Sunday, September 26, 2010

Loose lips

Hi, fellow health-care providers! Were your ears burning this week? They should have been, because people were talking about us.

Earlier this week, I met a man who, while not a health-care worker, is involved in a provincial health organization. Our conversation came around to a recent experience he had while one of his family members was being cared for in a local emergency department. His opinion was that there was a lack of professionalism demonstrated by the staff – physicians and nurses – in that ER. He had no complaints about the care provided to his relative. What troubled him was the seeming lack of concern for patient privacy and confidentiality.

He said it was impossible to ignore loud discussions that included details of other patient’s medical history and treatment, as well as staff’s “editorial comments” of their impressions about a patient’s demeanor. Some whispered comments were followed by laughter, which he admitted could have been innocent, but naturally made him wonder if some patients were being ridiculed.

His family member was admitted to hospital where he observed similar incidents on the ward. He was particularly annoyed that he regularly heard staff discussing their social lives at length, presumably while “on the clock”.

His final comments were that he was reluctant to raise his concerns with staff because he worried that it might have repercussions for his relative’s care, and also that he wondered who was responsible for overseeing appropriate staff behaviour.

Ouch! The truth hurts.

I’ve been guilty of these lapses, and see them regularly in the ER, hospital wards and other patient care areas. But, my first impulse was to explain to this man – who didn’t work in health-care – why this behaviour is sometimes unavoidable.

First of all, certain patient care areas – especially ERs, recovery rooms and critical care areas – bring together multiple patients, their families and medical staff in a confined space. Because staff needs to closely monitor the patients’ conditions, it’s not always possible to step away to a more private area to discuss care. Also, in order to be efficient, it’s sometimes more convenient for staff to have conversations about patients in the hallway outside a ward room, rather than searching for a more private spot.

However, I didn’t offer these reasons to the man, because my heart wasn’t in it. I knew they were more excuse than reason. We can do better. This experience had obviously affected his confidence in health-care providers, and empty explanations would only compound the problem.

Later in the week, I attended a meeting of our health region’s Patient and Family Centred Care advisory council. We heard a presentation about a proposed change in the ERs with the implementation of an electronic “white board”. Many ERs use a white board to keep track of patient status, pending tests, tentative diagnosis and consultations requested. While intended for staff use, they are often posted in very visible locations that anyone can see. As we move toward using a district-wide electronic medical record, these white boards will be replaced with large computer monitors that display the most current information about each ER patient. For example, if blood test results are ready, an alert would be displayed, letting staff know immediately that results can be reviewed. At present, staff need to remember to check intermittently to see if results are back, and this delays the next step in diagnosis and treatment.

While current (and proposed electronic versions) white boards don’t display patient names, that’s small comfort. Bed numbers are shown, so it’s easy to match the patient to the diagnosis. We rely on the anonymity granted by being a large urban centre, and the fact that it’s unlikely that ER visitors will know anyone who is currently being treated. But, what about smaller towns? And, good luck to you if you are a health-care worker being treated in the ER of your own workplace.

Imagine this scenario: You’re a consultant called down to the ER to see a patient. As you walk in, you see a colleague lying on a stretcher. As you walk by the white board, are you going to take a quick peek at his bed number to see what’s going on? Even if there isn’t a diagnosis given, you can see what tests are pending, and which medical service has been consulted. Cardiology? Uh-oh, probably a heart attack. Psychiatry? Hmm, interesting. Are you going to take a peek? No? C’mon, really?

The electronic white boards would not identify patients and, as was explained to us, the symbols on them would be somewhat cryptic so as to foil easy interpretation by unauthorized viewers. Well, short of using Klingon, I’m not sure we’ll have much success in disguising the symbols’ meaning. In any case, we don’t want staff to be confused as to their meaning as that would defeat the purpose of displaying them in the first place.

As one of the council’s community members pointed out, families might actually find white boards useful as a way to monitor their relative’s status and progress in the ER. In order to do that, they would need to understand the information and would naturally ask medical staff what it all meant, thus exposing the status of all ER patients.

Several community members commented that they would accept the display of patient information if it would improve the efficiency in the ER. Hearing that comment made me realize that we (health-care workers) are framing discussion about privacy issues in a way that makes patients and families feel that they are obliged to accept violation of their privacy in return for efficient and high-quality care. The impression that our community representatives had (because that’s the impression we gave them) was that, if we don’t prominently display private patient information, an ER can’t function properly. Take it or leave it. And, of course, when put like that, they’ll take it.

