Professionalism & Ethics in Psychiatry

1. Professionalism & Ethics in Psychiatry Kriska Shalin L. Joaquin MD 08-0053

2. Sample Scenario 1 • A first-year medical student is looking for a patient to interview as part of the course “Introduction to the Patient.” • While looking through charts for a suitable person on a medical inpatient unit, she discovers that one of her classmates has been hospitalized overnight. She is deeply concerned about her fellow classmate and wants to provide emotional support.

3. Which of the following is the best course of action for this student? • A. Approach the classmate-patient directly to give emotional support. • B. Ask a unit staff person what the medical issue is before approaching the classmate-patient to give emotional support. • C. Thumb through the chart to see what the medical issue is before approaching the classmate-patient to give emotional support.

4. D. Send a card to the classmate-patient, but do not look at the chart or speak with staff. • E. Do not look at the chart, speak with staff, or approach the classmate-patient in any way.

5. Sampe Scenario 2 • An unmarried male psychiatry resident has been treating an unmarried female patient for 18 months in psychodynamic psychotherapy. The resident finds himself increasingly sexually attracted to the patient.

6. In the final session of the therapy, he mentions his desire to the patient. She states that she is also attracted to him. The resident suggests that they wait 6 months after the termination of psychotherapy and then meet to consider starting a relationship.

7. Which of the following is true about this situation? A. Because of the decision to delay a personal relationship for 6 months after the termination of therapy, the ethical issue of a boundary violation does not exist.

8. B. Because the resident waited until the final session to discuss his attraction with the patient, the resident’s revelation is not a serious ethical lapse.

9. C. Because the attraction is mutual, it is not unethical for the resident to pursue a relationship with his former patient.

10. D. If the resident does not bill the patient for the planned meeting 6 months after the termination of the psychotherapy, this meeting will be ethically acceptable.

11. E. This scenario describes an unacceptable boundary violation.

12. Virtues that justify an absolute prohibition of doctor–patient sexual relationships: • Self-effacement making oneself inconspicuous and is a virtue related to humility and modesty. • Self-sacrifice the habit of taking reasonable risks to one’s self-interest.

13. REAL CASE: R.V. 27/F Present the case Identify the possible pitfalls in professionalism and ethics

14. Case of R.V. • R.V. 27/F , Filipino, single, Catholic, from Acropolis Subdivision, Quezon City. • She brought to the ER because of “changes in behavior, she was extremely talkative”.

15. 5 years PTC, patient started working for her stepfather’s appliance company. At that time she started feeling the pressure, being the child of the owner. She would work long hours and deprive herself of sleep. • 3 years PTC, patient’s stepfather died, and she inherited the company. She was very stressed “not knowing what she got herself into and would just sleep”.

16. In the course of 3 years, RV, entered MBA but decided not to finish her STRAMA because it was about her company. • She sold 80% of the company, still earning from profit-sharing. She would travel, buy expensive bags on impulse and few months prior, enrolled herself in a short course on EVENTS MANAGEMENT in New York. • She decided to go back to the Philippines and organize a huge event for her mother’s art.

17. She has been taking Bangkok pills for the past 5 weeks and without regular meals. For the last 3 days and nights, she has been spending most of her time in her mother’s room, “hyper and excited” for an upcoming Art gallery event for her mom. She would talk non-stop, revealing to her mother that she has been on Bangkok pills.

18. Work-up in the ER revealed she had decreased Serum Na and K. Toxicologist advised admission and referral to the psych department. Patient was then advised admission in the psych ward. Patient and mother refused. Mother wanted a room in the medical floors, however not possible at that time due to reasons unknown to the mother. She was discharged after hydration, given anxiolytics and given proper advice on what to watch out for.

19. The next day she was brought to the ER again, then described as euphoric, with (+) psychosis, overabundance of ideas, perseverance, and derailment. • Toxicology was done. • Still with decreased Serum Na and K.

20. She was then admitted to the medical floor and referred to Psychiatry. • Anxiolytics and appropriate IV fluids were given. • Potassium was supplemented.

21. Working impression were as follows: • T/C Substance-induced psychosis secondary to Bangkok pills • T/C Bipolar I Disorder • Hypokalemia secondary to Bangkok pills

22. CHECK POINT Were there any breeches or pitfalls? What? Why?

23. Now confined on the 4th floor, the patient was visited by IM residents, rotating intern and clerk. • After answering1 question adequately, RV ignored the doctors and continued talking to her mother and best friend (present in the room) about “the key of life” • After a while, the doctors met the mother and best friend (both in tears) outside the room.

