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One of the cornerstones of the medical consultation is that patients expect that what they tell their doctor or nurse will be kept confidential.2 However, arranging and partaking in a modern general practice consultation may involve the cooperation of several individuals including more than one doctor, reception and secretarial staff, nurses, health care practitioners, pharmacy staff and students. The patient too may invoke the assistance of family members and friends to make appointments, collect prescriptions, take messages or accompany them in the consultation. This increasing complexity inevitably increases the risk of breaching confidentiality. Consultations too have changed. The telephone, previously used mainly to negotiate appointments, has become increasingly employed as a means of consultation3,4 and almost all out-of-hours calls in the UK and other countries are now initially triaged in this way,5,6 raising practical concerns, especially with mobile phones, about ensuring confidential environments. Most of the research carried out on confidentiality in primary care consultations has been in relation to adolescent health7,8 and in the context of acquired immune deficiency syndrome HIV/AIDS.9 There is also an e-health and research governance literature10 on data security.11 By contrast, surprisingly little research has explored the views of patients and primary care professionals despite the acknowledged importance and gravity with which it is viewed by regulatory bodies2,12–14 and medical teachers.15 There have been no studies in primary care which have specifically explored the confidentiality issues of the use of the telephone. As part of a broader qualitative investigation into the views of patients, doctors, nurses and administrative staff on the use of daytime telephone consulting in general practice, among our aims we specifically sought to explore the impact of the use of the telephone in primary care on perceptions of confidentiality. This paper focuses on the main themes we found in relation to confidentiality and telephone consulting. The term ‘consulting’ in this paper refers to an exchange of clinical information between a clinician and a patient (for example history taking, discussing test or providing other information and treatment advice) whereas the term telephone ‘conversation’ includes all telephone interactions including discussions between non-clinical staff for example about making appointments and passing on test results. MethodsWe used focus groups because they have the advantage of using group dynamics to stimulate discussion, yield insights and generate ideas to pursue a topic in depth16 and are particularly suited to subjects with which participants are familiar and likely to hold diverse views. We approached GPs, practice nurses, administrative staff and patients and conducted focus groups in urban (Lothian) and rural (Highland) regions. We aimed to recruit a maximum variation sample encompassing people from a range of ages, both genders, living in urban and rural areas and with varying views about telephone consulting. RecruitmentWe purposively selected 39 practices in Lothian and Highland for recruitment of health care staff on the basis of training status, practice list size, deprivation indices and rurality. To aid purposive sampling, we wrote to the practice manager, senior receptionists, practices nurses and GPs in each practice and asked them to complete a screening questionnaire designed to capture their current use of and attitudes to telephone consulting. In addition, we approached GPs attending a large annual conference of widely scattered remote and island-based GPs and using the same screening questionnaire recruited participants to a focus group. Patient recruitment was conducted from seven purposively selected GP practices using national databases (ISD Scotland)17 based on deprivation, practice size and rurality. A screening questionnaire similar to that used for staff was posted to the most recently consulting 15 or 30 (depending on practice size) patients. We plotted the distance recruited patients lived from their general practice using electronic mapping aids.18 In addition, as telephone advice calls about children are common,19 we recruited parents from a ‘mother and baby group’ in Lothian. Focus groups lasted around 1 hour. A topic guide, incorporating similar questions for professional and patient groups, was used to stimulate relevant free flowing discussion. Focus groups were audio-recorded, transcribed verbatim and entered into a qualitative analysis software programme (NVivo 7).20 Concurrent data analysis allowed emergent themes to be incorporated into the topic guide and explored in subsequent interviews. Data generation continued until saturation occurred.16 AnalysisWe used a framework-based approach21 as this is particularly useful for applied or policy relevant qualitative research and makes use of the efficiency gained through relatively structured data generation, based on pre-set aims. Subthemes were charted into overarching themes and used to define concepts, identify important phenomena and allow associations to be drawn and explanations of the data to be considered. Two researchers, PW (a psychologist) and BM (a GP), independently analysed data and agreed coding allocations with a sample of these jointly agreed codes being independently checked by HP (a GP) and DH (a social scientist). Deviant cases and possible conflicting interpretations were actively sought. Our preliminary conclusions were fed back to a multidisciplinary group of clinical and lay participants to check agreement with findings and assist interpretation. Ethical approval was obtained from Lothian Multicentre Research Ethics Committee (ref 06/MRE10/27) and local research and development offices. ResultsStaff from 30 (86%) of 35 practices completed screening questionnaires. We conducted 10 focus groups with health care professionals and administrative staff and five with patients (see Table 1). Those responding did not significantly differ demographically from non-responders. Participants encompassed a range of ages, social backgrounds, rural/urban location and views on and experience of telephone consulting (see Table 1). TABLE 1 Characteristics of focus group participants
The main themes in relation to confidentiality were concerns about overheard conversations, the receptionist role in triage, difficulty of maintaining confidentiality in small close-knit communities, errors in identification and identity fraud, third party conversations (where one individual e.g. a parent or spouse speaks on behalf of a patient) and answering machines. Overheard conversationsMany of the concerns expressed by both professionals and patients centred on overheard telephone conversations. There was potential for this to happen in the surgery, at home, at work and with mobile phones in public places. In the surgery receptionThe surgery reception area was considered a particularly troublesome source of confidentiality breach; patients phoning in would, for example, sometimes have their personal details loudly confirmed by the receptionist within earshot of patients sitting in the waiting room and occasionally waiting patients subsequently heard a doctor being given a summary of the patient's complaint or results being given. Even vague overheard comments on results such as ‘its negative’ could give rise to speculation even if the nature of the test was not divulged. However, such breaches in the reception were not confined to the telephone and indeed the telephone was often seen as a ‘more’ confidential medium particularly in some smaller less well sound-proofed surgeries.
