When practicing becomes policing: Physicians balance patient privacy with society's right to know

Some physicians liken it to swapping a stethoscope for a badge. Increasingly, doctors are being called on to serve a policing role by screening their patients for society's ills. Laws have long required health professionals to report injuries from weapons and child abuse, but in recent years doctors have been asked to extend that reach to other areas.

Six states require physicians to report patients who may be unfit to drive, such as seniors hindered by illness. And although unsuccessful after public outcry, federal lawmakers tried to get doctors to notify authorities if they treated illegal immigrants.

Physician organizations have responded by giving doctors guidance on how to detect and report problems such as domestic abuse and unfit drivers, at the same time informing them about their ethical obligations and patient confidentiality. While there is overwhelming support for reporting child abuse, physicians are less comfortable turning in patients who might lose their driver's licenses due to medical conditions, and they oppose efforts to document immigrants who come for treatment.

Some physicians fear the demands on them to diagnose and report society's problems will only continue to increase.

"It's been evolving at a rate more than I would have liked over the past 10 years," said Sheldon Zinberg, MD, a California gastroenterologist. "It puts the physician in the policeman's uniform."

Each state has laws that require reporting of child abuse, including sexual abuse, according to the American Academy of Family Physicians. Most states have toll-free telephone numbers for receiving abuse reports, according to the Child Welfare Information Gateway, a national service that promotes child safety. Through mid-2003, 46 states had enacted laws specifying penalties for mandated reporters, including doctors, who fail to notify authorities of child abuse or neglect.

But doctors also are bound by ethics to ensure that patients are protected from harm and get essential health care, the AAFP said. Sometimes laws and ethics collide. In states that call for reporting of sex with a minor, for example, sexually active adolescents in a consensual relationship might avoid seeking care out of fear of being reported.

Texas family physician F. David Schneider, MD, MSPH, remembers a 16-year-old pregnant girl who came to his clinic. The baby's father was 27. Because the girl was not 17 and the father was more than three years older than her, the case was considered child abuse and was reported.

"It's a hard issue. As a doctor, my role should be to care for the patient from the health care side," said Dr. Schneider, AAFP representative on the American Medical Association's National Advisory Council on Violence and Abuse. He also is founder of the Academy on Violence and Abuse, an organization that advances education and research on the health impact of violence and abuse.

"If we end up being police, the patients will stop getting appropriate care because they know if they come in and there's an issue, they will end up getting reported," he said.

Protect physician-patient trust

Meanwhile, many states have passed tougher elder-abuse laws to protect senior citizens. In 45 states, physicians are mandated to report elder abuse, according to the National Center on Elder Abuse.

A study in the September/October 2006 Annals of Family Medicine of 20 primary care physicians in the Los Angeles area found that half of the doctors were concerned about the effects mandated reporting could have on patient rapport. Physicians thought their patients might feel deceived if a report were made. Fear of liability led some doctors to require absolute proof rather than suspicion before filing a report.

The study said the findings revealed a need to increase awareness about elder abuse and reporting laws among primary care physicians, noting that doctors' lack of familiarity with such laws may contribute to underreporting.

Other studies show physicians are doing a mediocre job of reporting family violence, which includes child abuse, elder abuse and intimate partner violence. Some doctors did not record when their patients told them about domestic violence, and some were reluctant to deal with the issue when women said they were victims of abuse.

Doctors screen for family violence less frequently than for other health risks, according to a 2005 AMA report. It said half of physicians screen for family violence, 10% to 30% never screen for it, and 6% to 12% screen routinely.

AMA policy states that "physicians should routinely inquire about physical, sexual and psychological abuse as part of the medical history." Policy also states that "the physician should comply with laws requiring reporting of suspected cases of abuse of spouses, children, elderly persons and others."

The American College of Emergency Physicians said it opposes mandatory reporting of domestic violence to the criminal justice system. Rather, it encourages reporting domestic violence to local social services, victims' services, the criminal justice system or any other appropriate resource agency to provide confidential counseling and assistance.

