact that a person chooses to call upon a certain doctor for his healthcare needs. One of the most extreme levels of doctor-patient confidentiality is witnessed in the mental health community, where some patients fear negative consequences if the mere fact of their treatment by a psychiatrist or psychologist is revealed. Even on the TV show “The Sopranos,” the character Tony Soprano noted the potential harm to his status as a feared mob boss if the fact of his therapy sessions with Dr. Jennifer Melfi were revealed. Some real-world psychiatry/psychology offices take doctor-patient confidentiality so seriously that they have an unmarked exit door that is separate from the entrance to the practice. 
No one expects that doctors of chiropractic will have a separate entrance and exit, but there are many chiropractors with “open” offices. Obviously, some patients are not concerned with the lack of privacy in an open floor plan; however, there are individuals who will not visit, or return to, an office where the floor plan says the doctor does not respect a patient’s privacy. Meanwhile, other patients may just be quietly uncomfortable in such a setting.   
Likewise, an office with a bulletin board listing those who have referred new patients or that announces patients’ birthdays and anniversaries can also be viewed as a sign proclaiming: “Doctor-patient confidentiality is not practiced here!” Talking with one patient about another patient breeds further distrust. A patient can rightly ask, “If the doctor will talk about my friend’s condition to me, who says he won’t talk about me to someone else?”  
Moreover, it’s not uncommon to hear a doctor talk about one of his celebrity patients as if the celebrity’s head was mounted like a trophy on his wall. I understand how having a famous patient can make a doctor feel validated; however, a doctor shouldn’t violate a patient’s trust to pump up his own ego or business.   
Keep in mind that concepts of privacy have changed over the years. For example, even though the press corps was aware that President Franklin Roosevelt was paralyzed, the public at large never knew because it was not reported. Nowadays, teams often report athletes’ health information, which gives the impression that they don’t deserve privacy, yet celebrities and athletes are just as deserving of privacy protection as the humble and the anonymous. We must always remember to preserve the privacy of our patients’ information—including the mere fact that we are their doctors.   
Dr. Perle is a professor of clinical sciences at the University of Bridgeport College of Chiropractic, where he has taught an ethics course for more than 15 years. To read ACA’s code of ethics, visit www.acatoday.org/ethics. Send questions to ethics@acatoday.org.