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Snooping at Britney's Chart: Why Should Docs and Nurses Have Different Rules?
by Robert Wachter, The Health Care Blog
April 22, 2008

Britney was hospitalized at UCLA at least twice in the past few years – once when she gave birth to her first son in 2005, and again in early 2008 for psychiatric care. Both times, dozens of UCLA staff members peeked at her medical records, despite having no clinical reason to do so.

This voyeurism, of course, is hard wired into our DNA, and we aren’t about to purge our inner paparazzis any time soon. But even celebs have a right to keep their medical records private. Although the Health Insurance Portability and Accountability Act (HIPAA) has caused some real mischief, one of its beneficial effects is that it put the issue of medical record snooping on our radar screen. Whether the victim is a Hollywood starlet or your next-door neighbor, it is just plain wrong.

Most organizations have hired HIPAA police and done extensive HIPAA training with their staff. Nevertheless, all the UCLA snoops were documented to have passed an on-line HIPAA tutorial. When Britney hit the door, Inquiring People just wanted to know.

Lest you think this is a UCLA thing, we had a similar situation (with another famous actress) a few years ago, as have dozens of other hospitals. In fact, human nature being what it is, I can’t imagine this not happening – unless the rules are clear, widely disseminated, and strictly enforced.

That means for everybody. As Charlie Ornstein reported last week in the LA Times, of the 53 people caught snooping, 18 of the non-doctors resigned, retired, or were dismissed, while no physicians left the staff. David Feinberg, UCLA’s chief exec, correctly noted that, “Historically, doctors have been treated in a way that may be more lenient than non-physicians...”

Well, yes. But why?

Hospitals have always hired nurses, respiratory therapists, pharmacists, and other staff, paid them a salary, and established an employer-employee relationship. Such relationships are governed by strict rules, overseen by a Human Resources department.

On the other hand, relatively few hospitals have hired physicians, at least in the past. Instead, docs were usually in private practice, using the hospital as their hobby-shop – in doing so, “bringing in the business” that kept the enterprise afloat. This meant that hospitals needed to play nice-nice with physicians, since the latter could always threaten to take their business (sometimes known as "patients") elsewhere if they weren’t treated with kid gloves. In fact, many old-time CEOs have told me that a decent chunk of their schooling was in “how to keep the doctors happy.” This is not a mantra that leads to the development and enforcement of standards of behavior.

On top of this organizational framework is medicine’s posture as a self-governing profession – which led to the system of peer review. Whatever its merits (and there are some – medicine is sufficiently complex that, for many clinical decisions only another expert can reasonably judge the conduct of a colleague), the peer review structure also meant that discipline could only be meted out by a colleague – who, naturally, was reluctant to be too harsh.

These forces quite logically led hospitals to develop two parallel systems of governance, rules, and enforcement: one for physicians, and another for everybody else. For the staff, rules fell under an employee-employer framework, transgressions were handled by HR (often in the context of negotiated ground rules, sometimes involving unions), and punishment was frequently swift and merciless. For docs, the rules (such as they were) were fluid, enforcement was negotiated through the peer review process, and decisions were made in the context of the organization’s strong desire to remain “doctor-friendly.” The result is UCLA’s present pickle, and many other similar situations.

If this seems wrong to you, you’ll be pleased to learn that it is changing, for several reasons. First, the nursing shortage has made it clear that nurses really are very valuable – perhaps not as valuable as the rock-star neurosurgeon, but valuable nonetheless. Second, more and more doctors are being hired by their hospitals, or receive significant support payments – creating a new environment of accountability that is less benign than a system in which one is judged by golfing buddies through the process of peer review. Third, and perhaps most importantly, the patient safety and privacy movements have created the need for a uniform set of standards that are not particularly clinically nuanced. It doesn’t take a jury of one’s peers to understand that peeking into a celebrity chart is wrong, nor to determine that the caregiver who refuses to wash his or her hands before seeing patients needs to be disciplined. It is just common sense.

This issue is particularly important in patient safety, since all of us are trying to establish a “safe culture.” One key element of such a culture is that there be “no blame” for honest mistakes made by competent providers. Yet in organization after organization, the CEO's cheerleading for a no blame culture is undermined (in a nanosecond) when front line staff members realize that there are different rules for doctors and nurses. (Yes, I know that we physicians have our own cross to bear in the form of the medical malpractice system, but it generally addresses – poorly – a different set of problems.)

Moving forward, we continue to need peer review for clinical decisions, since it really does take an expert to figure out whether a decision to anticoagulate or to operate was clinically appropriate. But for violations of unambiguous rules and policies (remembering that some rules and policies are dumb and need to be broken in the name of efficiency or safety, a process known as a workaround), there is no reason that the standards for physicians and other staff should be different. If, as organizations consider the implications of uniform enforcement, it looks like the physician staff will be rapidly depleted, then perhaps the enforcement policies for the other staff were too harsh and should be softened a bit. Both the goose and the gander need to be treated appropriately and fairly.

In the end, providing high quality, safe, and patient-centered care must be a team sport. We’ll never get there if team members are playing under different sets of rules.
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