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Spandorfer J, Pohl C, Nasca T, Rattner SL, eds. Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge: Cambridge University Press; 2010.

Video: Commitment to Patient Confidentiality | Commentaries


A Faculty Perspective

Confidentiality is typically the first crucial concept to learn in the process of the professionalization of medical students. It is an early chapter in all the textbooks for a reason: before you learn anything about a patient, you must understand the importance of having the right to that information. (1) The information to which it applies can be defined thus: If you would not have known that information were you not a medical student, then you cannot share that information with anyone who does not share your oath to confidentiality.

To first year medical students, the expectations placed upon them often seem unfair. This is totally natural: one cannot change one's sense of personal identity or self-image overnight. Yet that is what the faculty often appears to expect. The gap in expectations can be so great that some explanation may be needed for both groups to understand each other.

Here is my suggestion for how to mediate between medical student self-image and faculty expectations of professionalism with regards to confidentiality. First, the faculty must understand that professionalization is a gradual psychological process, and one that begins in first year but is not complete until the third year (or later). If there is reason to worry about whether students can maintain patient confidentiality, then the faculty might be burdening students with confidential information too early in their training. It might be better to offer only paper cases and standardized patients for the first semester or the entire first year while the students begin to make the adjustment to their new professional responsibilities.

Second, to take the student's perspective, I would suggest that we can help them understand their responsibilities with the following metaphor. Applying to medical school is not just applying to get into a highly competitive undergraduate institution. It is also akin to proposing to marry someone. When a school interviews you, it is like a first date. Much of what they were looking at was what sort of a person you were, and whether they would like to be seen with you in various settings. When they admitted you, it was like accepting your proposal: they didn't just like your grades, they liked you.

Once you were admitted you still had a chance to change your mind, rather like getting cold feet from the cost and complexity of wedding planning. But if you don't cancel your wedding plans, then you are making a lifetime commitment to another person. You will care what they think of you, and will be willing to make some personal changes to meet their expectations. Becoming a doctor is not just getting a degree, or learning a lot of new information. It also means a change in your identity. First others will start to see you differently, and later you will start to think differently and see yourself differently as well.

So what should you say to your friend at that party? You can tell them that medical school is harder than you thought, but it isn't just the science courses, it's learning how to react to the stories patients tell--what to say, and what not to say. Tell your friends about confidentiality, and how that's an important part of becoming a doctor. It is possible to keep your old friends, but gradually you will probably find, as have many others, that you have less in common with your old friends and more in common with your fellow medical students. And it isn't about science; it's about your developing new professional identity.

References:

  1. 1. Lo Bernard. Resolving Ethical Dilemmas: A Guide for Clinicians, third edition. Lippincott, Williams, and Wilkins (Baltimore, 2005). The chapter on Confidentiality is Chapter 5.

Jeffrey Spike, Ph.D.
Professor and Director, Campus-Wide Ethics Program
McGovern Center for Health, Humanities and the Human Spirit
University of Texas Health Science Center, Houston