A 16-year-old girl comes to the office for an initial patient visit. Medical conditions include asthma and mild acne. The patient does not smoke or use illicit drugs regularly but has tried alcohol and marijuana at parties a few times. She is not sexually active. The patient maintains average grades at school. When asked about extracurricular activities, she says that she is thinking about quitting her high school softball team because "the other girls are mean, and I just don't enjoy playing anymore." When asked to describe how she feels, the patient hesitantly mentions that she gets depressed at times and frequently feels self-conscious and that no one likes her. She appears uncomfortable and nervously asks the physician, "You won't say anything about this to my parents, will you?" Which of the following is the most appropriate response to the patient?
Protecting the adolescent's confidentiality is important to maintaining a trusting patient-physician relationship for discussions of sensitive topics, such as mental health, drug use, and sexuality. At the initial visit, physicians should prepare adolescents and guardians for increasing adolescent autonomy in health care decisions while promoting open communication between the parties. This discussion should also include situations in which the physician is ethically or legally bound to breach confidentiality (conditional confidentiality).
Limitations to adolescent confidentiality include determinations of imminent risk (eg, suicidality, homicidality) and threats to safety (eg, sexually abusive relationships, intoxicated driving). Additional risks to confidentiality should also be discussed with adolescent patients, including guardian access to information through the electronic medical record and patient portal, direct medical record requests, and insurance/billing statements.
When confidentiality must be breached, it should be discussed first with the adolescent, who should be given the option to broach the topic with the guardian. In this case, although the patient does not describe an imminent threat to her well-being, the physician should take the opportunity to set the framework for their future patient-physician relationship.
(Choice A) Establishing rapport and maintaining privacy with adolescents supports positive health practices, but there are circumstances that require disclosure to guardians (eg, imminent risk, recurrent safety concerns), to state protective agencies (eg, abuse, neglect), or to health departments (eg, transmissible infections). Keeping everything "between you and me only" (unconditional confidentiality) undermines the physician's duties to practice in the patient's best interest (beneficence) and to do no harm (nonmaleficence).
(Choices B and C) The physician is not obligated to divulge information to this patient's parents or to respond to questions about what the adolescent discusses unless there are significant health or safety concerns. If no sense of privacy can be expected, adolescents may avoid future health care interactions and may not pursue necessary health care interventions.
(Choice E) Although the Health Insurance Portability and Accountability Act (HIPAA) addresses provider responsibilities regarding patient confidentiality practices, it does not ensure unconditional confidentiality for adolescents or expressly prohibit guardians from lawfully accessing sensitive information via record request.
Educational objective:
Having an early, open discussion about confidentiality and its exceptions (eg, imminent risk, safety, legal mandates) with adolescents and guardians establishes a transparent framework for future patient-physician interactions. It also provides guidance on appropriate progression of adolescent health care autonomy while allowing for the promotion of open communication.