ACEP spokeswoman Leigh Vinocur, MD, an emergency physician in Baltimore, said reporting a female abuse victim to police can put her in greater danger, especially if the police don't lock up the abuser and the woman has no place to go but home.

"It's hard to protect them," she said. "We see all of the ills of society, and that's just part of our practice. Our main objective is always to do what's in the best interest of the patient."

Protect the patient -- and public

Many physicians said what's in the patient's best interest is often difficult to decide when it comes to a driver's license.

"With the aging geriatric population, it becomes a judgment call. Taking away driving is one of the last vestiges of independence," said Little Rock, Ark., internist William Golden, MD, chair of the Board of Regents of the American College of Physicians. Nevertheless, "somewhere down the road, physicians could be liable."

Six states require doctors to report patients who may be unfit to drive -- California, Delaware, Nevada, New Jersey, Oregon and Pennsylvania -- according to the National Conference of State Legislators. For example, in 2004, a Pennsylvania doctor reported a patient to state transportation officials after the patient said he drank a six-pack of beer a day. The man lost his driver's license.

Other states allow -- but don't require -- physicians to report drivers, and some states keep reports made to licensing bureaus confidential, said the American Assn. of Motor Vehicle Administrators.

AMA policy urges physicians to know and adhere to state reporting laws for medically at-risk drivers. Doctors should assess a patient's physical or mental impairments that might affect driving abilities, AMA policy states. Before reporting, the doctor should have a candid discussion with the patient and family and may encourage them to have a restricted driving schedule.

Illinois internist Peter Eupierre, MD, said his first step is to talk to patients who have health issues that affect driving. "The best thing is to deal with the patient directly."

But friction between a doctor and patient over driving and other reporting requirements might jeopardize the physician-patient relationship, doctors said.

"If you are put in a position that you have to report a patient, the patient might not be willing to be open with you to talk about a problem," said Dr. Eupierre, president of the Illinois State Medical Society.

One example of what physicians considered getting too close to a police society occurred in 2004. A House bill proposed requiring hospital workers to collect information, including fingerprints, from illegal immigrants who sought treatment. Hospitals and physicians opposed the plan, which later was voted down.

"It shouldn't be our job to identify illegal [immigrants]. If they come to the emergency room, they need to be treated," said Allan Goldstein, MD, president of the Medical Assn. of the State of Alabama and a pulmonary specialist in Birmingham.

Protect yourself

Existing reporting laws make failing to report a patient risky for physicians.

For example, almost every state imposes a fine or imprisonment for knowingly or willingly failing to report child abuse or neglect, federal officials said.

The Federation of State Medical Boards said it does not track cases of physicians disciplined for disobeying reporting laws. But doctors could face discipline from a state medical board if a complaint is filed.

"Physicians should realize there are consequences for not following [reporting laws]," said Dr. Golden of the ACP. "Clearly, anything that endangers public welfare should be reported."

Many states provide physician immunity from liability if the doctor reported a patient as unfit to drive before there was a car crash. Physician leaders said doctors should familiarize themselves with immunity laws in their states.

Protect other potential victims

Physicians said they expect states and federal agencies to ask doctors to police more areas, even if they are not mandated by law. One that is gaining attention is human trafficking, a modern form of slavery.

Federal officials said about 14,500 to 17,500 victims are trafficked into the United States each year. In 2004, the U.S. Dept. of Health and Human Services launched the Rescue & Restore Victims of Human Trafficking campaign to raise awareness about the problem and help physicians and others identify and respond to victims.

Last month, the 16,000-member Christian Medical Assn. called on President Bush, federal agencies and others to organize medical specialty groups to educate health care practitioners to recognize and treat trafficking victims.

"There are many doctors out there who have never heard of human trafficking," said Jeffrey Barrows, DO, the Christian Medical Assn.'s consultant on trafficking and an ob-gyn in Bellefontaine, Ohio. There are only two groups of professions, he said, likely to encounter trafficking victims: law enforcement and health care.