September 24th, 2014

Quick Question: How Do I Fill Out This Tricky Patient Job or School Form?

From a long-term and highly respected colleague comes this challenging query:

Hi Paul,
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

Dear Miffed,

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.

paperworkBut 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?


9 Responses to “Quick Question: How Do I Fill Out This Tricky Patient Job or School Form?”

  1. Carolyn Sax says:

    As the pediatrician wife, I can concur that “dumping” forms on the PCP is not appreciated. But I can tell you that this situation arises with practically every Well Visit done by a pediatrician. We fill out a health form with every single one of these visits and practically always leave the medication section blank. Is it the football coach’s business if a kid is on an ADHD med? Is it the art teacher’s right to know if a student takes an antidepressant? In most cases parents don’t want medication information shared, so we leave it out. We include asthma medicines and Epipens and that is about it. Kind of begs the question what good are all of these forms anyway?

  2. Lynora Saxinger says:

    Thanks for raising this: I am troubled by the same issues! How about “this information has no bearing on the fitness of my patient for the training program”…

  3. Michael Rosenfelder says:

    Good advice. I think I remember Gladys Gleepster!

  4. Interesting and certainly agonizingly considered all possibilities with many anecdotal asides.

    As for me I would list the medications I chose to list and would not tell anyone I am taking Viagra.

  5. Loretta S says:

    Paul, I think you and your colleagues are giving the nursing school admissions people (or hospital clinical site people) too much credit. You think they are as detail-oriented as you are and will immediately notice the blank medications section and jump to action. Nope. Trust me on that. Leave the section blank or omit the HIV medications. It is none of their dang business what medications she is taking, anyway. My patients who take antidepressants sometimes worry about this, too. HIPAA doesn’t go out the window when someone applies to school.

    Thank you for not dumping the form on her PCP! I am a primary care NP and we do get a tsunami of paperwork, most of which is appropriate for us to fill-out. But don’t get me started about surgeons that tell patients to have us fill out their disability paperwork — when they are disabled because of their surgery!

  6. Marvin Rabinowitz says:

    Loretta S stated HIPAA doesn’t go out the window. I get forms all the time that don’t have the appropriate release and I notify, usually a social service agency of the county, that the appropriate release wasn’t signed. Most of these involve Suboxone where I am not legally allowed to even tell them which release. Fill out the form with what the patient in the office signs as a release, different than the enclosed, if one is available.

  7. MarkAlain Dery says:

    I agree with Loretta S on this. As an HIV physician, I have to fill these forms out regularly, mostly for attendance to higher education schools or some summer program as a counselor or supervisor. There is no reason whatsoever that non-medical individuals or potential employees have access to this personal health information. If there is a medical emergency at the school, camp, or place of employment, my patients are instructed to disclose their status directly to the health care provider caring for them.

    On a side note, are people living with HIV in Massachusetts required to have a primary care provider as well as an HIV provider?

  8. Ramatu says:

    It is interesting to see that this problem isn’t just a problem in the developing world. I believe your last option of patient wanting that information confidential is the best way to go. A few years ago while working in a general hospital setting we would see lots of people who said they were refused jobs after the medical due to their HIV status especially in the banking sector at that time. When I made enquiries with other banking professionals the reasons were just simply to discourage contracting the disease which got me thinking about all the public health messages out there that don’t cause any changes in knowledge,attitudes or general practices amongst the populace. Generallying I don’t think employers need that type of information as it has the potential for discriminatory use and for the person in question the last option is definitely worth trying.

  9. Cathy says:

    As a pediatrician and an HIV provider, this is a daily issue. I do not normally put any medications the patient considers confidential on a school/work/training program form, as breach of confidentiality also could disclose dx or behavior to parents, friends or anyone who happened to see the form. If they are locked up or in a residential program, where they can’t get medications during their stay without disclosure, it is a different situation. However, some of our patients choose to go off meds rather than allow health care providers and staff in a residential program to know what they are taking. Thanks for bringing up this tough issue.
    In adolescent medicine, we often have to withold after visit summaries listing confidential dx and / or meds for this reason

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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