Sawbones: A Marital Tour of Misguided Medicine - Sawbones: Patient Privacy

Episode Date: March 9, 2017

This week, Dr. Sydnee's dad Tommy Smirl sits in for Justin as they explore the history of patient privacy. Why does the doctor have to keep your secrets? Find out this week! Music: "Medicines" by The Taxpayers

Saubones is a show about medical history, and nothing the hosts say should be taken as medical advice or opinion. It's for fun. Can't you just have fun for an hour and not try to diagnose your mystery boil? We think you've earned it. Just sit back, relax, and enjoy a moment of distraction from that weird growth. You're worth it. that weird growth. You're worth it. Alright, time is about to books. One, two, one, two, three, four. We came across a pharmacy with the two windows busted out. We were sawed through the broken glass and had ourselves a look around.

Some medicines, some medicines, the escalators were caught for the mouth. Oh, and welcome to Sobhones, a marital tour to misguided medicine. I'm your co-host Justin McAroy. Uh, no you're not. I'm not. I've definitely Sydney McAroy, but you're my dad. I'm your co-host Tommy Smurl, and I am just a dude. That's right. This is a very different solbones this week.

It's a crossover. We've switched it up. We hear it solbones. You're probably familiar. We like to talk about medical history and stupid, awful medical things that we've done throughout history because we didn't know anything. And my dad, who's named by the way, is Tommy Sparrow. I'm introducing you.

Oh, thank you. Does a podcast that does the sort of the same thing with legal matters called court appointed with my uncle Michael Meadows? That's right. And so we got the idea. I said, here's a topic that kind of is part medical and part legal. Why don't we do a big podcast? And then Justin said, let's just swap dumb guys.

You go over with Sydney and I'll go over with Michael and we'll do the same topic, but cover it from both angles. So you have a sister episode now. Now it should be noted that I did not refer to them as the dumb guys. It's a Twitter thing. It's a Twitter thing. Yeah, they talk about the dumb guys, oh no, it's just. No, you're just not the experts.

That's a lot more cumbersome, just the not experts. I clarify that by saying I'm just a dude. That takes me out of the equation. I'm not held responsible for anything. So we wanted to talk a little bit about patient privacy and HIPAA, which you hear thrown around a lot, but a lot of people don't know what that stands for, what that means. And this is definitely a topic that has both medical

and of course legal implications. Myself as a physician, I have my own kind of perspective on it and then on court appointed, my uncle Michael is a lawyer. So he'll be taking the same topic from a legal perspective. So, so let's talk about patient privacy. All right. That sounds like a good idea. Since that's our show. The idea of patient privacy is not new. It's very old. It goes back as far as, I mean, when we really think about the history of medicine, a lot of the time, especially on solbons, I'll start with

hipocrates. Now, of course, we were doing weird things to people even before that, but we kind of think of that as the beginning of the medical profession. In that ironic hipocrates and hippa, that's true. That's true. Yeah. I guess it didn't have anything to do with it because it's a, what do you call it, an acronym? Hippocrates and hippa. That's true. Almost thinking came from that. I guess it didn't have anything to do with it, because it's, what do you call it, an acronym? Yeah.

You know, it didn't, but they so often will choose those kinds of acronyms to like represent it. They do that with medical studies a lot too, or they try to pick something that sounds exciting or revolutionary as the acronym for the study. When it's really just about like, which cholesterol drug is better or something. So give it an exciting name and it makes it more exciting. Yeah, it's because it's our nerdy stuff, so we're trying to get people interested in it.

For the commercials later, when they try to convince you to tell your doctor that you want that. Well, according to this very cool trial. So, hipocrates, of course, wrote the Hippocratic oath. And patient privacy specifically mentioned in Hippocratic oath, and what it states in the original version is, and whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad,

I will never divulge holding such things to be holy secrets. So basically, I'm not going to tell anybody what we do. What happens in the doctor's office stays in the doctor's office. So they were like in Vegas. Exactly. It was the same idea. Okay. And this was largely tied to the fact that historically, doctors initially were very closely

tied to priests. So while by the time they had a panic killed a lot of people, what no. Wait, what do you think priests do? For the administer last rights. Well, that's a fair comparison. We didn't know what we were doing. Well, that's a fair comparison. We didn't know what we were doing.

