Tuesday, July 24, 2007

Guest Post: Dr. Mark Komrad on Ethics and Continuing Medical Education for the Psychiatrist

Did someone ask if we'd seen State of Mind, the latest greatest shrink show on Lifetime TV? So Annie is a psychiatrist, she's married to Eric who is also a psychiatrist, and they work together with a bunch of other shrinks in an old stately house which has been converted into The New Haven Psychiatric Associates. Annie is chatting with a colleague when oops, she suddenly realizes she's late to couples' therapy and she bursts into the session to find her shrink husband banging the shrink couples' therapist, and it's down hill from there. This show is trying oh so hard to be something, the high point being when Annie runs down Eric with her car. I'll spare you the plot line of the disturbed adopted Russian kid who runs away from his uptight American family to sleep at the foot of his child psychologist's bed. It doesn't help that the psychologist doesn't try very hard to dissuade anyone from thinking he's a pedophile. Have I told you how much I miss Dr. Melfi?

With that an introduction, we have a guest blogger joining us today. Dr. Mark Komrad of Sheppard Pratt Hospital joins us for a post and asked if we'd reprint a piece he wrote for the MPS newsletter. Without further ado:

Addressing the "Judgement Trance:" Why Ethics CME Should be Required
by Mark S. Komrad M.D.

You have 20 years of clinical experience under your belt. You feel that you know your strengths, weaknesses, and limits. You've come to believe that the therapeutic relationship is the key "medically active ingredient" in treatment. So, you start to think that it is the most important thing to develop, enhance and preserve in your work with patients. You are treating a new patient who believes that much can be learned from you; not just your knowledge but the way you live your life. You respond. You share stories about your life: your marriage, your struggles parenting your child, your experiences in college. The patient really resonates. This encourages you to start sharing more vulnerable stories--episodes that have much in common with the patient's experience. You find yourself sharing how a professor in college crossed some lines with you, got too close, actually seduced you. The patient feels your pain, because its similar. Next session, you get a gift form the patient. It's food. The patient invites you to share the food. You need no further reflection, after 20 years, than to check in with your own feelings. It feels right. Develop the relationship, don't allow the patient to feel rejection. You prepare your coffee table to share the repast. The next session, is a beautiful day, you move out to the balcony together and share food again. Feels right. Next session, another gorgeous day, and the park across the street seems like an inviting therapeutic environment. So you move the session out there, its like having a class outdoors on a beautiful day in college--no harm done.

The following session, you get up in the morning, see the weather is fine again, know that its a hot day, so that morning you dress in something more comfortable and casual for outdoors. It's slightly more revealing, but it feels comfortable, and that's important. Towards the end of that session, after eating, coffee feels right, so you and the patient swing by the cafe for a cup. The therapeutic relationship is deepening, the patient is trusting you more and more. You're getting to material than has never been reached before. You are feeling very effective, the sensation of a senior therapist, at ease in your complex art. You find yourself looking forward to these sessions. In fact, you start to make sure that there is nobody else scheduled immediately after this patient's hour, so you can linger a bit longer over coffee. It helps to move the session to the last one of the day. You are increasingly aware that you are treating a truly remarkable person, and feel fortunate for the serendipity of being matched up by referral and chance. Indeed, you feel that your years of experience permit you to try stretching, taking slight extensions of conventional technique--bending technical rules that are really designed more for beginners, to help structure their introductory years in the ill-defined and elusively broad art of therapy. Like training wheels, you sense there is a point where typical conventions are oversimplified and even unnecessary. This isn't something you can or even need to talk about with any colleague. They probably wouldn't understand. They have to be here, in this particular therapeutic relationship, to really get it. Only you can get it. It took 20 years, but you're really feeling you are starting to get it.

And so it goes: the slow procession of feelings, rationalizations, and instincts which propel you down a self-determined, well meaning, and increasingly self-deluded path. You drift further and further "off-the-reservation," a satisfying journey which, one day, ends in surprise, when you are being interviewed by the Maryland Board of Physicians about this case. Where did you go wrong? Did you ever know you had?

