Thursday, August 23, 2012

A New Kind of Abandonment

This third in my series of critiques of the Washington State Department of Health Medical Quality Assurance Commission (MQAC) focuses on the February 9, 2012 Stipulated Findings of Fact, Conclusions of Law and Agreed Order concerning physician Ronald Schubert, M.D. (Respondent).

I extracted the following from the complete Order:

"Over an extended time frame between January 2001 and September 2008... Respondent engaged Patient A in personal e-mails, kissing, dating, phone sex, watching X-rated media, and repeated sexual contacts and intercourse. These activities occurred at Respondent's clinical office, at their respective residences, and at other locations."

The Respondent agrees to take an ethics course in addition to other stipulations, including:

"Respondent's practice is restricted to the treatment of adult male patients."

"(a) Respondent will not have social contact with patients... (b) Respondent will see patients only during normal business hours. (c) Respondent will not treat individuals with whom he has had a social relationship... (d) Respondent will not accept gifts from patients. (e) Respondent will not engage in talk of a sexual nature with patients, except as necessary in the treatment of that patient. (f) Respond will not disclose personal information about himself to patientsg... (g) Respondent will I make house calls... (h) Respondent will not communicate with patients via text messaging, instant messaging or e-mail."

In item (h) the board would seem to see a technological solution to the boundary problem here. This naïve tendency to blame text messaging, instant messaging and e-mail raises questions about the extent to which MQAC members may be out of touch themselves with the realities of communication in 2012. Why for example do they implicitly allow the Respondent to continue use telephone to communicate with patients? Do they not realize that text messaging, instant messaging, and e-mail may create permanent records that might allow for tracking of continued boundary violations? According to the Order the respondent and his patient engaged in "phone sex." Does MQAC not appreciate that telephone contact usually does not create a permanent record and arguably allows for considerably more intimacy than do the prohibited textbased modalities? The Board seems blissfully ignorant of videoconferencing (eg, Skype).

I would argue that the Board should promote rather than prohibit use of textbased modalities to communicate with patients, and even consider adding a requirement that the Respondent maintain permanent copies of all such communications.

"Respondent will enter into psychotherapy with a Certified Sex Offender Treatment Provider therapist approved by the Commission or its designee.... Respondent will see the therapist at least once every two weeks for a period of one year. After this one-year period, the therapist shall determine the frequency of Respondent's therapy... therapist shall inform the Commission of Respondents progress... to protect the public... Respondent may terminate therapy only with prior written approval..."

This stipulation raises questions about the Board's understanding of psychotherapy, about the treatment, and about the ethics of providing that treatment. I will not attempt here to exhaustively analyze the entire subject of "treating" sex offenders. I believe this topic has been and probably continues to be discussed exhaustively elsewhere. The language used in this Order betrays a few of the inherent problems however. The Order speaks of "entering into" psychotherapy without specifying the target of treatment. Will the "patient" be deemed cured when he stops sexual involvement with his patients? Treatment usually implies illness, but no diagnosis appears in the order.

I suspect that no treatment will take place, but rather a "certified" professional will accept remuneration for meeting with (or "seeing" as the Order indicates) the Respondent and monitoring his attitudes for the period required while regularly trumping up reports to the Board in the hope of generating more referrals in the future. I believe this charade will accomplish nothing other than to line the pockets of a psychotherapist whose own participation in this endeavor may be unethical on its face by virtue of the inherent role conflict, while the "patient" learns how to present himself to the "therapist.' The duty of the psychotherapist here would appear to be not to the "patient" but to the Board. I believe this so-called psychotherapy differs little from that which would pretend to change one's sexual orientation, a practice which has been prohibited in some jurisdictions. That a medical board would dignify such a practice by requiring it reflects negatively on the Board as well as the therapist.

"Respondent's abandonment of Patient A without referral to another provider after conclusion of their affair..."

Does this unfortunate language suggest that physicians licensed in the state of Washington have an obligation to refer their patients to another provider at the end, rather than the beginning, of a romantic involvement? Maybe Dr. Schubert should have sent a letter giving 30 day notice: "I will only be available for sexual emergencies." This gaffe strikes me as almost tantamount to Sen. Akin's recent illusion to "legitimate rape." Surely we have a right to expect more from this august body.

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