No, because by the time not to be fair, but in hypocrite's time, physicians were beginning to become more regarded as like craftsmen, tradesmen, like guild members, that kind of thing. They were still very closely tied to their religious roots because for the begin, for ancient history, medical problems were largely seen as like punishments from the gods, or if you got better, it was a divine intervention. Whatever healer coached you through that, therefore, was imbued with some sort of spiritual powers as well. So you can see that like close connection. So priests, in fact, were doctors for a long time, you know, and I mean, like if you you look at shamans and medical men and that kind of stuff, the two were very tied.

I think you see that related that just as a priest holds your secrets very sacred. If you go confess to a priest, they're not going to tell anybody. The same was expected of a doctor for that reason. I never thought of that, but when you think about things like Native Americans, they had their doctors were also the spiritual leaders a lot of times there. And when they run into tribes and in the woods that have been back in there, people don't know much about. Usually the spiritual leaders also the medicine man or whatever like that.

Exactly. And if you think about the origins of diseases being thought to be divine, you know, punishments or whatever, it makes sense. You'd want somebody who understood the body, but also was in touch with the spiritual realm. Because then curing you of disease is very much like exorcism. And so then the corollary to a priest becomes very clear. That kind of goes back to your detox episode, huh? Yeah, that's true.

That's just some of all the bad stuff coming out. Get all the bad stuff out. So alongside this belief is the directive that we refrain from any wrongdoing. So we're supposed to keep our patient's secret, secret and secret and not tell anybody because that is the trust you put in your spiritual here, your physician, whatever, you know, whatever we are at that point in history. But at the same time, we're not supposed to hurt you. You know, that, that premium non-no-sarium first-do-no harm is not actually in the Hippocratic oath. That actually came along in like the 17th century. But it does make a point in the Hippocratic oath

that we should refrain from wrongdoing, which is, I mean, the same idea. That's a good idea in general. I mean, does it really have to be written in there? Try not to kill ups, you know? I mean, dad, I know you're new to this show, but trust me, we've done some pretty messed up stuff in history.

It was important to remind doctors like try not to hurt anybody. I think that DuNoHarm was a movie title too. It had something to do with that. It may have been, it may have been. But because we were also tasked with not hurting people, over time, physicians took this to mean that sometimes, in order to help your patient, you had to tell their secrets. That sometimes if they couldn't take control of their own health care, they weren't able to do

things for themselves that you might have to divulge this information to somebody else to help them, to help them manage whatever it is or make a decision or keep them from doing something that you thought would harm them. And so that's like a direct conflict. You wanna keep their secrets, but at the same time, if we're not supposed to hurt them, maybe sometimes, and it's a very paternalistic attitude of medicine. Sometimes for their own good, I'm gonna tell somebody their secrets.

And that was completely left up to the doctor. So it's your own discretion. What do you think you need to do in someone's best interest? Well, I don't know. It's up to each individual person who just happens to become a doctor. And some people are better at making those decisions than others. Exactly. That's a lot of power to just put in physicians. I mean, like I like to think that I'm okay at science and I care about people a lot. And so therefore I had a talent for medicine

and I was able to get through medical school. But that doesn't necessarily make me this great person. I think you're a great person. Well, thank you, Dad. I hope I'm a great person. But that doesn't necessarily make me one just because that's the job I chose. And so.

Your mom and dad, the two are. There are a lot of wonderful doctors, but that the two, you know, the two, you can't assume one. Um, and also the other exception that's in the oath is, and it's in that, that paragraph I read, if the information, be what should be published abroad, and what they're talking about is if this is important information that maybe we need to share with the world so that we, you know, further our understanding of the human body, then we need to share it as well.

So like if it's a big breakthrough about something that could save lives, you find something with someone that is a disease and you find a cure because of it, then you need to share it. Exactly. And so then at that point, you have to make the decision, is it something I need to do, to do that with or not, and then it's okay to do it if you decide it is. So we see that even though this was this sacred duty, we're already kind of like, well, but almost all the time. Almost. This idea that it was kind of this sacred duty, like it changed throughout the Middle Ages

when it became more of like a mark of decorum. A doctor would not be respected or trusted if you gossiped about your patient. You would think they were less professional. Sure. So maintaining privacy became more tied to professional behavior. And this was mentioned specifically in this treatise written by John Adurn in 1370. And it was a treat us on anal fistulas. And that is specifically,

you really shouldn't talk about your patients and you can kind of see why. Yeah. If you're writing a treat us on anal fistulas that you should be like, and also, please, don't go tell all your patients' friends about his anal fistula. Come on.

