• Ethics in Practice

    Fall and Balance

    When patient confidentiality and broader need are in conflict.

    Ethics in Practice

    Jake, a PT at Mountain View Hospital, is recognized by staff there for his excellent work not only with patients, but also with staff — many of whom have received his assistance over the years for work-related aches and pains. In fact, he's widely known at the hospital as "The Man With the Magic Hands." It's a description he both appreciates and tries his best to self-effacingly deflate. For instance, when he arrived at work recently with an adhesive bandage on one of his fingers, he told drily curious staff, "The magic clearly wasn't working when I closed the bathroom door on my thumb."

    Jake's always careful, though, not to take shortcuts or treat staff any differently than he would any patient when he's wearing his PT hat. He doesn't believe in quick "water cooler consults." He always asks staff who approach him with a physical issue to set up an appointment with him through the outpatient scheduler.

    "Any on-the-spot read or advice that I could give you might not stand up under closer scrutiny," he explains in such cases. "I owe you the same comprehensive assessment that I'd give to any patient, so that I can make fully informed determinations about your care — even if it's something that might seem relatively minor to you. If whatever's bothering you is significant enough for you to ask me about it, it merits sufficient scrutiny."

    Far from annoying staff whose hope for a five-minute consult in the hallway has been rebuffed, Jake's insistence on a proper office visit only enhances the esteem in which he's held by staff. And Jake must admit to himself that he enjoys the praise. Still, he's aware that he is willingly entering into dual relationships with staff members by serving as both their coworker and their PT. His feelings about that are mixed. On one hand, these are individuals with physical issues who have sought his counsel and assistance as a movement expert. On the other hand, however, having a dual role with staff means that Jake knows things about them that he wouldn't otherwise — which, in turn, can affect his interactions with them, and even his productivity.

    If, for example, Jake has just seen a nurse for low back pain, he can't stop himself from lingering in the doorway if he's passing by and sees her initiating a transfer, and then gently correcting her form if need be. And Jake sometimes catches himself being friendlier and more solicitous toward staff with whom he has a PT-patient relationship — which, he suspects, may negatively affect the group dynamic, even if only in a small way.

    Those experiences, however, haven't prepared him for the dual-role situation he's about to face with Terence, a renowned cardiologist and the hospital's chief of surgery. Arriving early one morning, as he always does, Jake is surprised to find Terence already waiting outside the PT's office, looking pale, with one eye blackened, and wincing in pain.

    "Ouch!" the PT exclaims. "What happened to you?"

    "A little mishap," Terence responds. "I took a little tumble. But look, I'm hosting the Mortality and Morbidity Conference in the auditorium in 45 minutes, so I'm hoping for a little short-term relief. I'm sorry to accost you first thing like this, but I'd really appreciate your help."

    "Okay, but only if you promise to come back this afternoon for a complete evaluation," Jake says.

    "Sure thing," the physician responds. Thanks a lot."

    Jake proceeds to perform soft-tissue massage and laser therapy, while attempting — again without success — to get to the bottom of what caused the injuries. Terence's answers are vague and evasive.

    "That's a definite improvement, Jake," Terence says afterward. "I appreciate it! I'll see you after lunch."

    True to his word, Terence returns to Jake's office that afternoon. The PT tries again to learn what happened. Jake's examination suggests no neurological or cardiovascular reason for a fall.

    "I'm a little embarrassed to say that I can't really remember what happened, to tell you the truth," Terence responds a bit sheepishly. "I guess I probably tripped over the leg of an armchair in my office, because the chair was askew when I came to."

    "You passed out?" Jake asks, surprised. "Anyway, what were you doing in so early today?"

    Terence is silent for several seconds, then confesses, "Okay, not to bore you with TMI, but I slept here last night. Jeannie and I have been having some marital issues, and she kicked me out. It already was 1 a.m., so I just came here. It was me and Mr. Jim Beam on the office sofa, drowning my sorrows. I've been under a lot of stress lately. My drinking's under control, don't get me wrong. I can manage my demons. But last night was maybe a little bit of an exception."

    Jake shakes his head and observes, "That's not good. Of course I'm concerned for your health, but I don't have to tell you that showing up for work off a bender isn't a small thing."

    "Of course," Terence says. "I know that, and I can assure you that it won't happen again. I want you to know how grateful I am for those ‘magic hands' — this morning and now. I'm good for the rest of the day, and with a decent night's sleep at a hotel tonight I'll be even better tomorrow. You don't have to worry about me, Jake. I appreciate your keeping this on the QT."

    With that, Terence exits, leaving Jake feeling overwhelmed by the confession he's just heard. True, the physician is his patient, and he'd spoken to Jake in confidence. But what about Jake's obligation to ensure the care and safety of Terence's patients?

    For Reflection

    Which ethical decision by Jake would best serve the greater good — keeping Terence's confidence or taking action to ensure that his patients are protected? Looking at the Code of Ethics for the Physical Therapist, is there one principle in particular that suggests what the PT's next step should be? (Consider your answer to that before reading the "Considerations and Ethical Decision-Making" box.)

    Kirsch, Nancy 75x110

    Nancy R. Kirsch, PT, DPT, PhD, FAPTA, a former member of APTA's Ethics and Judicial Committee, is the program director and a professor of physical therapy at Rutgers University in Newark. She also practices in northern New Jersey.  


    At www.apta.org/Ethics Professionalism/

    • Ethics documents (including the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant)
    • Ethical decision-making tools (past Ethics in Practice columns, categorized by ethical principle or standard; the Realm-Individual Process-Situation [RIPS] Model of Ethical Decision-Making; and opinions of APTA's Ethics and Judicial Committee)

    At www.apta.org/PTinMotion/ 2006/2/EthicsinAction

    • "Ethical Decision Making: Terminology and Context"

    Considerations and Ethical Decision-Making

    While it may seem clear that the need to serve patients' interests is paramount, how can Jake best do that? Also, what's Terence's proper role in this?

    Realm. The ethical realms here are individual — between Jake and his patient — and societal, in terms of serving the common good.

    Individual process.Moral sensitivity is required of Jake to recognize, interpret, and frame the ethical situation. He also must exercise moral potency and take appropriate action.

    Ethical situation. Jake faces a moral dilemma — there are two correct courses of action, but both cannot be followed.

    Ethical principles. The following principles of the Code of Ethics for the Physical Therapist provided guidance to Jake:

    • Principle 2E. Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law.
    • Principle 5D. Physical therapists shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.
    • Principle 5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.

    Author Afternote

    Several PT readers cited instances in which a patient of theirs who also was a health care provider shared information during a physical therapy session that held implications for individuals the patient might, in turn, treat. While acknowledging the importance in most instances of maintaining PT-patient confidentiality, these PTs emphasized the primacy of the Code of Ethics principle (5D) that directs practitioners to encourage colleagues with substance-related impairments that may adversely impact their professional responsibilities to "seek assistance or counsel." Jake the PT should, these respondents agreed, ask Terence the physician point-blank if he is willing to take steps to see that this situation doesn't repeat itself. They added that Jake also should challenge Terence on the specific actions he’s amenable to taking.

    Should Terence refuse to take appropriate responsibility, Jake is bound, these PT readers responded, to report matters to the appropriate authority, per Code of Ethics Principle 5E.

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