But how can I consent to what I haven't even read?

July 3, 2013 9:39 PM

Was my experience with a new medical office as egregiously wrong as I think it was? If so, how do I report what happened?

I had an intake appointment at a new doctor's office today, as a prelude for a later appointment with a prescribing doctor. The person conducting the interview asked me a bunch of questions as to why I was there, what my medical needs are, etc, and then handed over a ream of HIPAA paperwork for me to sign.

The HIPAA paperwork had paragraphs describing things to consent to as a patient on top, two check boxes saying 'I consent to x y z' and 'I do not consent' on the bottom, and lines below that to sign and date. As best I can remember, some of the information on the papers was related to HIPAA itself (e.g consent to share information with insurance companies and emergency contacts), some was more broadly related to general medical practice (e.g.the right to refuse medication), and some related to this clinic's specific policies for things like rescheduling appointments. Looking over the papers, I saw that the interviewer had gone ahead and pre-checked the 'I consent' box on every form.

I asked him, flat out, "what if I don't consent?" I told him that, while I personally consented to have my information shared for whatever purposes HIPAA allows and knew my rights regrading medication, I wasn't sure everyone necessarily would. He seemed to shrug me off; I couldn't entirely make sense of his response, but I'm pretty sure he told me he pre-checks those boxes for everyone to speed up the process.

I am not a lawyer and not a medical professional (yet), but this seems blatantly unethical. Am I right to be seeing red flags here? And if I am, who do I report this behavior to and how?

I should note now that I'm not sure if the person doing the interview was actually an MD/PA/nurse. His nametag had another title that I'm blanking on now, and I also, stupidly, forgot to take down his name. (Though I'd know it if I saw it written.)

Note: I was not impressed with this clinic for other reasons besides this, and will be getting my med consultation elsewhere.

posted by ActionPopulated to Health & Fitness (21 answers total)

Was there also a signature required at the bottom of each form?
posted by sparklemotion at 9:41 PM on July 3, 2013 [2 favorites]

It doesn't seem like that big a deal to me. If you didn't consent, they'd likely either send you home or discuss your concerns and then send you home. You're probably not getting past that point without consenting.

I'm guessing you're concerned on behalf of everyone who signs without reading? Those people also check boxes without reading.
posted by supercres at 9:47 PM on July 3, 2013 [9 favorites]

(I'm not a medical or legal professional either, but I do deal with lots of consent forms, including HIPAA. This seems functionally identical to a form that says "Your signature below indicates that you have read, understand, and agree to the above", as our research consent forms do.)
posted by supercres at 9:49 PM on July 3, 2013 [2 favorites]

I'm a medical professional. It doesn't seem unethical to me. He's not forcing anyone to sign the forms. If you don't consent, don't sign the consent form, is the usual protocol.

Most consent forms work this way, whether it's a checkbox indicating "I consent" or a form that just states "I consent." I'm actually not really sure why they'd make a form with an option not to consent, after all, it's a consent form. Rarely would someone not consent to having their insurance get copies of their records (required for billing), or getting medical treatment when they are in fact typically coming to that healthcare establishment for the purpose of treatment. Although they might be able to come up with some random workaround if you did not consent to part of the form, for the most part it's a formality to help them adhere to the law.
posted by treehorn+bunny at 9:56 PM on July 3, 2013 [2 favorites]

OK, here's the deal with these forms:

In the history of this clinic, no one except you has ever asked a question or even read the form. The person asking you to sign the form, maybe a nurse, maybe a medical assistant, probably has never read the form either. This is a thing that is experienced by 99% of the population and ALSO by a large percentage of the health sector employees who have to get signatures on them as a meaningless bureaucratic exercise, which, in fact, it in many ways, is.

In my younger days, I would occasionally cross out portions of the many weird fucked up consents I signed, and no one ever noticed - so you could go that route - but in terms of the staff person's way of dealing with this, the reality is, these consents are almost never treated as serious and important documents that you should engage meaningfully with.