Hey John, what's your paper about A-holes? Be a buddy and don't go tell everybody about the anal fistulas. Why would you want to tell people about the anal fistulas? Are all the topics I've picked. I've never picked that topic. You know, Dad, we did an episode on anal fistulas. They were in fashion for a while.

King Louis brought them into fashion. In fashion? You can an anal fistillab being fashion. He had one and he was the king, so it became the fashion. There's no accounting for taste. Oh my gosh, I mean, that's like a pierced belly button. I think it's more uncomfortable. And not as...

I've never had either, but... And not openly displayed. The first... When we see this idea being challenged from outside, because a lot of this we've talked about is like physicians are mandating it for themselves. We see this being challenged from the outside in the 14 and 1500s as the Great Pox, which was syphilis, is spreading through Europe. Physicians are being compelled by local authorities to report the names of patients with syphilis to them.

And this is clearly in violation of the oath and what physicians believe their job is. And this is actually taken to court repeatedly as physicians are fighting for their right to keep their patients' secrets and judges are trying to force them otherwise. And there are a lot of compelling arguments about trust. And this is where we start to see that argument.

If I start telling people, hey, this dude's got syphilis, nobody's gonna come to me for treatment for syphilis anymore because they're gonna know that I tell people. And so it's gonna be bad for patients, it's bad for the public health. They need to know they can trust me or else nobody will seek medical care.

That's where you start to see that argument arise. And physicians thought really hard and they made really compelling arguments and ultimately, in every case, the judges agreed with them. Like, well, you're right. And what usually turned it is that they said, you know, syphilis doesn't just strike. I mean, it's not like a class thing. Anybody can get syphilis, maybe even judges. And if a judge got syphilis, wouldn't that judge want me to keep it quiet?

And then they said, I would. I mean, yes, he would. And then they rolled in their favor. They did, I would know, they did make an exception where the judges were like, you're right, you're right, we could, we could reveal some really personal secrets for some people that we like. So, we won't do that, but you're going to give me a list of like the quote, ruffians and

prostitutes, right? Just the, the, the, Mayor do Wells. And the doctor's usually like, well, okay, that's fine. Yeah, of course, I'll do that. So. Oh, man. Yeah, obviously. Is that where they got a pox upon you?

That's it. One of, one of. That this is then, that syphilis was a great pox, as opposed to the small pox. Syphilis was a great pox. It was. And overall pox is, that's a great pox.

Man. I don't know that they mean great is in like, great job. I think they mean great is in like great job. I think they mean great is in like it's like like great. Yeah, you tell your friend, hey, I got syphilis. Oh, you got the great one, man, you're lucky. I just got an immigrant that could pop. Kya, Lee. And then Fred over there got that chicken one, that's no good.

Chicken, but now he'll be a Lable to get shingles later in life. There you go. I would know that if they didn't have the commercial And then you got to look at it Obviously we were far from really a great coat of medical ethics at this point since like it was okay to divulge You know the what we're considered at the time the lower tiers of society, it was okay to divulge their medical information, but not a judge. But that starts to improve. We see confidentiality kind of codified throughout writings in the 1700s in Europe,

as well as in the early days of the US. Throughout US history, you see more and more stress on patient privacy and on only disclosing a patient's information to them as opposed to family members. That notion in the US is really ingrained. The idea that you, that dad, you would be sick and I wouldn't tell you about it, I would only tell mom, if I was just your doctor and not your daughter, that would be crazy.

I wouldn't even think to do that. That has been, I think, unique in the US. Now that is true in other countries as well now, but it wasn't throughout history. Well, now you have to sign something for other people to get information. Exactly. I mean, like, even if it's your wife or something,

they'll only tell you, unless you sign something saying, it's okay for this person to hear this information. That's exactly right. And that can make it very tricky sometimes as a family doctor, where I take care of a lot of large families and you get a lot of like, hey, you saw a cousin Bob the other day, how's he doing?

