Secrecy and confidentiality in the doctor-patient relationship : ethical knowledge and opinion of medical students

Given that the medical secrecy is a moral characteristic of medicine and basis of the doctor-patient relationship, and the physician’s ethical thought reflect their academic background, it was necessary to research the ethical knowledge of medical students at the University of Para State. The study is characterized by a questionnaire with situations where the student should judge situations in which confidentiality could be broken. It was also asked whether they had read the Code of Medical Ethics and the Hippocratic Oath. 207 medical students were interviewed, from 1st to 4th year of University of the State of Para. It was observed that 25 students showed high-knowledge about medical confidentiality, with 135 as regular-knowledge and 27 showed low-knowledge about the issue. The ethical orientation to medical students becomes extremely important seeking to have graduates capable of practicing and respecting the patient confidentiality.

Secrecy and confidentiality in the doctor-patient relationship: ethical knowledge and opinion of medical students Medical secrecy has always been a moral and mandatory characteristic of the medical profession and the basis of the doctor-patient relationship, which is centered on the needs and rights of citizens to privacy, becoming understood as confidentiality 1 .The duty to maintain medical confidentiality arises from the need of the patient trust unreservedly in the professional, with views that a satisfactory doctor-patient relationship can be established so that treatment proceeds in the best possible way, with the least chance of error and iatrogenies 2 .
The first reports of ethical principles inherent in the medical profession are attributed to Hippocrates four centuries before the Christian era 3 .The Hippocratic Oath is still nowadays a reference for medical conduct and contains fundamental ethics precepts to the practice of medicine, such as philanthropy, non-malfeasance, fairness and confidentiality 4,5 .Based on these concepts, the oath is not only for doctors, but mostly to society, a factor that supports the commitment to the current ethical principles 6 .
Unfortunately, it not enough for the human being to know what is right and wrong to adopt the best practice, it is necessary to establish limits and punishments in the professional regulation 7 .In this context, the Federal Council of Medicine drafted the Code of Medical Ethics (CEM), in which specific rules govern integral and fundamental individually the practice of medicine; relationships between physicians, between physicians and patients; and among medical and health institution or state 8 .Several documents reaffirm the importance of preserving these ethical principles: the CEM in Chapter IX, the federal constitution 9 , in its article 5 and the criminal 10 and civil 11 codes advocate medical confidentiality as a right for all patients, with a fundamental observation to guarantee the principle of autonomy, defined in the Hippocratic oath itself: everything that has to do or not with the practice of my profession, see or hear of the lives of men should not be disclosed and I will not disclose, respecting everything that should stay secretly 3 .
To respond to these imperatives, ethical and humanistic training of medical students has been fairly valued and questioned nowadays.However, teaching ethics in medical schools of Brazil is still also characterized by markedly deontological view, which is necessary, but it is not enough to meet the needs of professional training.The classical model of teaching ethics through the disciplines of forensic medicine and deontology has become insufficient to meet the essential humanistic education to the doctor, since they have lost the ability to respond to moral dilem-mas presented by advances in science, especially by new technologies applied to biomedicine 12 .
If the medical school, as a training institution, has the obligation to oversee the ethical training of their future physicians, it is important the inclusion of ethical and bioethical principles early in the course as well as its maintenance throughout graduation.This task should involve all teachers, not just teachers of medical ethics, because each one of them needs to work the specific content of their discipline in order to contemplate the perception and the discussions of the guidelines, principles and ethical principles relating to professional training.Only then a social attitude can be stressed and make the student aware of the ethical conduct of the profession 7 .
Therefore, the doctor, to practice his profession, shall in obedience to the ethical principles guiding its activity, and work by ensuring optimal performance of medicine and the prestige and good reputation of the profession 2 .Hence the importance of ethics concept since the early years and throughout the medical graduation, because knowledge solidified during training is essential to their future professional practice 1 .Considering the importance of these assumptions to the correct student training, this study aims to assess the knowledge and ethics opinions from medical students at the University of Pará State, based on the principle of medical confidentiality.