24. When asked about the patient’s condition, the resident replied: • “ I do not think this is a case of dehydration because of the Bangkok pills. If it were just because of the pills, she would not have energy. She does not seem dehydrated right now”

25. CHECKPOINT

26. Incidentally, Clerk KJ, a family friend, was about to rotate under Psychiatry during her confinement. KJ’s sister is RV’s best friend. • The sister now requested KJ to look at patient’s charts, talk to the doctors and try to “check up” on the patient.

27. With KJ’s concern for the patient, and enthusiasm to learn as a medical student, KJ looked at her charts, with permission from the resident. • And visited RV, with permission from the mother. • During her visit the patient told KJ that she “went crazy for a while, but now [she’s] happy because [her] life is perfect”. “But [she] can’t be too happy because they will think [she’s] crazy”.

28. The patient convinced KJ to tell the residents that she’s generally a happy talkative person and that they should discharge her for the event later that week. • KJ, in passing, told the resident and intern that “the patient asked me to tell you that she’s really a happy and talkative person and she’s concerned about her event on Thursday”.

29. The resident explained possible options that the AP was entertaining and that it was the AP who would give necessary instructions.

30. CHECKPOINT

31. Ethics in Psychiatry • BENEFICIENCE • Good of the patient • NON-MALEFICIENCE • First do no harm • PATIENT’S AUTONOMY • INFORMED CONSENT • Information, Decisional Capacity and Volunteerism

32. The Centrality of Ethics in the Care ofPeople With Mental Illness

33. Six essential skills 1 The ability to identify the ethical features of a patient’s care 2 The ability to see how the clinician’s own life experience, attitudes, and knowledge may influence the care of the patient 3 The ability to identify one’s areas of clinical expertise (i.e., scope of clinical competence) and to work within these boundaries

34. 4 The ability to anticipate ethically risky or problematic situations 5 The ability to gather additional information and to seek consultation and additional expertise in order to clarify and, ideally, to resolve the conflict 6 The ability to build additional ethical safeguards into the patient care situation

35. Specific issues • BOUNDARY VIOLATIONS • BOUNDARY CROSSINGS • PATIENT NON-ABANDONMENT • Is transferring to another psychiatrist an abandonment? • INFORMED CONSENT AND TREATMENT REFUSAL • CONFIDENTIALITY • OVERLAPPING ROLES, DUAL AGENCY, CONFLICT OF INTERESTS • MISTREATMENT

36. Key ethical challenges in special circumstances • ACADEMIC PSYCHIATRY • ADDICTION PSYCHIATRY • CHILD AND ADOLESCENT PSYCHIATRY • FORENSIC PSYCHIATRY • GERIATRIC PSYCHIATRY • PSYCHOTHERAPY AND PSYCHOANALYSIS • TREATMENT OF DIFFICULT PATIENTS

37. PRINCIPLES OF MEDICAL ETHICS Section 1 A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.

38. Section 2 A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.

39. Section 4.2 A psychiatrist may release confidential information only with the authorization of the patient or under proper legal compulsion.

40. Section 4.14 Sexual involvement between a faculty member or supervisor and a trainee or student, in those situations in which an abuse of power can occur, often takes advantages of inequalities in the working relationship and may be unethical because (a) any treatment of a patient being supervised may be deleteriously affected; (b) it may damage the trust relationship between teacher and student; and (c) teachers are important professional role models for their trainees and affect their trainees’ future professional behavior.

41. Section 7.3 On occasion, psychiatrists are asked for an opinion about an individual who is in the light of public attention, or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his/her expertise about psychiatric issues in general. • However, it is unethical for a psychiatrist to offer a professional opinion unless he/she has conducted an examination and been granted proper authorization for such a statement.

42. PROFESSIONALISM • Interpersonal professionalism • Relationships and interactions with patients and colleagues • Shared decision making • Compassion • Honesty • Appropriate use of power • Sensitivity to diverse populations

43. Public professionalism • Fulfilling the expectations society has for medical professionals • Adherence to ethical codes • Technical competency • Enhancing the welfare of the community

44. Intrapersonal professionalism • Maintenance of the ability to function as a medical professional • Self-awareness • Knowledge of one’s limits • Lifelong learning • Self-care

45. SOURCES Roberts and Hoop (2008) Professionalism and Ethics: Q&A and Self-study guide. American Psychiatric Publishing Inc Lecture notes from “Ethics in the Practice of Psychiatry” given by Dr. Lovie Hope Go-Chu, March 15, 2010 at the ASMPH