I have to say, I can't. I can't speak about it. I can't say anything. He has the bad pox though. But you gotta say it in a way that they'll still like you. So I'll be like, I love cousin Bob. Anyway, how are your feet? Like, you know, like something, you know,

I don't wanna, but I can't talk about it. Well, at are your feet? You know, like something, you know, I don't want to, but I can't talk about it. Well, at least you won't have to worry about buying cousin Bob a Christmas present. Don't expect him to be around then. No. This was actually, there's a, you begin to see also a stress in early writings in the US on the health of women patients being kept private because throughout history, as you can imagine, since women were barely considered their own property, that their health information was certainly not considered their own property. And so you would see this in cases of like you want to marry somebody, but you want to make sure she's like good stock. And so you can get information from her doctor or a husband could

easily get information on his wife's health that his wife would never be given. I mean, the doctor would go examine the woman and then go tell her husband everything about her and she would just sit there quietly. Give me the load down, Doc. Exactly. I mean, and so you start to see this idea that,

you know, it's, I know it's crazy that women are people and maybe they have rights of their own and maybe you should tell them about their health. Which is- You have a look under the hood. Yeah, that, yeah. That kind of thing. To be fair, this could be true in the inverse

in some cases for royalty. There were cases where like a princess would be betrothed to somebody and they would say, well, let's check this guy out as he could stock too, so it could go the other way. Sure. The exception that lingers though at this period in history is the terminally ill patient. And this argument comes into play a lot between a lot of the great and like early US and European

thinkers of the time who were saying like, either is it okay to lie to a patient who has no hope of ever getting better and say, like they say, promise them cure in all cases even though they are hopeless. That is written. Like, go in and say, yes, I'm gonna make you better in two or three months, you're gonna be back on your feet again, don't worry. And then go in the next year and then tell their family, listen, you're gonna need to get funeral preparations underway. And that was a common idea at the time, and tell their family, listen, you're going to need to get funeral preparations underway.

And that was a common idea at the time, whereas you begin to see people in the US saying, I don't like that. We should, maybe we should start to tell people. Well, you know, you hear the thing about people would tend to live their lives differently if they knew they were on a limited time, maybe make more of the moments. Exactly. Maybe you'd want to do that if you knew, and if you keep that from them,

or the burden falls to the family, then to have to pass that news to them. Right, which is even worse. And a lot of this was again done with that. It wasn't malicious. It was that paternalistic idea, like this is in your best interest. It will do you no good to know this.

As your doctor, I get to make the decision, what is in your best interest in it. And so this is what I'm doing. This went so far as some doctors, especially there was one doctor back from the middle ages, Dr. McKinney, who wrote an NSA on medical ethics that you should never become knowingly involved with any who are about to die or who are incurable. So basically just stay away from really sick people so you don't have to deal with this ethical conundrum. They don't go to room 3B.

I mean, that's what really is advised to doctors was like, it's really difficult. You don't have to deal with this ethical conundrum. Hey, don't go to room 3B. I mean, that's what really is advice to doctors. It's like, it's really difficult. You don't know if you should lie or not. Basically, just don't get involved. Slide the tray under the door and run. That way, if you ask you any questions, you don't have to lie, I don't have you don't tell the truth either.

You can just, don't answer. Doc, be square with me. Am I gonna be okay? I gotta go, I gotta appointment. Oh, look at the time. We got to milk the cows and slop the pigs. I got bills to pay. Well dad things got better and I want to tell you about it But first why don't you come with me to the building department? Well, all right lead the way You've never been there before. No, I've never been to the building department

You've never been there before. No, I've never been to the building department. The medicines, the medicines that I skilled at my cards before the mouth. All right, our first sponsor this week on Sobbons is meandies. Now, you're going to wear underwear pretty much every day, and so don't you want them to be comfortable? And that's the truth with meandies. They are incredibly comfortable underwear. We talk about them a lot on the show because we wear them all be comfortable. And that's the truth with me, Andes. They are incredibly comfortable under where we talk about a lot, talk about them a lot on the show because we wear them all the time. They're made from sustainably sourced micro-model fabric that

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Oh. 50% off your first order. When you go to naturebox.com slash sobons. That's naturebox.com slash sobons for 50% off your first order. Naturebox.com slash solbones for 50% off your first order nature box.com slash solbones So as I said dad things had to get better. They had to get better Well, yeah, that's usually the turning point in the show something has to get better Like I said while this while this idea persisted in the 1700s and many parts of Europe that you could lie to a patient

who was terminally ill, were their own good, was the thought process. In the US, especially during the Revolutionary Period, things started to change. We've talked about Benjamin Rush on this show, the father of psychiatry, and I've thrown some shade. It'll bend, because he did some pretty questionable things, to add some pretty wax stuff.

