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PubMed2005

Consent to cataract surgery performed by residents.

BACKGROUND: Surgical teaching seems to be in conflict with the contract between surgeon and patient. We carried out a study to determine the prevalence of consistent disclosure to patients that a resident will perform part or all of their cataract surgery procedure. A second objective was to investigate the effect of such disclosure on patients' willingness to undergo the procedure. METHODS: We sent a survey to all 20 ophthalmologists working in our university-affiliated hospitals, inquiring about their practice of disclosure to patients regarding residents' involvement in surgery. Staff physicians were also asked to record their patients' consent to an operation performed partly or entirely by a trainee while under supervision. RESULTS: Of the 20 surveys sent, only 5 (25%) were returned. Those who declined to participate in the study mentioned several reasons, including that such disclosure might increase a patient's anxiety level, that they might lose potential patients as patients might be reluctant to have trainees perform their surgery, and lack of time to talk to patients about these issues. Of the five ophthalmologists who completed the survey, four were part-time affiliated staff and one was a geographic full-time physician working in our institution. Four of the five ophthalmologists said that they do not consistently disclose residents' involvement to their patients. Of the 49 patients enrolled, only 8 (16%) agreed to undergo the procedure after being informed that a trainee would be actively involved. INTERPRETATION: It is crucial to inform patients that residents may be involved in their surgery in order to avoid possible litigation. However, our results suggest that such disclosure may have a negative effect on surgical education because it could limit the number of cases available to trainees.

Cataract Extraction↗
PubMed2000

Delay in disclosure of childhood rape: results from a national survey.

OBJECTIVE: This study sought to gather representative data regarding the length of time women who were raped before age 18 delayed prior to disclosing such rapes, whom they disclosed to, and variables that predicted disclosure within 1 month. METHOD: Data were gathered from 3,220 Wave II respondents from the National Women's Study (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), a nationally representative telephone survey of women's experiences with trauma and mental health. Of these, 288 retrospectively reported at least one rape prior to their 18th birthday. Details of rape experiences were analyzed to identify predictors of disclosure within 1 month. RESULTS: Fully 28% of child rape victims reported that they had never told anyone about their child rape prior to the research interview; 47% did not disclose for over 5 years post-rape. Close friends were the most common confidants. Younger age at the time of rape, family relationship with the perpetrator, and experiencing a series of rapes were associated with disclosure latencies longer than 1 month; shorter delays were associated with stranger rapes. Logistic regression revealed that age at rape and knowing the perpetrator were independently predictive of delayed disclosure. CONCLUSIONS: Delayed disclosure of childhood rape was very common, and long delays were typical. Few variables were identified that successfully predicted disclosure behavior, but older age and rape by a stranger were associated with more rapid disclosure. This suggests that the likelihood of disclosure in a given case is difficult to estimate, and predictions based on single variables are unwarranted.

Child↗
PubMed1999

Psychosocial problem disclosure by primary care patients.

The vast majority of psychologically distressed primary care patients present exclusively somatic concerns at the outsets of their visits. However, it is not known how often such patients subsequently disclose psychosocial problems to their primary care physicians (PCPs) and what variables predict such disclosures. Our objectives were to measure, among psychologically distressed primary care patients, the frequency of disclosure of psychosocial problems (disclosure), the effects of prior psychosocial inquiry (prior inquiry) by PCPs and various patient variables on disclosure, and the effect of disclosure on mental health problem recognition (recognition) by PCPs. The study was based in the practices of 69 community-based PCPs and involved 308 adult patients with 28-item General Health Questionnaire scores of 5 or greater, indicating significant psychological distress. Disclosure occurred during 51% of visits overall and 67% of visits with prior inquiry. The odds of disclosure were increased by prior inquiry (p < 0.001), greater physician-patient familiarity (p < 0.001) and greater severity of patient psychological distress (p < 0.001). Prior inquiry and physician-patient familiarity had a negative interaction (p < 0.05) of smaller size than either variable's main effect, so that their combined effect on disclosure exceeded the effect of either variable alone but was less than multiplicative. The estimated odds ratio for recognition given disclosure was 24.13 (95% confidence interval, 11.28-51.63) after adjustment for the effects of significant covariates. We conclude that if PCPs inquire, most psychologically distressed, somatically presenting patients will disclose psychosocial problems. Inquiry is particularly productive with unfamiliar patients. PCPs can engender a substantial increase in psychosocial disclosure simply by adding one or two questions about mood or interpersonal problems to their clinical interviews.

Adolescent↗
PubMed2003

Stress, social support, and HIV-status disclosure to family and friends among HIV-positive men and women.