Overheard telephone conversations during consultations and in working areasDoctors were aware that urgent calls for advice interrupting consultations were a potential source of confidentiality breach and did their best to avoid confirming the patient's identity aloud. Similarly, in small communities where staff members were often related or neighbours, calls relayed through to the coffee room or answered in the reception area could breach confidentiality and attempts were therefore sometimes made to avoid such scenarios as is exemplified by the following expressed concerns:
Phoning patients at work or homeClinicians were generally sensitive to confidentiality issues when they were phoning patients at work, checking that they felt comfortable to speak and occasionally altering their questioning style to maintain privacy.
A similar problem could occur with mobile phone consultations which might catch the patient in a public place.
In general, patients were less concerned about calls to their home, although there was a possibility of a visitor or family member being present when they took a call who could overhear half the conversation. Participants particularly expressed concerns about teenagers’ confidentiality, especially in relation to sexual health. Leaving messages and caller identificationThe telephone could both enhance and endanger confidentiality. For example, dialler identification could be used by a parent to establish that a call had come from the surgery and question their child. Conversely, a phone call might avoid a young person being seen attending a surgery, with the risk that this may be relayed to their parents.
Speculation in small communitiesA particular problem arises in small communities where attendance at the doctors was seen as a cause for gossip and speculation not only among other patients but also among reception staff who may be related to the patient. Telephone consulting could avoid this as requests for sensitive medications such as ‘ViagraTM’ (sildenafil) could be arranged directly with the doctor over the phone and dispensed from non-local chemists.
Sharing information with reception staff on the telephoneSeveral patients were unhappy at being asked to provide information to receptionists and thought this was more likely to happen on the telephone. Some receptionists, however, felt such requests for information were important to help decide priority or to decide suitability for a telephone or face-to-face consultation. This was encouraged by some doctors, but some receptionists were unhappy about it and felt it placed too much responsibility on them.
Identity error and fraudOne concern raised predominantly by health care staff, although considered relatively uncommon, was the possibility that telephone consulting might facilitate identity error and fraud. However, even face-to-face consultations were not immune from this problem. In close-knit rural communities, it was less problematical, although several generations of family members with the same name could be challenging. When asked their view of the use of passwords or personal identification numbers (PINs) as potential safeguards, patients were more favourably disposed to this than clinical staff who could only see drawbacks to their use. Reception staff withheld information if they had any suspicions.
However, even face to face this could be a problem as this patient found
Third-party conversationsDoctors and nurses expressed the view that while it would be relatively unusual for someone to come along to see a clinician about their spouse or other family member's test result or to consult about their symptoms without them being present, such discussions happened more frequently by telephone. This could occur by accident (the patient was out when the doctor phoned) or by design (for elderly patients or older teenagers) and often left the clinician or receptionist in a quandary. It was not always clear to what extent permission had or might be given to hold the consultation. Clinicians and receptionists took a pragmatic stance, being occasionally willing to discuss non-controversial blood results, but rarely willing to reveal more sensitive information such as pregnancy test results.
Answering machinesHealth care staff were very loathe to use answering machines, as even leaving a message saying ‘the surgery called’ might be enough to breach the confidentiality of a teenager. If the answering machine message was in the known voice of the recipient and the message relatively uncontroversial (please call the surgery), some would leave a message.