But he did urge physicians to be honest and not lie about death. And that sometimes you just, even though it's hard, you got to tell a patient the truth and that that might actually be in their best interest, which was a revolutionary idea. So he was not good in some things, but in this case, he was all right. Yeah, in this case, he was not good in some things, but in this case he was alright. Yeah, in this case he was alright

He you know, that's a that's a whole argument I get I got a lot of emails about how Benjamin Rush was a good guy and like I yeah, he did some good things He he saw psychiatric patients as people and treated them as people which was Strangely enough revolutionary as well But then there were some crazy treatments too. We have an episode on it, you can check out. I will, I'll check that one out. Thomas Percival wrote the first modern,

what we consider, first modern code of medical ethics in 1803. And it was pretty widely accepted, even all the way across the Atlantic here in the US. It was adopted by the Early American Medical Association. There were a lot of things, obviously, in the code of medical ethics, not just patient privacy, but that was explicitly mentioned.

Although in that same section where they talked about you need to keep your patient's secrets private, they also said also if one of your other doctors is up to no good, don't tell anybody. Which is not true now. I'm actually explicitly tasked to tell somebody if one of my other doctors is doing something wrong. It's like the code amongst cops

and it's same amongst policemen, huh? But I don't tell on each other. No, I don't think that's true now. No, it was. I think a lot of guild probably. Superco, you've seen Superco. I think a lot of guild type professions were probably like that. Like've seen Serpent Crab. I think a lot of guild type professions were probably like that.

Like we got each other's backs. Now it's funny because I am actually asked constantly when I'm evaluating my fellow physicians and recommending them. Do I know of any problems with addiction or substance abuse or that kind of thing? Or do I know of any reason that they can't do their job? Like I have to sign paper that says I don't,

but they're not. So. Yeah. I would, you all have to report on each other? Oh yeah. That's part of professionalism is that if I know somebody's not fit to do their job, I've got to go tell somebody.

I mean, I can understand like administrative staff at a hospital that may, you know, have these judgments or about it. And they ask doctors to report on each other like that. Absolutely. Absolutely. Yeah, it's considered corridor our professionalism is that we wouldn't let another doctor knowingly, we wouldn't let another doctor, you know,

see patients if they were unfit for some reason. I guess just put yourself in the place, what if they were treating your family member? Exactly, exactly. So, I mean, I feel that way by my patients. I feel that way about their patients, even though I don't really know them. But I do. But you do.

We also begin to see at this point, courts and judges beginning to get involved dictating the bounds of acceptable disclosures. So instead of physicians just kind of deciding for themselves, this is in a patient's best interest, so I'm going to go tell this private information. We start to see it being like, made law. No, this is when you get to doctors. You don't get to decide anymore. We're going to decide for you. And as doctors begin to go to court over these issues because they are violating them, we also see less and less of them talking to patients' families instead of patients. You see it become pretty standard that, no, no, you should just talk to the patient about things. Don't go around them. And from here and through the Declaration of Geneva, which was in 1948, we start to see a stress more on the idea that as opposed to this kind of

this sacred thing like that, but the privacy of a patient is something that is sacred to a physician and that it's part of their reputation. It begins, it begins to become like an absolute duty to the patient. That is not just a good idea, it's not just for professionalism's sake, it's your duty to. And it's the law. Exactly. And you start to see that the idea

that there might be exceptions to that secrecy from an ethical standpoint begins to vanish. That that becomes a very absolute ideal. Like, well, no, I would always keep my patients privacy. And part of that was probably in self-defense for all the laws that were being made. But that was a big shift from an ethical perspective. From sometimes it's in the patient's best interest. And so I have to do it. It's doing no harm to. Nope. There is no exception to that. So it's kind of like when Ross started dating a student and he thought it was just frowned upon. And actually, he was against the law. They found that out the hard way. That's exactly it. Early on,

telling other people a patient's private medical history was frowned upon. By now, it is definitely illegal. You have to do the air quotes when you say it was frowned upon. It was frowned upon. So we see that shift from a professional issue to a patient physician relationship issue to purely an issue of patient right. They realize nothing to do with you as the doctor. It's the patient's right to privacy. So later in the 1900s, we get this need, okay, well then if it is now an absolute right, when is it okay to violate it?