Patterns of HIV-status disclosure and social support were examined among 331 HIV-positive men and women. Structured interviews assessed HIV-status disclosure to family and friends, perceived stress of disclosure, social support, and depression. Results showed patterns of selective disclosure, where most participants disclosed to some relationship members and not to others. Rates of disclosure were associated with social support. Friends were disclosed to most often and perceived as more supportive than family members, and mothers and sisters were disclosed to more often than fathers and brothers and perceived as more supportive than other family members. Path analyses tested a model of HIV-status disclosure showing that perceived stress of disclosing HIV was associated with disclosure, and disclosures were related to social support. Disclosure and its association to social support and depression varied for different relationships and these differences have implications for mental health and coping interventions.

Adaptation, Psychological↗
PubMed1992

It takes two to tango but one to infect (on the underestimation of the calculated risk for infection with HIV in sexual encounters, arising from nondisclosure of previous risk behavior or seropositivity).

The effects of nondisclosure of either HIV seropositivity or previous engagement in risk behavior on the estimation of risk in sexual intercourse is studied through the use of a probability model. Equations are utilized to derive an Underestimation Factor for three cases, which is shown to range from 2 to 20 in the case of insertive anal intercourse between an HIV+ and an HIV- man, and to 1 x 10(4) in a similar case of heterosexual insertive vaginal intercourse. This factor remains constant regardless of the number of sexual encounters between the same partners, and regardless of the protective measures as long as unawareness prevails. The discussion focuses on the implications of this formulation for education and social attitudes toward disclosure and nondisclosure in sexual encounters. It also raises the question of moral responsibility of sexual partners and some legal aspects of nondisclosure.

Attitude to Health↗
PubMed2001

Should a diagnosis of Alzheimer's disease be disclosed?

There is evidence that some health practitioners may be reluctant to disclose a diagnosis of Alzheimer's disease (AD) to patients. However, this reluctance towards disclosure may not be in accordance with patient expectation. This study examined the attitudes of 100 undergraduate psychology students towards disclosure practices in relation to AD, before and after exposure to AD education. After AD education, 93% of participants indicated a desire to be informed of a diagnosis of AD, and 95% of participants were in favour of telling a close relative a diagnosis of AD. Results are discussed in terms of the relationship between age and attitudes towards AD diagnosis. It is concluded that the high rate of support for disclosure of AD diagnoses to patients among younger adults may reflect a change in the information preferences of patients brought about by a shift away from a patriarchal medical model, toward a more autonomous model of health.

Adolescent↗
PubMed1998

Ethical decision-making in critical care in Hong Kong.

OBJECTIVES: Biomedical ethics has assumed an increasingly important role in medicine over the past 30 yrs, and its development has served the important goal of protecting patients' rights and interests. However, medical ethics has evolved within a Western tradition, and conflict often arises when trying to apply Western medical ethics to patients from other cultures. Using Hong Kong as an example, this article reviews the nature and sources of cross-cultural conflict in the intensive care unit setting that often arises between physicians trained in Western medicine and patients from a Chinese cultural background. DATA SOURCES: This article draws on the first author's experience as a critical care physician in Hong Kong, and on a review of the literature on cross-cultural interactions in medicine. STUDY SELECTION: Studies were selected that contrasted the approaches of different cultures to common ethical dilemmas in medicine. Review articles examining the relationship between culture and ethics were also selected. CONCLUSIONS: Hong Kong presents an interesting case study because of the coexistence of Western and Chinese medicine in a predominantly Chinese population that practices many Chinese cultural traditions. Whereas contemporary Western medical ethics focuses on individual rights, autonomy, and self-determination, traditional Chinese societies place greater emphasis on such community values as harmony, responsibility, and respect for parents and ancestors. Specific areas of cross-cultural conflict include: the role of the patient and family in medical decision-making; the disclosure of unfavorable medical information to critically ill patients; the discussion of advance directives or code status with patients; and the withholding or withdrawal of life support.

China↗
PubMed2006

Why tell asymptomatic children of the risk of an adult-onset disease in the family but not test them for it?

This paper first considers why it is important to give children genetic information about hereditary conditions in the family, which will go on to affect their lives in a salient way. If it is important to inform children that they are at risk for an adult-onset disease that exists in the family, why should they not also grow up knowing whether they actually carry the genetic mutation? Central to this discussion is the importance of the process of disclosure and the environment in which genetic information is divulged. It is concluded that the reasons given for defending disclosure of genetic conditions in the family to children are also important reasons to cautiously defend predictive genetic testing of children for adult-onset diseases.

Age of Onset↗
PubMed1999

Family consent, communication, and advance directives for cancer disclosure: a Japanese case and discussion.