For the last few years, as Chairman of the Clinical Ethics Committee for Sheppard Pratt Health Systems, I have been called upon widely to give lectures on topics in Medical Ethics, with a specific focus on ethical issues in mental health care. The audiences are almost always social workers and psychologists; rarely, if ever, is there a psychiatrist in the audience. Why is this? It turns out that for some years, both of these professions have required not just continuing education credits to renew their licenses to practice, but specifically, 3 credits yearly in ethics. In contrast to our fellow mental health professionals, though we are required to have yearly credits to renew our licenses as physicians, there are no specific requirements for psychiatrists to take courses in any particular area, let alone ethics.

I want to argue that a requirement in ethics training for physicians in general, psychiatrists in particular, should be implemented, in parallel with the already established requirements of social workers and psychologists. Historically, physicians were long resistant to the idea of medical ethics as an important clinical discipline. There was a sense that it belonged as a course in philosophy departments or at special “think tanks” like the Hastings Center for Bioethics in New York, but not in hospitals, on rounds, or in grand rounds. However, that recalcitrance was gradually eroded, partly with the help of the Joint Commission on Accreditation of Health care Organizations (JCAHO) which, over the last decade, has started to require that hospitals have an Ethics Committee, which could be consulted by staff or patients. Even prior to this, the federal government instituted the requirement of an Institutional Review Board (IRB) to review any protocol for human experimentation for ethical soundness.

One need not look past the headlines to observe that we live in times of great ethical confusion and misbehavior in many professions. My own work with ethics consultations in health care systems and on the MPS Peer Review committee has revealed to me that there is indeed considerable ethical confusion and misadventure (both knowingly and unknowingly) among psychiatrists.

Systematic ways of thinking through moral conundrums do exist and have been developed in the formal field of Medical Ethics. These processes are not necessarily merely a matter of following one’s intuition. Indeed, I have seen “clinical intuition” lead many a psychiatrist astray in this domain. The ever increasing pressure to make decisions quickly, to spend less time with patients and less time in consultation with colleagues, have all combined to increase the chance of clinical behavior that is not just substandard, but frankly, unethical.

It turns out that considerable thought, writing, and discussion has been taking place in the field of Medical Ethics over the last few decades, which is keeping up with developments. Issues that have challenged ethical thinking are evolving. Such issues as the ethics of relating to managed care organizations, doctor/patient boundaries, and patients refusing treatment are just examples of issues about which thinking has been rapidly evolving in systematic ethical analysis. Critical thinking about these areas is advancing, much as neuroscience and pharmacology are advancing. Yet there is little opportunity to avail oneself of training in these matters. Indeed, the demands of more concrete and procedural knowledge, such as psychopharmacology, can be seductive and can lead one away from the “softer” topics when considering how to spend precious CME hours.

Moreover, there are not many CME hours out there for ethical training of psychiatrists. I recently had an opportunity to give an hour lecture on a CME closed-circuit TV and webcast program. Though asked for more, it was impossible for the producers to find underwriters for more ethics broadcasts. In contrast, underwriters (read: pharmaceutical companies) were standing in line to sponsor programs on treatments of illnesses with pharmacotherapy.

The fact is that mandating continuing education in ethics for social work and psychology produced a market for such courses, and suddenly, they were commonly available. In my experience, they are eagerly attended, not simply because they are mandated. Attendees seem to find this training of immediate value to common practice conundrums. These seminars actually help to raise basic awareness of when one is actually on ethically controversial ground-- a basic awareness that, though fundamental, is often lacking. It is one thing to know how to skate on thin ice; it is another thing entirely to learn how to recognize that the ice is getting thin.

More than any other kinds of healing professionals, therapists and psychiatrists are often soloists. What we do is, by necessity, very private. Typically, we are utterly alone with our patients. This makes us vulnerable to creating a hermetically sealed zone in which our clinical judgment is deployed, without being readily accessible to feedback from other authoritative colleagues or sources. My work on the MPS Peer Review Committee demonstrates to me the kind of “judgement trance” that can be fostered, in which progressive rationalizations can lead to a subtle, gradual drift away from standard ethical practice. Unfortunately, it is often left to the patient or family member to ring the alarm bell, signaling that the psychiatrist is “off-the-reservation.” One need only read the report of sanctions by the Maryland Board of Physicians to see that psychiatrists are overly-represented in that roll call of dishonor.