But, it’s a false dichotomy. There are more than 2 choices here. The beauty of digital information is that up-to-date data can populate many different devices simultaneously. We don’t need a Jumbotron blurting out patient status. Instead, display it on desktop monitors and iPhones. That’s my quick take on how to address the problem – someone else has likely solved it more elegantly. My point is that we shouldn’t ask patients to give up an important aspect of their care because it will be simpler (for us) to maintain the status quo. As another community representative put it, patients shouldn’t have to “settle”.

Now, back to the first gentleman’s observations about medical staff’s behaviour. He didn’t confront anyone at the time because he didn’t want his relative’s care to be affected. He also mentioned that he thought it wouldn’t make any difference even if he did raise it with the offenders. His rationale was that if people were far enough out of touch with appropriate professional behaviour that they were compromising privacy, they probably had a mindset that would not react well to criticism. Our system forced him to “settle”.

I asked him how he would fix the problem. He suggested that senior staff should be setting an example, by insisting that conversations take place in private locations, or at least by keeping voices low and being aware of who is within earshot.

Great idea, but not so easy to do. This behaviour is so much a part of our local culture that I think even senior staff would hesitate to be perceived as being critical of colleagues’ behaviour and labeled as “oversensitive”.

Maybe having staff hear about privacy concerns in patients’ and families’ own words would have an effect, in the same way this gentleman’s story had an effect on me. We could solicit feedback from clients regarding their impression of how their privacy was respected while they received medical care. Two or three questions would probably do it. This wouldn’t be a secret undertaking. On the contrary, we would inform staff that the survey was going on, and that they would see the results.

And, of course, we would post the results for the public to see. On the white board.


  1. Privacy issues are a real concern, and should be addressed. As for the other concerns I would like to see where that guy works, and if theres no talk about personal lives aloud there. Just because you work in the health region people expect you to be straight faced and serious 100% of the time, get over it, its no different than any other job, if everyone worked like that we would have a health region full of depressed employees. We have the right to enjoy our jobs too.

  2. Hi "Anonymous",

    "We have the right to enjoy our jobs..."? I say we have the *duty* to enjoy our jobs! When we bring joy to our jobs, that's when we'll be at our best for our patients/clients.

    In fairness to the gentlemen to whom I referred, I didn't do him justice. He wasn't advocating for a hospital full of humorless robots. His complaint was that the discussions about social life were protracted and (in his opinion) were interfering with prompt attention to patients.

    I agree that sharing our personal lives with our co-workers builds friendship and fosters a sense of teamwork and community. However, I suspect that most of us have witnessed co-workers being distracted from patient care responsibilities by socializing while at work.

    If we rely on socializing with co-workers (while "on the clock") as our major source of satisfaction at work, then we're being robbed of the deeper satisfaction of connecting with our patients and delighting them with exceptional service.

    Anonymous, thanks for reading, and taking the time to comment and challenge.

    Bring the joy!

  3. Thanks Kishore, very thought-provoking instalment. I'm kind of a root cause guy: why do well-meaning health care workers routinely violate people's privacy? It's not malice; it's that they haven't thought about it much. And why haven't they thought about it much? I would venture two reasons: the "human side" of health care is not sufficiently emphasized in health science education programs, and in the workplace privacy is not seen as a fundamentally important aspect of both quality and the patient experience. How to solve? I would think that as part of orientation and continuing education programs, there should be role-modeling sessions that put the workers in the position of patients so they can "feel" the consequences. And all patients and those accompanying them should be actively informed of their entitlement to privacy and encouraged to identify violations. For instance, what if the admitting clerk said to each presenting person, "We are committed to preserving your privacy and confidentiality. If you see or hear something you think compromises privacy, please bring it to our attention immediately." Same goes for hand-washing!

  4. I am currently working in a small community ER and patient confidentiality is a tremendous issue here. We had a small white board in the little nurse's station that was used by the ER doc and staff to keep track of what was done, what is pending. (We are anticipating an electronic system some day!) The current ER director spent a few hundred dollars on a much bigger white board and posted it in the hallway. Now instead of a somewhat limited audience, every patient, visitor and staff member are now privy to what is going on in each patient room. In this town, most everyone knows everyone and now everyone knows you have diarrhea or a psych problem....

  5. Thanks for the comment. I wonder what the rationale for the bigger white board was? More efficient for staff to see at a glance? It would be interesting to conduct a survey of your ER patients to see if any of them were uncomfortable with having their personal information made public.