By Mark Komrad, MD
[Winter 2007; Vol. 33, No. 2; Pg 4, 10-11]
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 and seduced you. The patient feels your
pain, because it’s 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 on a beautiful day; you move out to the balcony together and
share food again. It
feels right. Next session, is another gorgeous day, and the park across the
street seems like an inviting therapeutic environment.
So you move the session outside.
It’s 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 and
know that it’s a hot day, so 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 as the patient trusts you more and more.
You're getting to material that 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.
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 that 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 frequently asked to give
lectures on topics in Medical Ethics, with a specific focus on ethical issues in
mental healthcare. The audiences are almost always composed of social workers
and psychologists; rarely, if ever, is there a psychiatrist present. Why
is this? It turns out that
both of these professions require not just continuing education credits
for members to renew
their licenses to practice, but specifically, three credits yearly in ethics.
In contrast to our fellow mental health professionals, psychiatrists are
not specifically required to take courses in any particular area, let alone
ethics.
I
want to argue that physicians in general and psychiatrists in particular, should
be required to take ethics training.
Historically, physicians have resisted the idea that medical ethics are
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 Healthcare
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 court 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. 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. Issues
such as the ethics of relating to managed care organizations, doctor/patient
boundaries, and patients refusing treatment are just examples of
where thinking is
rapidly evolving, 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 practitioners
away from the “softer” topics when considering how to get CME.
Moreover,
there are not many CME hours out there for ethical training of psychiatrists.
I recently had an opportunity to give an hour long lecture on a CME
closed-circuit TV and webcast program.
Though asked for more, the producers could not find underwriters for
additional ethics broadcasts. In contrast, underwriters (pharmaceutical
companies) were standing in line to sponsor programs on pharmacotherapy.
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.
These seminars help professionals to be more aware of
being on ethically controversial ground-- a basic awareness that 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 it is getting thin.
More
than other medical 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 others. My work on the MPS Peer
Review Committee demonstrates to me the kind of “judgment 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 may have strayed.
Therefore,
our specialty has a particular need for ethical education to cultivate a more
robust and effective ethical self-monitoring.
It
is time for us to join our colleagues, the social workers and psychologists, and
require 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)-- the malpractice attorneys call for it.