I submit that this is not surprising, considering the nature of our work. That means that our specialty has a particular need for ethical education to cultivate a more robust and effective ethical self-monitoring.

This is the reason that I think it is time for us to join the good sense of our colleagues, the social workers and psychologists, and require of ourselves mandatory continuing education in one particular area -- ethics. The zeitgeist of our increasingly ethically confused society calls for it, the virtue of humility in the face of a complex clinical art calls for it, and last (and least)-- our malpractice attorneys call for it.


Rach said...

So glad you guys shared this piece of work - as a patient, I'm very surprised that continuing education in the area of bio/medical ethics is not required. I definitely agree that generally, therapy is a private enterprise to a point that the practitioner will not know they are on a slippery slope until they are too far gone. In my area too, many of the wrist-slaps/license suspensions for psychiatrists are for these type of boundary crossings that could be prevented if physicians were more consistently aware (from being more consistently educated?) and conscious of boundary crossing behaviour.

I've been blessed with practitioners with solid boundaries. Hopefully others who read this board will be equally blessed.

Sarebear said...

Great post, and I agree.

My word verify is drhfpfl

Do you know any Dr. hfpfl? I keep thinking HufflePuff, with all the Harry Potter goings-on . . .

DrivingMissMolly said...

Very impressive post. Thank you for it.

I know there are patients that push the boundaries, yet they want to be reassured they're there, they don't *really* want them crossed. We test.

After seeing so many psychiatrists and therapists I know what feels *right* and *normal.*

Sure, I would love to talk to you all day, but I can't, so don't keep me over time too long or too often.

Sure, I want to hug you so hard that you gasp, but I walk on past you on the way out because I don't think that would be a good thing, even though I feel I'm seven more that thirty-seven. The same goes for my desire to sit on your lap and get you to tell me a story. Or to get you to dress up like a giant teddy bear and play with me. These are my secrets.

Although I am quite lonely, don't touch me. Not even a pat on the back. I hate it but just haven't worked up the courage to tell you, even after three years.

I liked talking about you remodeling your house, but we need to get back down to my business.

Don't tell me I'm being seductive on my first visit to see you. You don't even know me and I dressed up for *work* not for you. I think that statement was more about YOU than about me. You creeped me out but I blamed MYSELF and returned a couple more times before I fled for good.

I know you are a resident and think I'm interesting and I called you during a suicidal crisis, but don't take *too* much interest. You can't talk to me on the phone that long. No one's ever done it before and it feels weird. I like the attention. I'm afraid I will exploit you.

A Bad Patient

a psychiatrist who learned from veterans said...

Speaking of reprints from the Sheppard Pratt Hospital newsletter, could you repeat what you had on JCHO requirements for quantfication in your, Sheppard Pratt Hospital, oupatient treatment plans from some years ago. Sorry for being off topic though a moot court debating such requirements as unethical might be interesting.

Roy said...

drivingmissmolly- What a great letter! Thank you. This should be included in every psych resident's reading list.

FooFoo5 said...

We should all have such guests! It is sad, however, that it has to be written.

I will always remember the weekly "case presentations" depicted in Yalom's When Nietzsche Wept, initiated by physicians themselves to "problem solve," but I suspect to also see cases with "fresh eyes." Openness to critique is an act of courage that benefits the clinician & the patient.

And as I recall, Melfi herself had a supervisor.

Anonymous said...

DMM - I really like what you wrote there. I've been thinking a lot about it since you wrote it. While I might not put it in the same words that you do, I note some underlying themes and similarities - words and wishes and wants may change depending on the person. But what I want more than anything else is a "safe" place. I don't ask questions because I feel like if I ask a question that my psychiatrist won't answer, then I have crossed some boundary. And I must put up boundaries myself... He's always saying that I can ask him anything I want - and that it would be beneficial because we could then look at why I asked that particular question and what other meaning it might have. He says he would only ever answer a question if he felt it had some therapeutic benefit to me. Well, I rarely ever ask him questions because if he doesn't answer, then I feel as though I shouldn't have asked it. As much as I would like to be able to talk to him at any time or for him to be my friend - I don't really want that - what I want are boundaries, safeness, clarity as opposed to ambiguity and vagueness.

