How Much the Act of Secrecy Is Done by Medical Staff? A Descriptive Cross-Sectional Survey in South of Iran

Some information may be gathered during the medical procedures, including medical records or personal information. Many of them can be considered as secrets. The medical staff has the duty of privacy, which means keeping the secrets away from a third party. Hippocratic Oath accepts no exceptions but modern ethical references express the situations in which the disclosure of secrets is allowed, legal, or even necessary. The present study is about to evaluate the act of secrecy in medical staff of the tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran. This cross sectional study is done on 204 members of medical staff of 8 different wards in tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran, using a questionnaire of 31 questions in 5 major categories adding to a data sheet for demographic information (age, gender, ward).Validity and reliability of the questionnaire was proved by previous studies. Collected data analyzed by dependent T-test, Fisher’s exact and SPSS.17 using descriptive and deductive statistics. The mean rate of secrecy was 3.82± 0.75. Respecting others in the category of “goals of secrecy” earned 4.48, common medical services in the category of “reasons for disclosure” earned 3.89, damage to the patient in the category of “legal reasons for disclosure” earned 4.05, patient’s rights in “personal reasons for secrecy” earned 4.07, and informing the medical managers in “proper way to confront the offenders” with the score 2.85 were the highest scores of each category. The variant Ages (p=0.003) and wards (p=0.03) showed significant differences in the secrecy. Results show that the medical staff is not familiar enough to the legal and ethical indications of secrecy, so holding in-service courses may be effective.


INTRODUCTION
should not be told to others ,and I shame to do so" [3][4][5] . Many information of one's life may be obtained Secrecy is one of the main principles of during the treatment process and most of them are communication in the society which used to be seen so private that even very close persons to the patient in the relation between patients and physicians for may not know them. Medical secrecy means that decades, and is mentioned in Hippocratic Oath 1 .
the doctor does not disclosure the secrets of the The oath accepts no exceptions in the secrecy but patient 6 . Secrets are considered as the information newer ethical references express some conditions that the patient is not willing to disclose them, in which the secrets can be released 2 . adding to them which the doctor figured out himself 7 . The doctor is allowed to release that kind of Hippocrates says: " Anything I see or hear information which may cause damage, only for during the treatment process or even out of that persons who can prevent that damage.
Principles of medical secrecy are three; subject, individual and the time. The subject is any type of information receiving the doctor from the side of the patient which must be kept classified, even though releasing it is better for the patient himself. Religious and legal laws emphasize confidentiality and the physician will be reprimanded if the information were disclosed 8 .
Individual is simply the patient, who possesses some secrets. If the patient is alert and oriented, he talks about his own problem to the doctor. He would be able to tell or not every single secret or important information. In the case of children, mental retards or unconsciousness, the parents have the authority about the secrets 1 . One's health records belong to him and others should not have access to them without permission; if did so, the autonomy would be tarnished. All the medical staff is considered to observe the patient's secrecy 1 .
The third principle is time. Responsibility to keep the medical records secret would not be finished by the end of the relation between doctor and the patient. Records can't be released after the retirement of the doctor. Neither curing nor death of the patients don't cause releasing the information. Privacy is a life-long process 1 .
Secrecy is explained by either ethics or law. From the ethics point of view, patients don't give enough information to the doctor if they doubt the privacy. This causes poor performance of the doctor. Moreover, secrecy is an act of respect to the man's autonomy 9, 10 .
Law protects the secrecy. Offering any medical record to a third party without the permission of the patient is forbidden unless allowed by the law itself 11 . If there is a threat to the patient or others which can be prevented by releasing the secret, doing so would be not only legal but also necessary. However the possibility of danger should be real and imminent 12 . College of physicians and surgeons of Ontario accepts the disclosure of secrets when the patient strongly says he wants to harm another person. In these cases, secrecy would be considered as violation 13 . So on the CMA code of ethics, physicians are allowed to release the secrets whether requested by the law or if possibility of damage to the patient or others exists 14,15 . Disclosure of the information should be to the extent required, and only for the individuals who can prevent the damage 4 .

