From a long-term and highly respected colleague comes this challenging query:
One of my HIV pts, doing wonderfully well, is planning to enroll in a nursing program. She does not want to disclose her HIV status (fine with me), but the hospital requests a list of current meds which, of course, would blow her cover. My inclination is simply to leave the HIV meds off the list, but I asked our legal office who advises me not to do so -- they say just decline to fill out the form. However, I don't like that advice, since it essentially means my patient cannot enroll in the program. Of course I question whether the employer has the legal right to know all the meds, but I can't change that in the short term.
What sayest thou?
Miffed in Malden
I completely share your frustration with these forms, which have bedeviled us ID specialists for decades. One of the more excruciating questions they sometimes ask is, "Does this patient have a contagious disease?" Hate that one; I've figured out that it's best to interpret it as, "Does this person have a disease that would be considered contagious in the context of these job activities?" making it much easier to answer.
But the nursing program wants to know your patients medication list, which brings up the question of why. If they find out she were taking HIV meds -- or psych meds, or immunosuppressive drugs, or five antihypertensives, or echinacea -- would they reject her application? I hope not, as that would be highly discriminatory -- people with these conditions can certainly work in healthcare provided they are medically stable. It's not as if she's applying to be an airline pilot, where the FAA has a very clear list of exclusionary medical conditions and medications. (At least I hope they do.)
So yes, the form stinks. But in the meantime, you have to decide what to do, which leaves you with several alternatives -- none of them perfect, but some clearly better than others.
- Decline to fill out the form. This is what your legal office advises, and while it may make sense legally, is it the right thing to do? Definitely not -- in other words, I completely share your opinion. We overall want to be our patients' advocates, especially for something that enhances their global well-being (something like enrolling in a job program). So if this isn't the right answer (and it's not), why did your lawyers give this advice? Let's just say there's a reason they went to law school, and we didn't, and perhaps this example nicely sums up some differences between doctors and lawyers. (Some of my best friends are lawyers. Really.)
- Leave the medication section of the form blank. While this isn't technically lying, it raises the uncomfortable possibility they will call you: "Dr. Miffed, this is Gladys Gleepster from Regional Community Hospital, and it's about your patient Ms. Smith -- you left a section of her health form blank. Could I fax this back to you so that you can complete it?" Then what are you going to do? Fess up that you did this intentionally? Continue to stonewall? Not a comfortable situation.
- Selectively leave the HIV medications off the list. In other words, lie about it. It's a small lie, yes, and unlikely to hurt anyone, but a policy of "No lying on forms" is something we made official in our clinic years ago, and I strongly recommend it. It became particularly important back in the late 1990s, when some of our previously disabled patients had (miraculously) become quite robust on HIV therapy -- it seemed (and was) deceitful to fill out forms stating that a patient "Can walk a maximum distance of one city block" when just that day they were boasting about finishing a strenuous mountain hike or a triathlon. Plus, there was that person who asked me for a letter granting him "automatic upgrades to business class, in particular on international flights" due to his "severe claustrophobia" that, as far as I could tell, only manifested itself when he flew coach. I suggested that he have this unusual problem verified by a psychiatrist before we could write such a letter, because "we can't lie on forms." Policy.
- Dump the form on the primary care provider. Yikes. As someone married to a primary care provider, who is figuratively looking over my shoulder as I write this, I emphatically state that this is definitely the wrong choice. (Though tempting. Sorry.) ID doctors may be dumped on with paperwork from homecare companies who insist that you resolve the final date of home antibiotics and, while you're at it, please tweak that vancomycin level, but this is nothing compared to the deluge of forms PCPs get. Plus, many of our longitudinal HIV patients don't have a primary care provider, so like it or not, you're it.
- Write, "Patient prefers to keep this information confidential." This, I think, is the best approach -- especially if it's preceded by your telling her that this is what you're going to write. If she doesn't like what you propose, tell her you "can't lie on forms," and she'll most certainly come around to this being the best solution. Additionally, filling out the form this way will put the ball in the hospital's court, perhaps even forcing them to reconsider the requirement that people list their medications before joining their nursing program. And wouldn't that be nice if they changed it!
I said none of the solutions was perfect, but that's my take. Any other ideas?
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.