I don't test boundaries really. And this is because I don't want my worst fear to come true - that boundaries in this safe place will budge. Even though I know logically that they won't, there is still a part of me that fears that if I test the boundaries, then they won't be as firm and solid as they are when I enforce them myself by staying far far away from anything that I may perceive as a boundary.

The fact of the matter is that it is an inherently tragic relationship. (Terminology based somewhat on Lott's "In Session".) To have someone know you on such an intimate level while you really know nothing about them. To still be on the other side of the line. To wonder all kinds of things about who this person really is, but to never be able to find out. And that the relationship is destined to end at some point - just when you're feeling well enough to have a healthy relationship, it will end. This makes it difficult, and almost tragic. What we really want out of the relationship - someone to understand us completely and listen to us fully - we can never have completely, because who really wants a relationship that is so one-sided? But in reality, while I may think or even say that I wish it was not so one-sided, I don't really want it to be two-sided. But that's for him to protect.... It is his job to make sure that it stays one-sided and safe and that the boundaries remain in place. I take a lot of boundary-providing on myself because there is this part of me that fears if I don't throw up boundaries, then they might not really exist. I can tell myself logically that of course they exist - but my history tells me that people who are supposed to keep boundaries and make things safe don't always do so. I'm not talking about psychiatrists breaking boundaries - but I'm talking about other people in my life breaking boundaries in some way....and that has made me even more guarded about making sure boundaries are in place, even though it's not really my job to ensure that...

I'm still fascinated by the whole realm of psychotherapy and the dynamics at play.

Take care,
Carrie :)

FooFoo5 said...

A day later and I am underwhelmed by the lack of commentary regarding psychiatrists being responsible and pro-active in the examination of themselves - "degrandizing," if you will - and their sensitive interactions with patients, as Roy put it, "in real life." "Back patting" this is not; scrutiny speaks to what I (and most of us) believe is essential to proper clinical practice.

In a teaching environment, I have never gotten comfortable with being video/audio-taped, or 2-way mirrored, or with a "open-door policy" for supervisors to enter a session unannounced to "observe." I am always embarrassed when I am critiqued - and video never lies - but I have never been harmed. Listen when it hurts. Learn & move on.

I am disappointed that this wonderful post has not elicited more instructive, constructive, & inspiring commentary like DMM.

Anonymous said...

Well Foo Foo,

For all of that commnetary you wish to see to be written, it would seem logical that psychiatrists would first need to own the fact that they really do hold the balance of power. (Not holding any breath here.)

FooFoo5 said...

I envisioned this multi-post issue(s) beginning with Roy "Boudini" Shrinkrap holding up Dinah in the ring, fists raised over her head, shouting, "I shook up the world!" (with all due respect to The Greatest). Agree or not with the premise as you will, but I applaud Dinah's forthrightness. Throwing the gauntlet down in front of me, anonymously yet, on Shrinkrap strikes me as quite impolite.

Should you wish to exhale, stop by my blog and discover that I am, in no uncertain terms, as powerless a physician as you will come across. I consider myself a well-trained and experienced caregiver who frequently feels downright helpless and overwhelmed by patients who fail 3 times as often as they "succeed," despite my best efforts. I pray for the apparent cockiness you believe to be the balance of power. You bark at a cat, my friend.

Now if you want to debate the psychodynamics of the "balance of power," speak with my oncologist. "How high, sir?"

Your Mother said...

I think it's interesting how the importance of boundaries described here is not unlike the boundaries parents set with their children. (I was just posting about this on my own blog.)

I don't mean to stir up anything. I just noticed the similarities.

Sarebear said...

I have some things to say on this, but I'm letting the matter perambulate around my mind, soak and coalesce, marinate and steep.

If that's not a sentence with clashing adverbs/adjectives, I don't know what its. I had trouble pulling up words, and common words, to express that.


