Saturday, May 12, 2012

Board Certification Patient Feedback May Be Unethical

According to the APA Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry Section 1.1:

 “A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient.”

From an APA Ethics Opinion: Section 2-RR:

“Their consent, while ‘freely’ given, is likely to be heavily influenced by their transference feelings, the need to please you… suggests an exploitation of your patients for your personal gain that outweighs the potential benefit...”

And yet the American Board of Psychiatry and Neurology (ABPN) has apparently implemented plans to require psychiatrists who want to maintain board certification status to not only solicit evaluation by other health care providers, but also from their own patients. According to ABPN policy the patient would complete a feedback questionnaire and give it to the psychiatrist who would keep it on file. As I understand it, based on feedback from both other providers and patients, the psychiatrist would look for opportunities for improvement, plan and carry out steps to improve their practice, then measure improvement over time with follow up questionnaires. ABPN would conduct audits of selected psychiatrists to confirm compliance.

One can easily imagine problems with such an approach. Psychiatrists might agree to provide glowing reports to other psychiatrist who agreed to reciprocate. Patients might suggest that an increase in dose of Xanax or a few prescriptions of OxyContin might lead to a more favorable evaluation. At best such data would seem unreliable.

Even the patient who would never think of submitting a dishonest assessment of the psychiatrist might fear the consequences of submitting a critical report. As stated in the ethics excerpts above a physician should never put the patient in the position of having to make such a choice which could hardly be made freely.

Unless I am missing something here I would suggest that patients consider refusing to complete such assessments and even consider filing ethics complaints against physicians who asked them to do so. Let us see to what extent organized psychiatry will sacrifice ethical principles to create an illusion of superior ability has represented by a framed piece of paper hung on the wall.

Better yet I hope psychiatrists will refuse to participate.


  1. It is worse. In other speciaties, physicians are then also REQUIRED TO IMPROVE patient care-i.e. IM docs to reduce the average HbAC1 to some "better' Average. This entails an experiment done for private "gain" (recertification) without informed consent or consideration of cost or side effects (i.e. drove off the road in a hypoglycemic stupor). There are so many reasons this recertification industry scam is wrong and it will probably take a federaql intervention or lawsuit to rectify.
    kmpnpm MD

  2. Oh, come now. Neither we nor our patients are such delicate flowers that we can't stand to look in the mirror. You can give the feedback form to any five or more patients and get the results back anonymously. Twenty-four months later after improving your practice in whatever way you see fit, you give the form to any other five or more patients (or the same ones, it doesn't matter) and get the results back anonymously. You can even choose which patients you give the forms to.

    Highly reliable? Hardly. Unethical? Not in a million years. In fact, it's likely to lead to some good discussions with your patients about what they really think about you, something all of us should hear once in a while.

    It's like the CME credits you have to get. You can choose to get them in topics that will improve your knowledge of psychiatry, or you can choose to get them in topics you have little use for but are easy to find at conferences held in warm and sunny climates. Your choice.

    This is really a very easy requirement to meet. If you choose to treat it as a nuisance, you can do that, and learn nothing. If you choose to treat it as a chance to learn more about yourself and how to improve your practice, well, you can do that, too.

    So, if you don't want to do these things, feel free to gripe, or even refuse to do them and give up your Board certification. But don't claim it's because you're concerned about your patients. They'll be just fine.

  3. I don't like that at all. I'm all for improving the system, and I like my psychiatrist, but I wouldn't give him a report I felt would change or affect our working relationship. I'd be willing to submit a survey anonymously to a third party, but giving it to him and him keeping it is a risk for me. It's hard enough just to tell him what's wrong with his behavior.