DiscussionAs far as we are aware, this is the first study which has explicitly explored issues of confidentiality related to telephone use by in-hours primary care. It is clear this is an important topic for both patients and staff, with the risk of overheard conversations being the area of most concern. This was particularly concerning in close-knit communities, where the use of the telephone, depending on the circumstances, could pose a risk or offer a solution to maintaining confidentiality. Identification error or fraud was considered a rare, but potentially serious problem with no agreed simple solution. Strengths and limitations of the studyOur investigation was limited to ‘in-hours’ telephone consulting and we are aware that our findings may not be transferable to the out-of-hours context. It is important that future research focuses on this area. While there is always a risk with qualitative research that important viewpoints may be missed, our purposive sampling framework and use of screening questionnaires ensured recruiting people with a range of experience and views about telephone consulting. We sought out discordant views and continued data generation until saturation occurred.16 We recognize the potential influence of our own health care and sociological backgrounds on data interpretation; however, we sent a summary of our findings and interpretation to participants for comments and presented findings at a multidisciplinary workshop. Respondents and delegates agreed with our interpretation of the findings, with comments largely confined to emphasizing some aspects of our conclusions. Interpretation of findings in relation to previously published workThe promise of confidentiality in the consultation allows two individuals, who may not know each other well, a high level of intimacy and permits a safe and constructive discussion of personal matters.22 Patients and health care providers in this study as in others23 confirmed that confidentiality is extremely important. The increasingly used medium of telephone consulting was considered to carry some carry some additional risk with respect to confidentiality in that identification could be difficult. Other researchers have identified what they considered to be sloppy practice in routine telephone identification.24 Although attempted identity theft was considered to be a potentially serious problem in our study, it was believed to be a rare occurrence happening in the main in certain high-risk contexts. Participants were more concerned with the deliberate or accidental overhearing of conversations. This problem was not confined to telephone consulting; it also occurred in face-to-face encounters, especially at the reception desk or in poorly sound-proofed small surgeries. Indeed, the telephone was seen as providing a means for much needed anonymity, particularly for those living in small close-knit communities. Clinicians felt uncomfortable with third-party conversations which seemed to happen more often with telephone consulting but tried to be pragmatic about revealing low-risk information. This was also found in a Spanish study25 where 95% of doctors interviewed had given some information to family member, largely assuming consent, but were careful about the types of information they gave. Interestingly, contrary to the findings of research among teenagers, which indicates this group are particularly worried about confidentiality breaches,7 health professionals were particularly concerned about keeping their confidences. Many of the concerns of adolescents and HIV/AIDS patients around issues such as overheard consultations, being identified by relatives and friends when attending the surgery or dealing with particularly sensitive areas such as sexual health, pregnancy, substance misuse and mental health,26 echo those of the adult patients we interviewed. Similar findings have also been expressed in an American focus group study of patients and primary care practice nurses on the subject of privacy.23 Although the use of PINs or passwords has been suggested by others,27 in our study there was little enthusiasm for it among professionals who thought that they would be impractical and rural staff in particular, who knew their patients well and thought them unnecessary. Recent research, however, suggests that it is rare for staff even to check dates of birth or postcode24 which, while weak security measures, may at least prevent some ‘same-name’ errors. Interestingly, patients were more supportive of PINs seeing this as an extension of use in other contexts. Implications for clinical practiceThe telephone is an invaluable tool in medical practice. Many of the concerns that patients and health care staff have about confidentiality breaches, both on the telephone and face to face, are amenable to careful management (See Box 1). Given the emphasis placed on confidentiality by regulatory bodies, such management strategies should be mandatory. Maintaining confidentiality in small rural surgeries is particularly challenging, but should be achievable with suitable procedures. Although rare, identification error or fraud is a potentially serious problem and further thought needs to be given to the problem of misidentification on the telephone and pragmatic solutions (e.g. using PINs or passwords) considered. BOX 1 Managing confidentiality in telephone consultations and conversations Managing the office area
Phone etiquette
DeclarationFunding: The study was funded by the Chief Scientist Office (CSO) of the Scottish Government. BM and HP are supported by CSO career scientist awards. Ethical approval: Lothian Multicentre Research Ethics Committee (ref 06/MRE10/27) and local research and development offices. Conflicts of interest: none declared. We would like to thank The Scottish Primary Care Research Network and Dr Jim Douglas for their help with recruitment and all the participants. References6 , , , , , . General practitioners’ satisfaction with and attitudes to out-of-hours services , , , vol. pg.7 , , , , . Teenagers’ views on general practice consultations and other medical advice. The Adolescent Working Group, RCGP , , , vol. (pg. -)19 , , , , . Telephone consultations to manage requests for same-day appointments: a randomised controlled trial in two practices , , , vol. (pg. -)23 , , , , . Privacy concerns of patients and nurse practitioners in primary care—an APRNet study , , , vol. (pg. -)25 , , , . Balancing confidentiality and the information provided to families of patients in primary care , , , vol. (pg. -) |