1. Dilemma 2: Side A The Right to access medical records

2. STATED DILEMMA: Claire, a pt who exhibits paranoid tendencies, desires to see her medical record. Her psychiatrist is refusing to allow her access to the records

3. WHAT KNOWN FACTORS ASSOCIATED WITH THIS PATIENT CONTRIBUTE TO HIS DECISION?

4. The physician has already learned much about Claire’s history in his previous sessions with her. It is known that she has trouble maintaining long term relationships. Claire has not been able to stay employed for lengthy periods. She has often accused those around her of trying to sabotage her personally and has, in turn, become hypercritical of them. The doctor has noted her to be difficult, as well as, unpleasant. He has documented that patterns of paranoid thinking and underlying personality traits are causative issues related to her inability to function healthily in society.

5. What adjectives can be used to describe someone suffering from paranoia? It is also known that these traits escalate over time.

6. What are his options in regards to her request?

7. Claire’s physician has decided that at this point in treatment, it would potentially do more harm than good to release this information to her. He chooses to use his “therapeutic privilege”. This physician apparently believes strongly in this decision as he knows that it can potentially lead him into a court of law…at which time, this very documentation is the only thing capable of defending his decision for nondisclosure. He also has to make moral and ethical decisions that he can personally and professionally absorb in the event a poor choice inadvertently harmed this patient.

8. Many patients fail to realize that physicians are held to Principles of Medical Ethics and Standards of Conduct. This fact would be lost on a patient suffering from paranoia. She would also not respond to any reasoning or rationale that he would provide to her defending his decision.

10. Claire also expressed concerns that the physician would disclose the information to future employers… In her current mental state, the physician would unlikely be able to explain to her the concepts set forth in the Americans with Disabilities and Civil Rights Act…employers cannot ask and he cannot tell. These and other issues could be explained and discussed with someone not suffering from paranoia…again, this is lost on Claire in her current state.

11. In closing, there is a need to paraphrase a portion of Appendix U in the Principles of Informed Consent in Psychiatry: Disclosure of medical information does not necessarily have to occur at a single point in time…it can and often should be revealed in stages as the patient becomes more readily able to process the information…hence, the patient’s ability to process this information is known to increase as the symptoms they suffer from begin to resolve… This is a concept that is not lost on a competent, ethically sound, caring and compassionate physician offering his best medical judgment….in this case, access denied.