Participants
The present descriptive cross-sectional survey was conducted in summer and autumn of 2012. The census samples included 204 members of treating staff in 8 different wards of gynecology, pediatrics, surgery, orthopedic, internal medicine , coronary care unit (CCU), neonatal intensive care unit (NICU), and the emergency department of tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran.

Procedure
The researcher obtained a license from the research council of the Iranian Ministry of Health and attended the hospitals in order to explain the goals of the study to the eligible staff and fill the questionnaires. After explaining the objectives of the survey to the authorities at the studied health care centers, the assistant visited all the wards to gather data. The questionnaires were distributed in different working shifts. The questionnaires, handed out all at once, were completed by the nurses at their leisure and returned.

Questionnaire
The validity and reliability of the self-made questionnaire confirmed by 5 experts .The reliability was confirmed by Cronbach's alpha= 0.8. The questionnaire consisted of demographic information (age, gender, job experience and the ward) adding to 31 questions in 5 categories: goals of secrecy (questions 1-8), reasons for disclosure of secrets (9-19) , legal cases for disclosure(20 23), personal reasons for secrecy (24-27) and confronting the offenders (28-31). Each category contained 5 scores in which score5 showed the best and score 1 showed the least satisfaction.

Data Analysis
The sample size was calculated using 90% confidence intervals, with 2% precision. A sample size of about 177 individuals was suitable for this survey. To compensate for any refusal to provide data or nonvaluable subjects the sample and the chi-square test (or Fisher's exact test if size (177 individuals) was increased by 20%. required) for categorical variables. P values of 0.05 Results were reported as the means ± standard or less were considered to be statistically deviation (SD) or median for quantitative variables significant. All the statistical analyses were and percentages for categorical variables. The performed using SPSS version 17.0 (SPSS Inc, groups were compared using the Student's t-test Chicago, IL, USA) for Windows.     The study was undertaken after being completely approved by the Institutional Review Board of the Iranian Ministry of Health. Written informed consent was obtained from each participants before their enrolment to the study.
Highest scores of every category is as follow: Goals of secrecy: 4.48, reasons of disclosure: 3.89, legal cases for disclosure: 4.05, personal reasons for secrecy: 4.07, confronting the offenders: 2.85. The mean scores in category of goals of secrecy is shown in Table 1. Respecting others earned the most (4.48) and preventing the defensive behavior of the patient got the least (3.94) scores in this category.
The reasons for disclosure of the medical records is shown in Table 2. Mean scores of subcategories are too close to each other (3.31 to 3.89) which may be concluded as low knowledge of the medical staff of allowed disclosure occasions According to Table 3, the major legal reason for disclosure is paralysis of the patient (4.05). However, no significant differences were seen between the subcategories (P>0.05).
Observing the patient's rights (4.07) and professional ethics (4.03) are the major personal reasons of secrecy, in front of social norms (3.75) ( Table 4).
According to Table 5, the results of the question" how to confront the offenders?" legal procedure was the most popular answer (3) and cutting the salary and benefits earned the least score (2.53).

DISCUSSION
Faber et al concluded that internal specialists do not decide to disclose the secrets according to the probability of violent actions from the side of the patient. History of previous violence and criminal records increases the probability of disclosure (16). Most of the patients of Cheng et al had issues that they didn't wanted to be disclosed, which resulted in a poor tendency of following up (17).
Physicians should respect the privacy of the patients. The only information which is allowed by the patient himself may be a subject to offer a third party. For this, medical staff should be aware of the legal procedures. Ensuring and convincing the patient before the disclosure can also help.
In the case of strong threat for damages, act of disclosure would be preferred to secrecy, even there is not enough of legal request.The doctor should evaluate the dangers which threaten the patient from the disclosure, and which threaten a third party if kept secret. The correct decision is that prevents further damages for everybody. Making the right decision is serious.
As a conclusion, Secrecy is essential, but not absolute. Making the least damage for individuals and the society is the determinant of secrecy or disclosure. The best decision would be proved by wisdom and the law. Physicians are responsible for their patients' medical records and any other kind of secrets lifelong. Base on the results which showed that the medical staff is not familiar enough to the legal and ethical indications of secrecy, so holding in-service courses may be effective.