Method
The study is characterized as prospective and cross-sectional, which was applied to a sample of 207 medical students, from first to fourth grades of Uepa, from a total of 407 students regularly enrolled.From the 207 medical students interviewed, enrolled between 1st and 4th grades, 20 protocols were discarded due to improper filling (9.7%).Thus, the study had effectively with 187 protocols, which fulfillment has been proved as suitable.
In these 187 protocols that comprised the analytical underpinnings of the study, the following distribution was found: 48 (25.66%) for the first year students; 43 (22.99%) for the second year; 47 (25.13%) for the third year and 49 (26.20%) to 4th year.All students of 1st to 4th year of medical school, enrolled, of both sexes and of any age were included.In addition to the instruments which were wrongly completed, there were also excluded from the study students who have already attended another course of health area and those who Secrecy and confidentiality in the doctor-patient relationship: ethical knowledge and opinion of medical students agreed to participate or did not sign the Informed Consent.
In research protocol there were 12 options of everyday situations for which students should judge in which medical confidentiality could be broken.Only in two the development of medical confidentiality could be reached (Annex 1).It was also asked if they had read the CEM or had some knowledge of the Hippocratic Oath.In addition, we recorded the year in college they were enrolled, if they received guidance on medical confidentiality, if they commented cases experienced in the practices and their opinion on the subject.Importantly, in Uepa, the discipline of medical deontology and human rights is taught in the second year of medical school.
To evaluate the results we adopted the following criteria: academics who scored only two viable alternatives obtained a total recovery and were considered the group of proper knowledge; in turn, those who did not report any of the two correct alternatives were classified in the group with no knowledge about medical confidentiality; those who were in an intermediate situation, i.e., those who scored only one correct, one correct and one false or both correct and one or more false, were classified in the group of poor knowledge.
The research protocol was validated through a pilot test using 23 students of 5th and 6th year medical students -whose results were not used in the final findings of the study.The contingency test in C was used to compare the degree of knowledge with the other studied variables.It was adopted as a significance level p <0.05.

Results
The performance of students in completing the study protocol was represented by 25 (13.36%) of them classified in the group that dominates knowledge; 135 (72.19%) included in the group of poor knowledge and 27 (14.45%)without any correct answer, belonging to the group of ignorance of the subject.Table 1 shows the distribution of the degree of ethical knowledge related to year of college.It is noteworthy, however, was not observed any statistically significant result, with students from 1st to 4th year presented the same degree of knowledge about medical confidentiality.
It was found, however, a statistical difference between the degree of knowledge of the students who had read the CEM (p < 0.05) or the Hippocratic Oath (p < 0.05), which could allow us identifying those who read one of two presented more knowledge when compared to those who did not have access to such documents.
Evaluating the ethical attitude of students regarding medical confidentiality, 164 (87.7%) of respondents claimed to comment regarding the patients met in extra-curricular stages and disciplines of the faculty.Among these, 118 (71.95%) think their attitude of breach of doctor-patient confidentiality as ethically acceptable.When asked whether, during the consultations, some guidance regarding medical confidentiality had been passed, only 70 students (37.4%) reported receiving this kind of ethical guiding.