We need it very clearly spelled out. What are the times that I can break that confidentiality and go tell somebody because I'm not going to do it unless you give me a list because I don't, you know, I also don't want to get sued. And that's where we get, that's where hip-a comes into play. Now, hip-a wasn't just about patient privacy. No, that was just a small part of it. It was actually about the portability of your healthcare

so that you didn't lose coverage going from one job to another. That's exactly right. And you know what's weird is as a physician, when I, I mean, as I was, I have been Educated on HIPAA many times so I understand that I guess but

For me when I say HIPAA I'm always thinking patient privacy and I think most people do absolutely That's all I thought I mean until we were getting ready for this Mm-hmm I have to deal with it in in my business handling documents confidential documents Medical records and things, and things like that. So we have to be hipocompliant. And you think that's what the main thrust of the whole law was, but that was just a piece of it that didn't come into about halfway down the actual law. That's exactly right. It's just, it's like one subsection of a section is the security provisions. And a lot of that was because, so the law was, like you said, dad was to help make

health insurance more portable for patients. That was a big part of it. To streamline the process, reduce waste and fraud, and that kind of thing. And part of that was not a mandate for, but a big push for electronic health records. That was a big piece of it, that that would make it more portable.

Your information would become a lot more portable if it was electronic. Well, and more secure too. Yes. You know, if it's done properly, it's more secure, because I can remember one of the projects we had when this first came about,

was to go to a hospital that had files identified with social security numbers down the spine. So of course, you didn't want social security numbers hanging the spine. So of course, you didn't want social security numbers hanging out there because, you know, before that, you didn't really have identity theft. Now this was tied to that as well.

So we had to go through and relabel all these files for them because they were changing to a different type of identification system as opposed to your social security number. Well, and that's a good idea. I wonder if they've, see at the VA, they always use social security numbers. And I and that's a good idea. I wonder if they've seen at the VA, they always use social security numbers. And I don't know if that's ever changed.

On their files, were there visible? Yeah. Yeah, those were the patient numbers. Were social security numbers. Wow. So I don't know if that's still true though, because I haven't worked there since I was a student. But back when I was a student, that was.

I would have to think that it's changed by now. I don't know. I don't know. Because that was why HIPAA always came into play, but whenever we rotated through the VA, we had like multiple more hours of training and reminding and taking tests and filling out more papers. And man, if you tried to walk out of that building

with any kind of PHI protected health information, they were all over you. Right. Because social security numbers were all over everything. So all this push for the EMR, the electronic health record came with a lot more privacy issues because if it's gonna be on a computer, people can have access to it.

And so we see how these security rules laid out. And since then up to 2013, the law has been continually refined to add for like ways to make the information, encrypt, so what I'm looking for, encrypt the information better in a computer, so it's harder to get to. And this has come in to play with like, now we have things like the patient portal

where patients can send me messages, and I can send the messages back over a secure, sort of like email server. And in some cases, patients could get access to their own medical records. The hospital gives them access to it, whatever they have on file. We have that too. Yeah, through the portal, you can access your own records.

We even have like a secret doctor texting now. It's like a secret text program that is, that is HIPAA compliant so that I can text other physicians about patient information, you know, so that we can... That's through an encryption process, probably. Exactly. And so like in the hospital, we use that to communicate quickly with specialists often, and that kind of thing. That's why you can't email documents unless it's through an encrypted protocol.

Exactly. I have to explain that all the time. If a patient emails me, I can't answer an email. I can't answer a Facebook question. Right. I can't do this. Large breaches of HIPAA can be very expensive. So like if a hospital has had some sort of break in their encryption

or something, and you have to assume every patient who has been through their system has maybe been exposed, it can be like $200 a patient at least to the fine for that or to deal with that. This doesn't even include state laws which can add as much as $250,000 for a breach of HIPAA. They're constantly have to tweak the law because of the technology. You have such new technology rolling out all the time in different ways.

