First of all, let me make it clear—This blog is NOT about the issue of Gun Control. While the gun control debate is a very controversial issue and I certainly have an opinion regarding the protection of our Second Amendment rights, this particular blog is focused on the fallout that Presidential politics may have on our ability to care for our patients.
Obama’s executive action on gun control this week may have a significant and potentially long lasting impact on the doctor-patient relationship. Doctors have always been held to a very high standard of conduct when it comes to protecting privileged patient information. When a patient steps into the exam room or establishes a doctor-patient relationship, a physician CANNOT discuss anything that the patient discusses (even with other physicians) WITHOUT the patient’s permission. Records cannot be released without a patient signature and, unless the patient makes statements that suggest that he or she is a danger to himself or others (or communicates threats), the physician cannot report any illegal activity to the authorities. This “zone of confidentiality” is in place in order to encourage patients to interact with physicians with HONESTY and develop TRUST with healthcare providers. This protected relationship is important as it provides doctors with accurate data when considering a diagnosis and treatment plan for a patient. More importantly, it protects patients from any repercussions from employers, family, government or others as a result of any information that they may voluntarily provide.
During his press conference, Mr. Obama outlined the specifics of his Executive Action (without Congressional approval) regarding changes to gun control laws in the United States. While the specifics of the new law are a bit difficult to understand it is clear that physicians are part of his plan for limiting access to guns. As part of the action, physicians apparently are no longer held to the high standards of the Health Care Portability and Privacy (HIPPA) act when it comes to patients with mental illness. The action relieves physicians of the duty to maintain complete patient confidentiality when an individual provider notes that a patient may be mentally ill—in fact physicians are encouraged to contact the National Instant Criminal Background Check System (NICS) and report the name of the patient. The NICS is a government organization that maintains a database that is used for determining if prospective firearms buyers are eligible to make a gun purchase. It was mandated by the Brady Handgun Violence Prevention Act (Brady Law) of 1993 and launched by the Federal Bureau of Investigation (FBI) in 1998. As part of the reporting process to NICS under the new executive action, no actual diagnosis or other privileged medical information can be revealed—only a physician’s hunch that a patient may suffer mental illness is necessary for disarming any patient. No guidelines as to what type of mental illness should be reported–so I guess anything is fair game from depression to social anxiety and beyond. Any physician report, even without due process or investigation, will preclude a patient from purchasing a gun. More disturbing is the fact that ANY physician—even a cardiologist like myself who is definitely NOT trained in the diagnosis and treatment of mental disorders—MAY prevent a patient from purchasing a gun by filing such a report.
Don’t get me wrong—gun violence in the US is horrific. Mental illness is widespread and many patients go unnoticed, undiagnosed and untreated. No one with mental illness should be allowed to own or possess a firearm. We must make changes to prevent senseless killing. However, asking physicians to screen potential gun owners is NOT the answer. Our President should have thought more about the implications and fallout of using a “phone and a pen.” He may have forever changed the way doctors and patients interact and his executive action may serve to erode the purity of the confidential nature of the doctor patient relationship. His new “law” is also in direct conflict with a Supreme Court ruling from July 2015 when the Court upheld a Florida law that prohibits doctors from asking patients and families about gun use or possession.
As physicians our job is to use our training and our understanding of medical science to provide our patients with the best possible care in order to produce the best possible outcomes. We should NOT be put in the middle of a political debate regarding guns and mental illness. We should not be put in a position to make a legal determination that may forever limit the rights of our patients. The Affordable Care Act and Electronic Medical Record mandates have already overburdened busy medical professionals in every specialty. Primary care doctors certainly screen for mental illness as part of their routine wellness visits (and are trained to do so) but surgeons and other specialists have little or no experience with the diagnosis of mental illness and quite honestly rarely consider these issues during a patient interaction. Psychiatrists and other mental health professionals are well equipped to make such determinations, but are often in short supply and unable to perform “emergency” consults outside of calls for commitments, etc from Emergency Department staff.
The unilateral actions of our President are likely to have far reaching (and likely unintended) impacts on healthcare. It is essential that there is a bond of trust between doctor and patient and this relationship must remain sacred. Patients should feel free to discuss anything with their physician without fear of legal repercussion or fear of imposed limits to their constitutional rights after a visit with their healthcare provider. I fear that patients may not be as forthcoming with their physicians during regular visits due to a perceived lack of confidentiality—how can they know that they will not be reported as mentally ill to the FBI? This new law influences what doctors and patients may say to one another during the most critical part of the doctor-patient relationship, when the patient is most vulnerable—the private medical exam. Most importantly, patients may not follow up regularly with their physician due to a fear of being reported to government agencies and losing their right to bear arms. The exam room is designed to be a safe place—a place where patients can share intimate details of their lives and health history and develop a bond with their healthcare provider. I fear that this legislation will only serve to erode the sanctity of this very unique relationship and ultimately impact health outcomes in a negative way.
While in my state physicians do have an obligation to report any patient who communicates threats to harm themselves or others, this new “law” calls on physicians to do something quite different—report any patient whom you suspect MAY have any type of mental illness—irrespective of any stated threat or danger. Doctors need to care for patients. Doctors must respect patient privacy. Doctors should not be FBI informants. Politics has no place in the exam room and government should not be in the business of dictating the way highly trained medical professionals practice Medicine. As Doctors, we must stand up for our patients’ rights. We must protect our privileged relationships and we must leave gun control debates to the politicians and lawmakers. Gun violence prevention efforts should be focused on the communities in which they occur and target the criminals who commit the heinous acts—these laws should NEVER come between doctor and patient. So Mr. Obama, I implore you, let doctors do what they do best—Heal.