Ethics NBME 2

[Jccripe]

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So a guy admits to you about cheating on his wife 2 weeks ago and now has chlamydia. The next day his wife calls you and asks if her husband has an STD. What do you tell her?

see your OB

I cant discuss this without your husbands permission


I cant remember the other choices cause I was between these two. Does anyone know what to say since she is at risk from the bug but these are just not worded clear enough.

 

[Elfy]

"Chlamydia and genital herpes are not reportable in most states."

Fadem Behavioral Science 3rd ed (2000), p. 220

So you can't report to health department and notify the patient's contacts.

The best answer, if that's an option, is always to encourage the patient to tell the wife himself, so they can be both treated and prevent reinfection/spread.

If that's not an option, I guess the next best thing is "I can't discuss this without your husband's permission." This puts the ball back in the patient's court where it belongs.

"See your OB" is delegating to another physician/calling a consult, which for the purpose of the board exams is probably something you should not do. If the wife wants to become your patient as well, she can. You're supposed to take responsibility for your own patients in the context of this exam. The husband is currently your patient; the wife isn't.

 

[BoneNibbler]

"Chlamydia and genital herpes are not reportable in most states."

Fadem Behavioral Science 3rd ed (2000), p. 220

So you can't report to health department and notify the patient's contacts.

The best answer, if that's an option, is always to encourage the patient to tell the wife himself, so they can be both treated and prevent reinfection/spread.

If that's not an option, I guess the next best thing is "I can't discuss this without your husband's permission." This puts the ball back in the patient's court where it belongs.



"See your OB" is delegating to another physician/calling a consult, which for the purpose of the board exams is probably something you should not do. If the wife wants to become your patient as well, she can. You're supposed to take responsibility for your own patients in the context of this exam. The husband is currently your patient; the wife isn't.

But I also thought you can breach confidentiallity to prevent harm to others......such as infectious disease (or does this only apply to the reportable ones?)??

 

[Elfy]

You can break confidentiality 1. if the patient poses an immediate threat for self-harm or harm to a third party (the Tarasoff decision, California 1976) in which case you should notify the police and the third party, or 2. if there is reportable disease in which case you should notify the health dept and encourage the patient to let his sexual contacts know so they can seek treatment, otherwise the health dept will notify them.

If the pt still refuses to notify their contacts and there is a life-and-death threat such as HIV, you can inform their partners as long as you let the pt know first that you are going to inform the partners. This is chlamydia not HIV, it's no immediate life and death threat and it's not even reportable as an infectious disease.

See Fadem above, p. 220:

"Doctors are not required to maintain confidentiality when an HIV-positive patient habitually puts another person at risk by engaging in unprotected sex."

 

[Jccripe]

chlamydia IS A REPORTABLE DISEASE see the link
http://www.cdc.gov/ncphi/disss/nndss/PHS/infdis2009.htm

 

[Elfy]

chlamydia IS A REPORTABLE DISEASE see the link
http://www.cdc.gov/ncphi/disss/nndss/PHS/infdis2009.htm

It's not listed as a reportable disease in either FA 2005 or 2009. There's even a mnemonic listed in both for reportable diseases, and the C in there is for chickenpox. Neither is it listed in Fadem 2000 (3rd ed) as reportable.

Fadem 2003 (4th ed) on the other hand on second look does list it as reportable so I guess they should sort it out between themselves.

http://books.google.com/books?id=S3...g=ARIqE7WN2UiWnPNa1mZDL1xfXC0&hl=en#PPA444,M1

If the dr does report it, then the health dept will notify the contacts eventually so the dr doesn't have to. There's still not the same degree of urgency met here for chlamydia as in the Tarasoff decision - it's not threat of suicide, homicide, or HIV.

It would be helpful if you remembered the other answer options as well.

 

[pseudoknot]

It's not listed as a reportable disease in either FA 2005 or 2009. There's even a mnemonic listed in both for reportable diseases, and the C in there is for chickenpox. Neither is it listed in Fadem 2000 (3rd ed) as reportable.

Fadem 2003 (4th ed) on the other hand on second look does list it as reportable so I guess they should sort it out between themselves.

http://books.google.com/books?id=S3...g=ARIqE7WN2UiWnPNa1mZDL1xfXC0&hl=en#PPA444,M1

If the dr does report it, then the health dept will notify the contacts eventually so the dr doesn't have to. There's still not the same degree of urgency met here for chlamydia as in the Tarasoff decision - it's not threat of suicide, homicide, or HIV.

It would be helpful if you remembered the other answer options as well.

OK, if the CDC and state health departments (I just checked VA and CA) say that it is reportable, then it is. You can't come back and challenge primary sources by saying that First Aid and other review books disagree. That's ludicrous.

 

[Elfy]

OK, if the CDC and state health departments (I just checked VA and CA) say that it is reportable, then it is. You can't come back and challenge primary sources by saying that First Aid and other review books disagree. That's ludicrous.

I suggest you read carefully what I wrote. I wrote that Fadem 4th ed does list chlamydia as reportable, that Fadem 3rd ed doesn't, that FA doesn't, and that they should sort it out between themselves. How I would answer the original question (what to tell the patient's wife) also depends, as I said, on the other three answer choices, which weren't listed by the OP. I don't have a preferred answer the way you seem to think. I am interested in scoring an extra point on the test if this bug comes up and that's all, especially on a Friday night.

 

[BoneNibbler]

OK, if the CDC and state health departments (I just checked VA and CA) say that it is reportable, then it is. You can't come back and challenge primary sources by saying that First Aid and other review books disagree. That's ludicrous.

So if you take the test in New York then you would get the question wrong, now wouldnt you?? 😴

 

[pseudoknot]

So if you take the test in New York then you would get the question wrong, now wouldnt you?? 😴

1. Are you trying to be funny?

2. Chlamydia is reportable in New York as well. I just used those states as examples because that's where I'm from.
http://www.health.state.ny.us/profe...municable_diseases_reporting_requirements.pdf

3. This isn't relevant to the OP's question, since he wasn't asking about which diseases are reportable to the health department. Even if an STD is reportable, it is not permissible or appropriate for a physician to tell a patient's partners about anything without consent.