Also, driving miss molly has a superb comment; that gave me further to add to the mix, too.

DrivingMissMolly said...

Thanks, all, for your positive responses to my comment. I have continued to let this issue "marinate" in my brain and realized that I had more to add.

At first I was put off by "anonymous'" comment, but he/she is correct. The power of the doc over the patient has to be acknowledged, as is implicit in Foo Foo's use of the word "de-grandizing."

I believe that there are plenty of doctors across most specialties who break boundaries with patients. I believe that most are between two people that are consenting and whole psychologically and therefore we don't hear about those.

About 10 years ago, my mother-in-law showed me the latest copy of the small town newspaper which featured a small blurb on the *front page* about the sanctioning of my primary care physician for "improper conduct with a patient."

These were my thoughts, in order;

1) Crap! I guess I need to find a new doctor.

2) Why is this on the front page? This is a small town newspaper, not the 'Enquirer!"

3) Wait. Who says I need to find a new doc. Wait and see.

The story is that he had a relationship with a patient without "properly terminating the doctor-patient relationship."

OK. So, why did she wait so many years to report it? Hmmmmmmm. It smelled to me of spurned lover's revenge. He had to take ethics classes and see a psychiatrist. There were other things put in place to "safeguard" his patients for a year or so, pretty basic stuff like having a nurse always present...

I believe that the reason psychiatrists don't "do" ethics classes, besides the fact that they are not a requirement, is that they, like the therapist in the guest column, don't think they need it. Indeed, I expect that docs take ethics courses as part of their medical training. I work at a law school and students have ethics requirements such as a special class and special test they must take before they can practice law.

You are gods. Yes. Although I believe that newer generations are not as awed by docs, I am. I know I am smart and that I can hold my own when it comes to asking questions and making requests, there is still a strong wonder factor. Of course, it is deplorable for a physician to take advantage of any patient, but there are those populations that are more/seem more vulnerable. Children and the mentally ill. Geriatric patients.

I think that just about everyone has heard the saying that "Ginger Rodgers had to do everything Fred Astaire did, only backwards and in high heels," right?

So it is with social workers and psychologists. They have to be super good. They have to be better. Why? Could it be that they know that psychiatrists and the AMA are waiting in the wings for a chance to say that those therapists are inferior to psychiatrist therapists? I'm just guessing.

Roy: I hope you know that each vignette was about a different doc.

Foo Foo: I can't believe you are complaining about the lack of comments. You were gone FOREVER. I finally gave up checking your page only like 2 months ago.

Carrie: It's weird but I sit as far away from my psychiatrist as I can. I cluch the end of the ugliest green couch you've ever seen. Am I afraid of him or am I afraid of *me*? I did not even look at him at last Tuesday's appointment.

My space got invaded a lot as a kid. Parent in my face yelling. Slapped in the face. No privacy.

Yesterday I got soaked in the rain right before seeing the therapist. I was glad my shirt was thick, but still, a tank. My hair was also soaked. His shirt looked so warm and soft that I wanted to grab it. As I left, whereas he usually pats my back on the way out, he touched my bare arm. I think I'm OK with it.

My biggest fear is that someone (therapist/psychiatrist) will accuse me of being seductive again.
I really am such a good girl. A good Catholic girl. No men in my life except my ex-husband.

I still want to jump in my psychiatrist's lap. I just want him to say that I am not bad. To hold me and rock me.

The consistent older shrink/younger patient dyad doesn't help matters if you have daddy issues.

I'm considering ECT.

(good girl/bad patient)

NeoNurseChic said...

No new posts for a week here!! Are you guys on a hiatus? I keep checking back!! Maybe you said you were going on a hiatus, and I missed it somehow...!

Missing your posts and great discussion!!

Carrie :)

Anonymous said...

Wow - it's like you've described the relationship I had with a therapist 10 years ago - walks in the park, homemade meals, presents, late-night phone calls, hugs and hand-holding. Some sessions were paid - some were not. By the end, I was so confused I could barely think straight. When I ended the relationship, it felt like a break-up and when, years later, I requested my records - she refused and told me I was probably borderline.