Request to Withhold Diagnosis in Medical Record for Fear of Stigma

Case Description: 

You are both a medical school professor and general internist (physician) at a prestigious medical school and its affiliated medical clinic. You have been particularly impressed with, and have become fond of, a medical student named Sophie. Sophie is finishing her third year of medical school, often considered the hardest because of its grueling in-hospital clinical rotations. In her 4th and final year, she will apply to residency programs in several states. Given her stellar record, you expect Julia to be competitive for top nationally-ranked hospital residency programs. (Residency is the period of supervised practice that beginning-physicians complete before they can practice on their own.) 

You have noticed Sophie looking tired lately, but since medical students often do, you didn’t think much of that until she asks to speak to you about a personal health problem. 

You advise that it would be inappropriate to do so without a doctor-patient relationship, and explain that as a general policy you don’t take medical students as patients. Sophie protests that her longstanding physician in her home-town retired recently and she doesn’t have any personal doctor, let alone one she knows and trusts. You offer to refer her to a colleague in community practice, but she begs to talk to you, because she fears her health problem could affect her professional future and feels you would best understand that. You agree to make an exception and accept her as a patient for the short remainder of her time in medical school, and ask your office staff to work her into your clinic schedule promptly. You ask Sophie for access to her medical records, which are unremarkable. 

At her clinic visit, you find Sophie has lost some weight from her previous healthy weight. Sophie tells you that she is suffering from symptoms that she believes are serious depression: generalized sadness, loss of appetite, and lethargy. She confesses that she is struggling to get up in the morning and come to the hospital to meet her responsibilities as a medical student. She isn’t aware of any trigger or cause; she just thinks the heavy schedule and emotional weight of third-year training is “getting to her.” She tells you she had approximately year-long spells of depression that “felt like this” twice before, once in high school and once in college. In both cases, her family physician prescribed an antidepressant, but at her request recorded the reason as menstrual irregularities, so she would never have to report a history of depression. (Relief of certain menstrual symptoms is a common off-label use of anti-depressants. Sophie reports that she does have some mild menstrual irregularities, such as uneven cycles and moderate PMS, that have incidentally improved when on the antidepressant.) She felt the anti- depressant helped greatly in her past episodes of depression, and that she was able to wean off easily after an adequate period of stability. 

Sophie asks you to do the same, prescribing antidepressants without acknowledging depression as the reason. Since her training in medical school has emphasized the desirability of combining pharmacological treatment with therapy for many kinds of depression, she notes she is also willing to try therapy, too, for the first time in her life, and to consider your recommendations for therapists. However, she asks that you not put that referral in her medical record. She says she will find a way to pay for therapy out-of-pocket rather than seeking insurance reimbursement, which would create a record of the depression. She says she hates to ask you these two favors “because the world shouldn’t be this way,” but she believes “you know how it really is.” Sophie will need to apply for medical licensure in whatever state she pursues residency, and in whatever state she practices medicine after that. She notes that medical licensing boards in many states continue to ask if applicants have any history of depression, as well as whether they currently are suffering from depression, and answering “yes” could slow down or even result in the denial of her application for licensure. 

What should you do? 

Discussion of Case:

Get the facts: 

• Is this student correct to fear any acknowledgment or medical record of mental health treatment might adversely affect her specific target residency programs and licensure boards? What is the official policy? What do you know about unofficial practice? 
• You may feel torn between loyalty to a student whom you think will make a fine physician (especially because you think lingering prejudices against any known prior mental health treatment in some residency programs and licensure processes is wrong but existent), and the simultaneously ethical and clinical ideal of straightforward truth- telling in the medical record. 
• You may feel role conflicts between your role as a physician, as a supporter of this student who will recommend her to residency programs and serve as a licensure reference, and as a teacher who would like to model de-stigmatization of mental illness. 

Tension between ideals: 

Identify options: 

• Agree to prescribe the medication with the gynecological issue stated in the medical record. Provide the therapist recommendations and ask Sophie to keep you informed. 
• Tell Sophie that as a physician, a teacher of physicians, and a holistic practitioner in terms of mental health care, you feel it is important to state the true underlying diagnosis (the depression) for a prescription in the medical record. At the same time, emphasize that you would not raise the issue of depression in a reference as long as you continue to feel her approach to addressing it enables her to meet her professional commitments. 
• Tell Sophie you feel a role conflict between acting as her physician and her mentor. Explain what option you prefer to negotiate that tension, while offering to assist her to transfer care to another physician if she is not comfortable with that. 
• Other? 

Practice preventive ethics/systems issues—potential responses: 

• Lobby your medical society, medical professional societies, and residency programs to eliminate obstacles to practice for competent physicians with histories of depression or mental health treatment. Articulate that related practices not only impede good clinicians, but also can discourage health professionals from seeking mental health services they would recommend for similarly situated patients. (This in no way would reduce professional obligation to report colleagues whose impaired mental health or substance abuse poses a threat to patient care.)