In terms of ethics and the law, I mean, the person was not signing the forms for others, so perhaps it's legal. After all, the patient can cross out the check mark or whatever. And in reality, 99.9% of people will consent to the entire form.

Again, this person is basically focused on getting their job done quickly and easily.

This kind of way of interacting with a legal contract and with people's agency in their own health care is upsetting to me as well, but it is absolutely the norm.

I'm not saying this is right, I'm just saying it's normal.
posted by latkes at 10:02 PM on July 3, 2013 [9 favorites]

these consents are almost never treated as serious and important documents that you should engage meaningfully with.

I work in a medical type office (though not a typical doctors office) and deal with consent forms and this is categorically not true. Often these forms are important from a legal or medical standpoint or both. Patients are welcome to ask questions or not sign them, but if they don't consent they're welcome to go elsewhere. If we noticed someone crossing out sections of the consent form we wouldn't treat them.

Think of it like a contract that reads "by signing this document I agree to $X". You wouldn't ask "what if I don't agree to $X?!" You would understand that your recourse is to not sign he contract.
posted by no regrets, coyote at 10:19 PM on July 3, 2013

Well, I work in a hospital, and meaningful conversations around consent forms are rare and reserved for consents for high-risk procedures. Likewise, in my experiences receiving care for myself or my daughter in clinic settings, I have rarely experienced any kind of meaningful conversation about a medical consent form.
posted by latkes at 10:22 PM on July 3, 2013

1) If you don't consent you don't sign. If you don't consent to some things I'm sure they would get you a new form or tell you they can't treat you.

2) I assume this is poor form design, and that they check the boxes for you because perhaps they have had issues with people missing a checkbox and it causing problems with that patient. Therefore they probably just check the boxes ahead of time so you don't miss one. Really it's not different than when someone marks an X where you need to sign.
posted by Crystalinne at 10:22 PM on July 3, 2013 [2 favorites]

Yeah, I don't think they're considered unimportant. If your insurance fails to cover something and you're on the hook for it, this is the form they'll point to to prove it to you. Consent forms are probably exhibit A in a medical malpractice lawsuit.

The checkbox is pointless. It's probably pre-checked because 30% of people either check the wrong one or don't check one at all, making their signature meaningless. Checking the "no" box is also pointless; it's functionally the same as not signing at all.
posted by supercres at 10:25 PM on July 3, 2013

It's not that the forms are meaningless, it's that most people never read them. He was trying to save you time, and save everyone the trouble of a do over if you signed but didn't notice that you had to check the boxes.

It would have been unethical to sign for you. He didn't do that.
posted by alms at 10:56 PM on July 3, 2013 [1 favorite]

I don't like it. I wouldn't say it is unethical practice, but I do think the ethical thing would be to point out the boxes to make sure you know what you are signing. By acting like consent is unimportant or discussion of your relationship should be streamlined ... well, I personally don't like that attitude in my medical provider.

Some of the content of the form sounds important enough to make the time -- personal information, refusal of medication, what you will be charged if you are late etc. these things are important.

I'm not saying you should complain to any authority or not see this doctor, I agree with other people's points about how this kind of thing happens, but I thought I'd chime in and say this would give me a similar gut feeling.
posted by chapps at 1:01 AM on July 4, 2013 [1 favorite]

Was my experience with a new medical office as egregiously wrong as I think it was?
No. It wasn't. You are massively overreacting.
posted by ewiar at 3:43 AM on July 4, 2013 [11 favorites]

Checking the "no" box is also pointless; it's functionally the same as not signing at all.