It's like when they first did this in 1996, who would have envisioned something like, where I read in the paper where, I think it was a nurse in a room, took a picture. Yeah, I heard about that. Of some guys, Joan, and sent it to her friends. I don't know why she wanted to, I don't know if they knew him. That's terrible.

I don't know who would do that. That wouldn't even occur to me. And of course, in 1996, they didn't have any view of something like that taking place. And so you've got to constantly upgrade it because of the different law, or I mean the different technology and stuff. Yeah, yeah.

No, if we want to take a picture of something, like a rash or something, I have to ask the patient to like sign all these documents and we have to be careful, like we can't just take pictures with our phone, we have to get like a camera, like it's a whole thing. Because we do that sometimes for like, because I work at a medical school,

so like, oh, this is, I want to keep this for students, I want to include this in a presentation. I have like 30 things I have to do before I can do that. I can't just take pictures. You don't ever want to be the guy that's getting examined by the doctor. And the doctor comes in and looks and says, wow, I've never seen that before. Hey, hey, get those other three doctors. That's all. Have them come in.

Hey, if you ever seen this before, look at this. Get this, get this, dude. Oh, we got to take some pictures of this. Now, as I said, there are some exceptions. So there are certain scenarios under which I can disclose your protected health information. And it's okay, other than when I ask you, anytime that I ask you and you sign a paper that says it's okay, I can.

But these are times when I don't have to ask you. So you don't have my permission, and but you can still go ahead and tell somebody about it. Yes. So like for instance, if I'm going to send you to a specialist for something, I can send them your records. That's pretty obvious. I don't have to ask you. I just send them. To get paid, so I like put your diagnoses on a bill. When I bill your insurance, I have to put something on it. So to get paid, I, you know, I disclose your information. Common sense. Healthcare operations, like we have to put something on it. So to get paid, I disclose your information. Common sense.

Healthcare operations, we have to do quality improvement programs and things or training. Those would be things that would be acceptable uses. There's mandatory reporting of certain diseases, so like communicable diseases, I have to report to state health department to authorities. A lot of sexually transmitted infections are reportable. So we have a list that is mandated. The health department handles it from there. Exactly.

And we have a mandated list that we have to report. So, you don't like put it on Craig's list or anything. No. And actually, I say, I, the lab usually reports this stuff. It's not me, the lab tech just reports the positive result. In addition, certain things like death statistics are tracked, you know, that's released. Well, if you're a death statistic, you're not going to probably complain about them releasing

information. Well, you might not complain, but it's still private. It's now indefinite. It used to be 50 years after you pass away, your information is still protected, and then it times out. I believe with the 2013, there was like this omnibus regulation that was passed. At that point, it just became indefinite. So you're protected forever. You're good. I'll rest more peacefully knowing that. The FDA has some mandatory reporting

for like adverse events or product failures that then would I would have to disclose your information. Workplace injuries are like workers comp issues. Sure That I have to report that sometimes. Audits, if Medicaid or Medicare wants to come in and audit stuff, then I disclose your information to them. They want to make sure that you're billing properly or something like that. Exactly. To make sure I'm not committing fraud. Law enforcement.

You can do that. I know you will. I don't. I don't do that. I know. I have a bad treat. They come in again and ask, you tell them to call me. I'll tell them to call my dad. That's right. I'll vouch for you.

Law enforcement has very specific instances when they can, although they can broadly apply that, because basically if a judge tells you you have to, you have to. Yeah. I still think they need even further redefining on that though. Yeah. When you have prisoners that walk away from hospitals

and the police department doesn't know about it. That's true. If I have a patient in the hospital who has been arrested but then they have a medical problem so they bring them to the hospital for care, I can't call the police officers and tell them when they're discharged. And so then they just walk off.

Yeah. And there's something wrong there. But I mean, we've had a couple couple instances around here and the hospitals have said, look, we can't. We'll be in violation if we report it. No, I'd have to have like a, I think I'd have to have a court order telling me to. That's just whack, man. For research, we do it all the time, although you, most of the time we tell patients that

they're part of research, you know, but we do collect data for research, for organ donation, obviously, for driving. If a patient is deemed unsafe to drive and I tell them not to drive and they're not going to comply, I can report them to the DMV, you know, that makes good sense. Yeah, so that we keep people who, for whatever reason, shouldn't drive over. It's for the greater good. Exactly. That's what a lot of these come down to, the greater good.