The dilemma of whether and how to disclose a diagnosis of cancer or of any other terminal illness continues to be a subject of worldwide interest. We present the case of a 62-year-old Japanese woman afflicted with advanced gall bladder cancer who had previously expressed a preference not to be told a diagnosis of cancer. The treating physician revealed the diagnosis to the family first, and then told the patient: "You don't have any cancer yet, but if we don't treat you, it will progress to a cancer". In our analysis, we examine the role of family consent, communication patterns (including ambiguous disclosure), and advance directives for cancer disclosure in Japan. Finally, we explore the implications for Edmund Pellegrino's proposal of "something close to autonomy" as a universal good.

Advance Directives↗
PubMed2001

Professional recommendations: disclosing facts and values.

It is not unusual for patients and their families, when confronted with difficult medical choices, to ask their physicians for advice. This paper outlines the shades of meaning of two questions frequently put to physicians: "What should I do?" and "What would you do?" It is argued that these are not questions about objective matters of fact. Hence, any response to such questions requires an understanding, appreciation, and disclosure of the personal context and values that inform the recommendation. A framework for considering and articulating a response to these questions is suggested, using as a heuristic the phrasing "If I were you.../If it were me...".

Counseling↗
PubMed1998

Publication of the OIG's provider self-disclosure protocol--Office of Inspector General (OIG), HHS. Notice.

This Federal Register notice sets forth the OIG's recently-issued Provider Self-Disclosure Protocol. This Self-Disclosure Protocol offers health care providers specific steps, including a detailed audit methodology, that may be undertaken if they wish to work openly and cooperatively with the OIG to efficiently quantify a particular problem and, ultimately, promote a higher level of ethical and lawful conduct throughout the health care industry.

Documentation↗
PubMed2000

[Does disclosure of medical records to patients influence medical care?].

UNLABELLED: Disclosure of medical records to patients has been assessed, but the influence of disclosure on medical care has not been well researched. To address this situation, this study was conducted to test three hypotheses: 1) doctors think that the disclosure can influence medical care, 2) whether doctors think disclosure can influence medical care depends on how they rank medical records (for example, as evidence for diagnosis and treatment, a process to reach a diagnosis, a tool to communicate with other medical staff, etc), and on whether they think medical record disclosure could change the content of the record. Questionnaires were sent to 881 doctors who work at two hospitals affiliated with N Medical School and K Medical University. RESULTS: Four hundred eighty-eight doctors responded. The findings related to the hypotheses were as follows: 1) Those who answered that the disclosure could have an influence on medical care were 49.1% of the total. 2) There was no relation between how doctors ranked medical records and whether they thought disclosure could influence medical care. 3) Doctors who answered that there were things that they would not be able to write if medical records were disclosed accounted for 73.5% of the total. These doctors answered "yes" significantly higher to the question that the disclosure could influence medical care than others (Odds 3.6, P < 0.01). Doctors who thought they would not be able to enter the diagnosis, the name of the disease for insurance, self-evaluation, information that could be judged and subjective information answered that disclosure could influence on medical care (P < 0.05). It was assumed that disclosure of medical records to patients could change the content of the medical records and that could influence medical care. How to deal with information will become an important issue if records are disclosed.

Attitude of Health Personnel↗
PubMed1996

[Dynamics of child suggestibility in accusations of sexual abuse in divorce proceedings].

A case of a mother confabulating an extended sexual abuse of her 13 and 15 year old children involving bizarre sadistic features is presented and discussed. The kinship to Munchhausen Syndrome by proxy, identity diffusion, Posttraumatic Stress Syndrome, folie à deux and other concepts is highlighted. It is suggested that sexual confabulations are generated within incestuous family structures as a means to stimulate and satisfy needs of personal closeness when losses and disruptive events have occurred. The disclosure or suspicion of sexual abuse may prove neither true nor false but may hint to an impending emotional breakdown of a parent and to ongoing subtle incestuous traumatisation of a child.

Adolescent↗
PubMed2005

Parental attitudes toward disclosure of the mode of conception to their child conceived by in vitro fertilization.

