An interesting drug trial has just concluded in my community. The case involves Bill Romanowski, linebacker for the Denver Broncos. Reportedly, Romanowski felt some phentermine would help him perform better in his job, and he was shy about this becoming public knowledge.
Like many people (not just public figures), he wanted to preserve the confidentiality of his pharmacy record.
Romanowski's dilemma was aggravated because phentermine requires a doctor's prescription. He solved this by working out an arrangement with his personal physician to have his prescription written in his wife's name. According to everybody except the district attorney, there was no intent to deceive.
The doctor and Mrs. Romanowski both testified that using her name on the prescription was to spare Romanowski possible social embarrassment, in the almost certain event that somebody in the information pathway talked out of school.
I'm not clear whether this possible embarrassment was because phentermine might be disapproved by the NFL, for either weight control or mood control. (I haven't gotten anyone at the NFL to answer this, so far.)
In any event, Romanowski's doctor allegedly wrote the prescription for Mrs. Romanowski. (Never mind that she had as much use for diet pills as for a fondue fork.) According to newspaper reports, there was an understanding on everybody's part that Romanowski was the real patient. All appropriate information and cautions were supposedly provided and observed. The medical record was allegedly accurate.
Is it fraud?
Then, of course, Murphy's Law took effect. Somehow, the Board of Medical Examiners, the DEA, local police, and readers of USA Today became aware of this arrangement. The physician was disciplined. Romanowski and his wife were charged with various crimes.
It was the feeling of the authorities that writing — or obtaining — a prescription for a third party to administer to somebody else was an improper use of the pharmacy system.
Interestingly, the jury acquitted Bill and Julie Romanowski of felony drug charges. Their physician remains in trouble with the state Board of Medical Examiners.
Throughout these events, which received a fair amount of press coverage, no mention was made of the standard clinical indications for phentermine, which I guess were tangential to the legal case. Although I have qualms about the therapeutics, the more interesting issue for me is the question of the right to anonymous treatment.
Let's ignore the fact that Romanowski's doctor seemed to have been snookered into a bad judgment. Let's suspend any questions for a moment about using phentermine for the off-label indication of performance enhancer. I'd rather ask the broader questions: "Can a doctor ever use a pseudonym to preserve medical privacy without committing technical fraud?" And, "Is a third party's name the best available pseudonym?"
Is there any right to anonymous treatment, anyway? Under what conditions? For whom? Should I be able to walk into my local ER and ask for some Percocet in the name of "John Doe?" This goes beyond confidentiality, which is about the protection of identified records. Confidentiality is ordinarily fairly secure for folks who aren't celebrities, mainly due to disinterest on the part of the numerous individuals in the data stream.
Nevertheless, political candidates, entertainers, and other public figures are choice targets of the press and public curiosity, even when that curiosity is morbid or illegitimate. Never forget, the press is an arm of the entertainment industry. For popular figures, "confidentiality" may be impossible to provide using the standard defenses of our medical records systems.
But, I see all sorts of problems if we use "deception" as our next line of defense. Romanowski's case illustrates a few potential pitfalls. In other cases, I can imagine severe medical errors resulting from substituting identities in medical records in the name of protecting privacy ("OK, now it's your turn to use the ID bracelet.").
We debated something like this in the early days of AIDS, with anonymous HIV testing. Proponents argued that it would increase the number of people tested. Skeptics pointed out that anonymous testing contradicted the principles of public health, and potentially excluded people from necessary counseling and support.
As it turned out, anonymity was the only acceptable solution in many localities, and the counseling and support functions worked well in the network that developed in the male homosexual community that, initially, had been most affected. This example doesn't prove or disprove the value of anonymous testing for conditions like hypertension, however.
"Name?" "Mickey Mouse"
In another example, it's common practice in some hospitals that treat public personalities to use pseudonyms on admitting records and medical charts. This creates huge problems in domains like insurance, quality management, and telecommunications. And, what does the pathologist do when "Mickey Mouse" pops up with a melanoma?
Still, there's potentially a remedy lurking among these approaches. There are good reasons not to use somebody's real name as a substitute for the identity we want to conceal.
This doesn't mean we couldn't work out a more formal system akin to what many of us use daily, when we log on to our computers.
Perhaps a way to protect Romanowski's privacy, or that of anyone in public life, would have been for his doctor to employ a legitimate, registered "user name." Ideally, this would be a nonsense alphanumeric like, "Xyzabc123" linked to his record in the doctor's files.
The doctor, pharmacist, pathologist, and he could use this ID for all medical purposes, with no one but the original registrar knowing his true identity.
Unless his wife started calling him "Xyzabc123" in public, or he put it on his vanity license plates, no one would be the wiser. Insurance processors, pharmacy assistants, pharmaceutical statisticians, DEA agents, and newspaper reporters loitering in drug stores would have no way to identify the celebrity's medical transactions without going through several extra steps.
Why wouldn't this work for the rest of us, too? I like the receptionist at my dentist's office greeting me by my real name. Still, I might not miss that little intimacy, in exchange for her addressing me as, "YourMajesty007." America Online is way ahead of us here. Why can't my insurance ID card simply list me by my "medical user name" when I go in for my annual Rorschach test?
Granted, user names aren't unhackable, and constitute only a weak firewall in the face of a serious attack. For people with natural name recognition, however, risk of inadvertent disclosure could be significantly reduced by the use of cool "handles."
Michael S. Victoroff, M.D., is medical director of Aetna U.S. Healthcare of Colorado, and chairs the committee on medical informatics of the Colorado Medical Society. His opinions are not necessarily those of Aetna U.S. Healthcare, its management, or its employees.