Case Scenario

I met the patient, a 15-year-old girl accompanied by her older sister, during a check-up. The girl's mother, waiting outside the examination room, told me that her daughter had recently run away from home, and she wanted the girl to have a thorough gynecological examination.

When I asked the girl why she came to see me, she shrugged and said, “I guess it's for a checkup.” I began by talking to her about confidentiality and the doctor-patient relationship in hopes that she would confide in me. Her sister, whom she had explicitly asked to stay in the room, sat silently during this discussion. The girl shyly denied using drugs or having any romantic involvement with a boyfriend. She told me she ran away because her parents were too strict. At that point, the older sister blurted out that the girl was prostituting herself for drugs, and their parents were very concerned. The patient shrugged and admitted only to using marijuana recently.

On gynecologic examination, the patient appeared to have genital warts and herpes, although she denied having noticed anything unusual or having any pain. The patient gave me permission to test for human immunodeficiency virus (HIV), syphilis and other sexually transmitted diseases, but she refused to let me talk with her mother. At the end of the visit, the mother was told that her daughter was going to have some blood drawn for laboratory tests, and that her daughter could call for results in a week.

The results were positive for gonorrhea and Chlamydia. Her Papanicolaou smear was normal; the syphilis and HIV tests were negative. The girl's mother called to find out the results of the tests, saying that the girl was unable to care for her own health because of a borderline I.Q.

Having spoken to the girl about developing a relationship based on trust, I felt torn about breaking confidentiality. I compromised by telling her mother that the girl needed follow-up care with antibiotics.

Soon afterward, the girl ran away from home again, and no follow-up could be done.

Commentary

This case highlights a family physician's dilemma regarding confidentiality when caring for a minor patient. This sort of scenario is not uncommon in an office practice.

The physician's initial approach was to establish a therapeutic alliance. The physician used positive strategies to gain the patient's trust: sharing information about the confidentiality of the physician-patient relationship, agreeing not to talk with the mother and respecting the patient's wishes to allow her sister to sit in during the visit. However, the physician was not successful in achieving a therapeutic alliance.

Overcommitment to confidentiality with minors can create barriers to information-gathering and appropriate decision-making. Therefore, it is appropriate to review with the minor the limitations of confidentiality and share with them what information may be made available to parents.

Exceptions to confidentiality include cases of medical emergency, danger to self or others, childhood abuse or court-ordered evaluation in which the physician is obligated to provide information to a judge. Parents also have access to general medical information without the patient's permission. An exception is information about substance abuse evaluation and treatment, which is protected by confidentiality regulations under federal law. Therefore, information about substance abuse of a minor patient can be released to a third party, including parents, only with a patient's written consent.

Primary care physicians should know their state statutes about confidentiality governing the care of minors and reporting of infectious diseases. Consent from the mother for evaluation for HIV and syphilis would have been appropriate. In addition, a urine drug screen may have been helpful for future management of this patient.

Given these considerations, the physician in this case did not violate confidentiality. However, if the physician had emphasized to the patient a need to communicate with the mother or other family members, he or she might have obtained additional information about the patient's emotional, behavioral and sexual problems. The sister provided some information, but this was not validated by either the patient or a collateral source.

The patient-physician relationship might have been enhanced by seeing this patient alone. This approach would have reduced the dilution of the patient-physician relationship by the presence of a third party, her sister. One-to-one interaction may have allowed the physician a better opportunity to explore. It is also obvious that problems exist in the mother-daughter relationship. The physician might have asked why the patient was afraid of letting her mother talk with her physician. Was it that she was afraid her mother would share or obtain damaging information about her? Or was the patient afraid that such disclosure might have negative effects on the family system?

The physician might have explored the reasons for runaway behavior, specifically information about the reasons for running away from home. Is it excessive parental discipline as perceived by the patient or is there evidence of physical, emotional or sexual abuse in the family? What is this patient running to and what reward is she deriving from this behavior? The runaway behavior may constitute an emergency in itself, especially in a patient with a borderline I.Q. In this situation, the patient may require protection through close parental supervision or the involvement of other agencies, such as juvenile authorities, if the parents are unsuccessful in stopping this behavior.

Also, information indicating potential danger to self might have prompted psychiatric consultation. It is suggested that the patient should not have been allowed to leave the physician's office without assuring her protection within the family. Scheduling an appointment with a mental health professional would have been useful.

The presence of genital warts suggests that the patient had been sexually active for some time, because the virus has an incubation period of one to six months, and it requires months to fully develop warts. This finding, as well as the family's insistence that she have a gynecologic examination, required further exploration, specifically for any history of sexual abuse or the extent of sexual acting out.

Following through on such suggestions requires a significant amount of time, which may not be available to a family physician in a busy office practice. However, a nurse or nurse therapist in the office may provide this needed service, including evaluation of family dynamics and assessment of emotional and behavior problems. Perhaps the physician who has worked with this family over time has this information, but it is not apparent in this case report.

Finally, during the telephone conversation, the mother stated that the patient has a borderline I.Q. and is unable to care for her own health. This information may raise questions about the competency of this patient. Therefore, her capacity to make medical decisions and assist her physician should be assessed during future visits. This may have relevance if the patient seeks substance abuse treatment.