A 46-year-old truck driver comes to the office due to fatigue. He has consumed energy drinks during the past 3 months to complete his driving routes. He sleeps most of the day on weekends and avoids his wife and kids. The patient says, "I even slept through my son's baseball game. I felt really bad about that." He has a history of chronic back and knee pain due to a motorcycle accident. The patient's medications include naproxen. He drinks a few beers with friends but has not socialized much lately. The patient's wife says that he is never there for her and they fight constantly. He has no history of manic symptoms or other psychiatric history. Physical examination and routine laboratory studies are unremarkable. Mental status examination shows depressed mood and sad affect. The patient says he has had thoughts of suicide but would never do anything because of his children. He is diagnosed with depression and started on sertraline. He returns for a 3-week follow-up, reporting little change. The patient says, "Some days I think I'm feeling a little better, but other days are really bad. I don't know about these pills. I've been taking them and don't have any side effects, but I still feel pretty bad."
Additional history shows that the patient was drinking 4 or 5 beers at the end of the day to help him fall asleep. He also obtained amphetamine/dextroamphetamine and some oxycodone pills from a friend and used these daily to manage his back pain and stay alert during his most recent road trip. The physician counsels the patient on the adverse effects of substance use and explains how alcohol, stimulants, and opiates may be contributing to his symptoms. The patient says he plans to take a medical leave of absence from work and abstain from alcohol, stimulants, and pain medications. He continues taking sertraline for his depression. At the patient's next follow-up a month later, he is doing well and not using any alcohol, stimulants, or opiates. His depression has improved, and he is attending Alcoholics Anonymous meetings. The physician receives a letter from the patient's employer asking when he can return to work and if there are any restrictions or safety concerns. The patient has signed a release of information.
Which of the following would be the most appropriate response to the employer?

Question

A 46-year-old truck driver comes to the office due to fatigue.  He has consumed energy drinks during the past 3 months to complete his driving routes.  He sleeps most of the day on weekends and avoids his wife and kids.  The patient says, "I even slept through my son's baseball game.  I felt really bad about that."  He has a history of chronic back and knee pain due to a motorcycle accident.  The patient's medications include naproxen.  He drinks a few beers with friends but has not socialized much lately.  The patient's wife says that he is never there for her and they fight constantly.  He has no history of manic symptoms or other psychiatric history.  Physical examination and routine laboratory studies are unremarkable.  Mental status examination shows depressed mood and sad affect.  The patient says he has had thoughts of suicide but would never do anything because of his children.  He is diagnosed with depression and started on sertraline.  He returns for a 3-week follow-up, reporting little change.  The patient says, "Some days I think I'm feeling a little better, but other days are really bad.  I don't know about these pills.  I've been taking them and don't have any side effects, but I still feel pretty bad."
Additional history shows that the patient was drinking 4 or 5 beers at the end of the day to help him fall asleep.  He also obtained amphetamine/dextroamphetamine and some oxycodone pills from a friend and used these daily to manage his back pain and stay alert during his most recent road trip.  The physician counsels the patient on the adverse effects of substance use and explains how alcohol, stimulants, and opiates may be contributing to his symptoms.  The patient says he plans to take a medical leave of absence from work and abstain from alcohol, stimulants, and pain medications.  He continues taking sertraline for his depression.  At the patient's next follow-up a month later, he is doing well and not using any alcohol, stimulants, or opiates.  His depression has improved, and he is attending Alcoholics Anonymous meetings.  The physician receives a letter from the patient's employer asking when he can return to work and if there are any restrictions or safety concerns.  The patient has signed a release of information.
Which of the following would be the most appropriate response to the employer?

Quizplus · Accepted Answer

Explanation: This patient has signed a release of information authorizing the physician to provide information to the employer. Although the physician must respond to the employer's request (Choice A), he also must adhere to a fundamental principle of the Health Insurance Portability and Accountability Act Privacy Rule that requires "minimum necessary" disclosure. This patient is currently doing well with no evidence of depression or substance use. Protecting confidentiality is important, and the physician should provide only the minimum information necessary to address the employer's questions about this patient's medical status and ability to return to work. (Choices B, D, and E) Disclosing (or suggesting) that the patient is being treated for depression or has ongoing issues with substance use or medication nonadherence is inappropriate. Employers are not entitled to receive non-employment-related medical information, and they do not need to know the employee's diagnosis, except in limited cases when public safety is in imminent danger. Commercial driver's licensing requires that employers follow alcohol and drug testing rules. Although random urine drug testing is indicated given this patient's job, it would not be appropriate for the physician to recommend it as it implies that the patient might be using. Educational objective: The Health Insurance Portability and Accountability Act (HIPAA) requires a patient to give the physician written authorization before protected health information can be disclosed to an employer. The HIPAA Privacy Rule limits disclosure to the "minimum necessary" information required to complete a request for information. References: HIPAA privacy rules and compliance with federal and state employment laws: the participant authorization form. (http://www.ncbi.nlm.nih.gov/pubmed/12645240)

A 46-Year-Old Truck Driver Comes to the Office Due to Fatigue