I may be splitting hairs here, and have no actual experience of either law or medicine, but it's not entirely the same: If you check "no" and sign, the doctor now has proof that a form was given to you, a record of your non-consent, and a documented reason for sending you away.
posted by Dr Dracator at 4:39 AM on July 4, 2013 [3 favorites]

I've seen intake forms with real options recently, such as allowing them to reveal negative test results or appointments to whomever answers your home phone or leave them on your answering machine. You could check no on these and still be treated.
posted by Jahaza at 6:10 AM on July 4, 2013 [1 favorite]

The clinics I've been to have a "I have seen all the HIPPA rules" checkbox on the form but never show you the rules. They seem confused if you mention this. So, this is business as usual.
posted by RobotVoodooPower at 6:42 AM on July 4, 2013

I think the office were making an ethical mistake (though I agree this is a very common mistake, and I doubt any other clinic would not ask you to sign more or less the same paperwork). If not signing a form is important enough to the physician so that they will refuse to treat a patient over a lack of signature, then whoever is asking for the signature should give the patient the time and space to look over the forms, ask questions, and they should be able to explain the reasons for the form.

Ethically, obtaining consent is a process, not just a stroke of ink on a sheet of paper, and this process should not be abridged.

Often, when going to a doctor for the first time, you may be given a HIPAA "Privacy Practices" pamphlet that explains the rights of the patient and the obligations and rights of the health care provider with respect to sharing data. These rights are given by law-- by HIPAA specifically. You do not consent to them-- they already exist. The form that requires a signature is to inform you, and the signature acknowledges that you have received the pamphlet. If you do not sign that form, the provider can check a box that says "patient refused form" and sign themselves (like on this form), and continue on with what they planned to do. The purpose of the form is to provide a record that the health care provider is handing out these pamphlets, and nothing more. So in short, you really don't have a say about HIPAA provisions anyways.

There are other times when consent is required-- like consent to perform a medical procedure, and in those cases, refusing will result in not being treated.
posted by Maxwell_Smart at 6:51 AM on July 4, 2013 [3 favorites]

I think it's a bad idea, but not severe.
I saw a doctor in a practice affiliated with the largest hospital in my area. One form says "I've been given a copy of the privacy practices" so I asked for a copy. They dug it up for me, and it states that they have the right to use your story for marketing purposes. To block this, which I think is creepy and nasty, I had to call the something-or-other office at the hospital to be put on a list.
posted by theora55 at 6:52 AM on July 4, 2013 [1 favorite]

If you didn't consent, then you would make the appropriate correction on the forms, initial, and date. If you don't consent to something neccessary for them to provide you with care, they'd talk with you about it and you'd have the option to either change your mind or change your provider. They haven't done anything wrong here, unless they were bullying you into signing something you don't understand, or forging your signature or something.

So you're being a touch hypervigilant here. This is regular and fine.
posted by windykites at 8:03 AM on July 4, 2013

On a practical level, I've always thought those are akin to the lengthy User Agreement Notices that you have click through mindlessly to install a program. Who, aside from that one character on South Park, ever read through them?
posted by Pantalaimon at 8:45 AM on July 4, 2013 [1 favorite]

I have signed forms with check boxes. The interviewer always touched the paragraph in question and gave me a summary of it. Also, in most cases I was required not just to check the box, but to initial it. Your interviewer didn't seem to do his job very well.

This of course doesn't speak to the content of the forms you signed, but I'd guess that the consent you gave had less to do with your well-being than that of the the organization. I would be surprised to find out that you signed over your house and car to this place, but I confirm that I, too, would be nervous about giving someone permission to do something if I was not clear about what my consent allowed them to do.
posted by mule98J at 11:14 AM on July 4, 2013

It seems to me that whether it was unethical depends on what the forms actually said. For example, if it was agreement to the clinic's cancellation fee, it would be fine to have the box pre-checked, because if you don't agree to it, they could just refuse to see you. If it was a release of medical history to an emergency contact, it should be a real choice - some people might want that information released, some people might not want that information released.

And as a side note, don't think it's true that no one reads the forms, though I do agree that it's unusual. I'm a lawyer and I read almost everything that I sign, and most of the lawyers I know do the same. Recently, I was at the dentist and I didn't understand a poorly-written form so I had them explain it to me. I thought about refusing to sign it (because it was written so badly), but decided that it didn't really matter and wasn't worth the hassle.
posted by insectosaurus at 5:16 PM on July 4, 2013