Well, and we have, and we have an ethical obligation to public health. So that makes sense. Sex offenders, identities are routinely disclosed. I report child abuse cases to CPS. In addition, since there was a case in 1976, Terrace Office Regents were a patient revealed to their psychiatrist that they intended to kill somebody, and then they left and killed that person. And so if I know someone is a direct, imminent threat to someone else, then I then can reveal, in fact, I have a duty to reveal that information

to save that other person's life and protect that other person. Good, I would hope so. Yeah. And then there are specialized government functions. Like if you want to fly a plane or be an astronaut or be in certain parts of the military, like I can disclose your information in order to allow or prevent you from doing so.

So those are a lot of cases. Yeah. A lot of situations. Tell the army about my flat feet so they can't draft me. Exactly. Your F- F- Forth?

Is that what it is? I don't know. I don't know. Your unfit. I wasn't involved in any of that, so I don't know. I don't know. Your outfit. I was involved in any of that. I inherited your flat feet so I won't have to worry either. As long as you don't get my bad knees. I don't know. But anyway, I hope that was helpful. It was very helpful. Well, I think that applies to you too, Dad, with document storage and scanning this, you know. Absolutely. And I thought that the mandate for medical records came about from that same 1996 law that HIPAA comes from,

but it's actually the mandate for it actually came from the Affordable Care Act, which didn't take effect till 2010. Exactly, exactly. So it's two different things. A lot of us were already kind of there though. I mean, it makes sense. Medical records just make sense.

Absolutely. And there's so much easier. And as a person that sells them, I agree. They absolutely make sense. Well, is a doctor that uses them, I appreciate them. But, and they're also coming into play, not just in the medical field, but in business and industry and stuff like that.

Sure. And you have human resource departments and things like that. Sure. And then you have human resource departments and things like that. And there again, you have sensitive information that needs to be protected. So it comes under the same type of hippo requirements. Exactly. And that's the thing, I would say at the end of the day, as a doctor, I consider my primary goal to keep everything you tell me and everything we discuss secret at all times. It is rare. If somebody is going to, I don't want to say violet hippo, but disclose PHI.

If we think one of those scenarios that I just listed really matters, I am going to take a long hard look and stop and consider what do I need to disclose? Is it okay? Is it not something I can ask the patient first? I'd much rather get your permission than do it against your will. I mean, these are not things we take lightly. So I think I should have that. Did you normally have someone to confer with? Like, would the hospital provide like a staff lawyer or a senior doctor of some type or something that you would confer with? I actually have legal counsel available to me all the time at work if I just want to ask a question. Just like, is this okay for me to do or not?

I feel it's my obligation to report this this okay for me to do or not? I feel it's my obligation to report this person to authorities. What do you think? Then I have somebody I can talk to about it. So, yeah, because I would take that very seriously and I think the vast majority of physicians would. Yeah, I'm not a rat.

I'm not a rat. Every now and then, you got to. Well, thank you, dad. This has been fun. Well, thank you for having me. I know that it's Justin's irregular and I then don't want to mess up the good thing. It may be that I go back to court appointed and they might have voted me off the island. They might want Justin back all the time.

So I might have just talked myself out of a job. Yeah, I don't think so. I don't think so. Now, this has been a lot of fun and you should definitely check out quarter pointed. Quarter pointed. It's on iTunes or you can get it from audio boom. There you go. And you can check it out for the legal perspective on this with my uncle Michael, who is a lawyer

and Justin will be there as the, I'm not going to say the dumb guy as the jokester as the goof stir. So I appreciate you having me in and participating in this crossover event. Well no problem dad. You should check out maximumfund.org for a lot of other wonderful podcasts. Thank you to everybody who listens to our show. Thank you to maximum fun for hosting us and thank you to the taxpayers for our theme song Medicines. I am your co-host Tommy Swirl not Justin McAroy. I had a hiss thing. I didn't know who that was. And I'm Sydney McAroy. Don't drill a hole in your head. Alright! Maximumfund.org

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