OBJECTIVE: To survey the level of disclosure of conception method within families of children conceived by conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and to examine the factors that might influence parental attitudes and plans for disclosure. DESIGN: In-depth questionnaire. SETTING: Participants recruited through fertility clinics in the United Kingdom. PATIENT(S): Parents of children aged 5 to 6 years conceived by IVF/ICSI (n = 181; 51% survey response rate). INTERVENTION(S): Mothers and fathers of IVF/ICSI-conceived children were sent questionnaires to complete and return in a postage-paid envelope. MAIN OUTCOME MEASURE(S): Responses to the questionnaire. RESULT(S): Most parents had told somebody about their child's method of conception, mostly close friends and family. Fewer (26% of mothers, 17% of fathers) had already discussed the child's mode of conception with their child. Fifty-eight percent of mothers and 57% of fathers intended to tell their child at some point. Sixteen percent of mothers and 21% of fathers were undecided. Four percent of fathers never wanted to discuss the subject with their child. Children were more likely to be told if conception was ICSI, rather than conventional IVF, and if an only child. Twenty-nine percent of undecided fathers and 36% of undecided mothers stated that they would tell their child if appropriate, child-friendly explanatory literature were available. CONCLUSION(S): The majority of parents wish to tell their child about their conception by IVF/ICSI at some point but are unsure as to the most appropriate timing and method of disclosure. Fertility clinics might have a role to play in providing the necessary support. Child-friendly literature might be helpful.

Adult↗
PubMed1998

Do attitudes toward disclosure in donor oocyte recipients predict the use of anonymous versus directed donation?

OBJECTIVE: To compare the demographic and psychological characteristics of oocyte recipients and to determine whether the issue of disclosure about the use of a donor is a correlate of the decision to use an anonymous or directed donor. DESIGN: Cross-sectional study. SETTING: University teaching hospital. PATIENT(S): Ninety consecutive recipients of donated oocytes (64 of whom used anonymous donors and 26 of whom used directed donors). INTERVENTION(S): Pretreatment psychosocial evaluation. MAIN OUTCOME MEASURE(S): Recipient opinions and attitudes regarding the choice of donor type and disclosure to others as determined through a semistructured interview. RESULT(S): There were no statistically significant differences with regard to demographic characteristics between recipients who used anonymous and directed donors. There were statistically significant differences between the groups with regard to the issue of disclosure. Recipients who used directed donors were more likely to have told others about using an oocyte donor and were more likely to indicate that they intended to inform the child about the nature of his or her conception. CONCLUSION(S): Oocyte recipients who use known donors differ significantly from those who use anonymous donors with regard to the issue of disclosure to others. Further studies are needed to determine the causal direction of this relation.

Adult↗
PubMed2005

Gay and bisexual men who disclose their sexual orientations in the workplace have higher workday levels of salivary cortisol and negative affect.

BACKGROUND: Previous research has shown that gay and bisexual men who conceal their sexual orientation suffer more adverse physical health problems relative to men who are more "out." However, little is known about the physiological mechanisms underlying this association. PURPOSE: This study examined whether concealing sexual orientation in the workplace was associated with increased workday levels of salivary cortisol. METHODS: Seventy-three gay and bisexual men responded to questionnaires assessing the extent to which they are open about their sexual orientations at work and other aspects of their work environment. Men then provided saliva samples and reports of negative affect throughout 2 consecutive days--1 at home and 1 at work. RESULTS: Contrary to expectations, being more out at work was associated with higher workday levels of salivary cortisol (B = 0.21, SE B = 0.09, p < .05) and higher workday reports of negative affect (B = 0.14, SE B = 0.07, p < .05), controlling for home day values. CONCLUSIONS: These findings suggest that it is disclosure rather than nondisclosure of sexual orientation by gay men in the workplace that is associated with emotional and physiological activation; a pattern that may have implications for their long-term adaptation.

Adaptation, Psychological↗
PubMed1990

Legal review: AIDS patient records--legal issues of access and disclosure.

All 50 states require AIDS cases to be reported to the department of health. Many jurisdictions require HIV and ARC reporting, as well. Many states have also enacted confidentiality provisions that prohibit health care providers from releasing HIV-related information without the patient's consent, although exceptions to the statutes authorize disclosure without consent to other health providers, spouses, and other persons under certain conditions set forth in the legislation. In addition, the patient may obtain access to his or her own records and may authorize release to third parties. Providers who violate the provisions are subject to liability. The patient usually has a private cause of action for damages and costs; in addition, the state may impose fines and jail terms for more egregious violations. Finally, courts may authorize disclosure of confidential HIV information in certain situations. In the absence of a statutory provision governing court-ordered disclosures, courts will balance the patient's privacy interest against the plaintiff's need to know and the public interest involved. Several states have enacted statutes that modify this traditional balancing approach, although it is unclear whether these statutes provide additional protection for health care providers and patients seeking to prevent disclosure of information. Health record practitioners should keep abreast of legislative and regulatory developments in their states that affect use and disclosure of AIDS patient records. Careful discussion with the health institutions' legal counsel of any situation not covered clearly by applicable statue or regulation is strongly recommended.

Acquired Immunodeficiency Syndrome↗