Discussion
The guarantee of confidentiality is one of the key points for the development of the doctor-patient relationship.This ethical principle is fundamental to ensure the veracity of the narrative and prevent facts are not hidden 13,14 .However, in some situations there is a need to breach that confidentiality, especially when the fact can cause damage or death to the patient -in such circumstances the patient must be previously informed, with justification, about the reasons for such attitude 15-17.The knowledge of the situations where confidentiality can be Secrecy and confidentiality in the doctor-patient relationship: ethical knowledge and opinion of medical students breached is of vital importance, and it must be built from the basic training of medical student.
Another key point for maintenance of the confidentiality of patient data refers to the limitation of people with access to patient records.In 1982, Siegler 14 reported that a patient underwent cholecystectomy had their data exposed to more than 100 health professionals and students, who held off unnecessary information to carry out their duties, thus promoting the breach of confidentiality 16,18 .
In relation to students, when they are not directly connected to the health-disease process of the patient, they should not be informed about his data 18,14,17   , such as, for example, students who attend wards with the purpose to learn signs and symptoms should not have personal information of patients.However, by participating directly in the health-disease process, always under the supervision of a supervisor, there is plausible justification to know patient's data, but the maintenance of confidentiality is an essential requirement to future professionals 18 .
In this study it could be shown that a large proportion of students from Uepa does not dominate the subject about medical confidentiality, as found in many other medical schools in the country 19 .The teaching of ethics in medical schools of Brazil is also markedly deontological and punctual 20,21 , and ethics need to be taught continuously since the basic subjects and during clinical disciplines, in order to ensure that the students can assimilate it.
It is estimated that more advanced students in the course are more educated in the point of view of medical confidentiality, since they attended a greater number of disciplines and had contact with a larger amount of patients, acquiring greater collection to medical training 22,23 -however, in this study there was no difference in the degree of knowledge in relation to the year of the course.Additionally, a distinction is made between two forms of ethics -which complement each other -in the formation of the individual: the moral ethics and spontaneous ethics 3,24 .The moral ethics concerns precepts acquired, exogenous information which is internalized in the individual from experiences lived, among which the course of medicine itself; on the other hand, the spontaneous ethics, appears as something natural, with no relation to the acquired knowledge.
In this study it was noticed that the year of graduation did not influence the knowledge of students.Thus, it is assumed that knowledge of them was based on a spontaneous ethics, not being influenced by the experience.So, one can assume that in the course of his practice there have been very few discussions about the importance of the doctor-patient confidentiality.This lesson can be fundamental in the fact that the majority of respondents believed to be ethically acceptable to comment on the cases experienced during the practical activities.
The breach of confidentiality on the part of healthcare students was verified by other studies [25][26][27][28] , in which one realizes that they have a higher tendency to disregard this principle in relation to professionals, with many reasons that collaborate to such reality, such as the impossibility of the students being punished by the advice bodies of their societies and believe to be correct to report friends cases experienced in the practices as a means to share the experience.
The curricular content has been not showing itself as decisive in the ethical knowledge dissemination process for students.One could also argue that, in order to students assimilate the ethical reflection on their professional practice, it is important to develop, together with the already consolidated disciplines, learning methodologies that emphasize the recognition, in practice, of ethically conflicting situations.In addition, it is essential that both types of content dissemination can be introduced earlier in the curriculum, gradually and well-distributed in the course graduation 29,30 .
The students who reported have read the CEM or the Hippocratic Oath had greater knowledge than the other students, according to the studies of Bittencourt 4 and Almeida 31 who have shown that the higher the frequency of CEM reading, the greater knowledge of ethical precepts, revealing that the knowledge about the specific rules that govern it, fully and separately, the practice of medicine gives greater authority and insight to future professional.CEM represents a moral code that serves as a behavior model to be followed by doctors, but it is not a model for medical already graduated professionals, which does not correspond to the reality of the students, even showing an important role in medical education 32,33 .An alternative to this elusiveness framework is based on the implementation of codes of ethics of medical students, which by presenting an educational character would also assist in the ethical training of undergraduates 33 .
The foundation of the ethical bases of traditional medicine was based on the Hippocratic Oath and in deontological and normative books of the field.In the oath, there was the commitment of the doctor to use the medicine for the benefit of patients; to keep the medical knowledge in secrecy, ex-Secrecy and confidentiality in the doctor-patient relationship: ethical knowledge and opinion of medical students cept for their peers; no sexual intercourse with patients and do not administer substances that could lead to death or cause damaging effects.For being an oath which emphasizes ethical conduct that the doctor should perform, it became, throughout history, an important parameter for physicians to assess their practices 34 .
The nature of ethical precepts contained in that oath is still current, serving as a point of reference also for the students better understand the medical profession.However, as well as the code of medical ethics, it shows no mechanism to limit misguided conduct of students, which indicates, again, the importance of a code of ethics of medical students, which should include the fundamental guidelines of both the Hippocratic oath and Code of medical ethics.

Final considerations
From the study described and analyzed in this work the fundamental importance of ethical, theoretical and practical guidance for the training of students throughout the course of medicine is assumed.It is believed that training based on humanistic and ethical values will largely contribute to fostering respect for the millennial principle of medical confidentiality, which is the primary foundation in a good doctor-patient relationship.When allowing and encouraging the future professionals since graduation to develop the sensitivity towards each other, it will also strengthen their ability to detect problems and detours to ethical conduct in order to practice their profession based on ethical and moral conduct applied for the good of their patients and society.

Table 1 .
Distribution of the degree of knowledge about the doctor-patient confidentiality, according to the year of the course