Healthcare Privacy in the 21st Century

While working as a physician for several decades, I’ve observed the dramatic changes in policies and attitudes relating to privacy.  These changes have a potentially negative impact on psychiatric care.

When I was growing up in the 1960’s and 1970’s, a doctor’s office was considered a safe place, where every employee had the patient’s best interest at heart.  Anything that was talked about was considered private.  I still remember a moment in 1978, when I told my doctor that I had tried marijuana at the age of 17,   I knew that regardless of the doctor’s relationship with my parents, the information that I shared about my own health would not be shared with anyone else, without my consent.

Fast-forward to my doctor’s appointment yesterday, where a nurse entered my health history into the healthcare network’s database.   There was no discussion about my options for sharing that information.  I received a sheaf of papers that contained information about privacy and signed a form related to HiPAA, but the text was far too small to read without my reading glasses (again, I’ve been a doctor for a long time!), and had I taken the time to read the form, the people in line behind me would likely have complained.

We did not discuss the article I saw in the news yesterday, that described the lack of security with digitalized healthcare records.  We did not discuss whether it is truly a good idea to put every person’s healthcare history  online, so that every doctor, nurse, or secretary affiliated with a clinic can read the things I tell my doctor.  We didn’t discuss what could happen in the future, when the government has access to my health history.  We didn’t discuss the difficulty I would likely have with getting life insurance, given my health history.  We didn’t discuss the ways that disclosure of my health history could someday affect my ability to find employment.

The experience made me wonder about the amount of privacy that patients should and do expect today, when they see a psychiatrist.  Do patients feel safe, disclosing personal information with their psychiatrist?   They should — because in many areas of mental health care, secrets keep us sick, by preventing appropriate care or counsel.

In the big picture, the crazy trend toward universal access to healthcare information interferes with the potential benefits to seeing a psychiatrist.  If patients have the thought that everything they say will someday be read by someone else, then they are not going to speak openly about their problems.  I’ve written about the problems with ‘mass-produced psychiatric care’, where patients are seen for 9 minutes and then prescribed psychotropic medications….   perhaps in that model of care, there is no time to say anything that really matters!  In that case, online medical histories are just ‘garbage in, garbage out’, and the loss of privacy is ‘no harm, no foul.’

I do not agree, though, that details are irrelevant.  People have different reasons for being depressed, and some minds work differently than others.   I know that I have a better chance of success in improving the quality of a patient’s life when I take the time to learn how that person understands and reacts to the world.   Patients therefore have an interest in being open with their psychiatrist about more than their medication history.

Patients who use my psychiatric services should know that their privacy will always be secure. I do not place patient records online, and I have no plans to do so in the future.  I type patient records myself, and do not use transcription services (where many strangers gain access to patient histories).

I want patients to feel comfortable allowing me to know their true selves, as that type of psychiatric relationship can be liberating.  To get there, patients should now that whatever they say, stays here.

Evidence--Based Medicine

‘Gray Areas’ in Psychiatric Treatment

I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry.  She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor.  “Add a little of this, and if that doesn’t work, try adding some of that” she said.  “Psych is all a gray area.  You can be creative.”

Now THAT’S crazy.  Her recommendations, sadly, will likely be followed in a number of actual patients.  No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.

At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.

Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches.  They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.

Evidence-based medicine encourages practitioners to ignore their own experience, and to instead anchor practice patterns to those supported by peer-reviewed research.  Practitioners should know the difference in predictive value for comments by a mentor, the findings in a case report, and the results of a large, prospective clinical trial.  Practitioners should appreciate the perils of using their knowledge of basic science to extrapolate findings from one set of conditions, to a case where some variables differ.

These distinctions are especially important in an era where insurance companies increasingly try to influence treatment patterns.  For example, there is considerable evidence that Abilify effectively augments the antidepressant effects of SSRIs.  Insurance companies often refuse to cover Abilify, instead demanding substitution with risperidone, a less-expensive medication from the same general class of ‘atypical antipsychotics.’  But there is no good evidence that risperidone provides any benefit for depression.  There are a number of similar situations where insurers require ‘prior authorization’ for the treatment best-supported by clinical evidence.  Many insurers even require a period of treatment failure with a bad medication, before they will consider the best medication. Insurers would argue that they recommend medications that are much less expensive, at the cost of ‘minor’ side effects.  But practitioners who use evidence-based approaches to treatment know that the insurer’s medication selections are influenced by cost to a much greater extent than efficacy.

Back to the original discussion, those who practice evidence-based medicine know that someone who views psychiatry as a ‘gray area’ is someone who didn’t have a strong education in psychiatry or neuroscience, and who doesn’t read much of the psychiatric literature.  To a Board Certified Psychiatrist, the field of endocrinology is a ‘gray area.’  But when treating depression, the psychiatrist knows—or should know– that adding a ‘one milligram sprinkle’ of Abilify has no scientific basis for treating major depressive disorder, whereas a dose between 2 and 15 mg has been effective in controlled, clinical trials. Nothing gray about it.

Patients treated for depression or other psychiatric conditions should be aware of efforts to increase the use of evidence-based medicine in psychiatry.  How does your treatment measure up?