Stephen Michael Thielke, MD, incoming president of the Washington State Psychiatric Association programmed this years meeting around a theme of technology.
WSAP President Elect Robert Hilt, MD led off with a presentation describing experience of delivering child psychiatry services to remote underserved areas of the state, emphasizing the program's telepsychiatry services in a model providing for remote offices staffed and equipped through the program. I disagree with Dr. Hilt's definition of telepsychiatry excluding the telephone which makes teleconferencing look inadequate relative to face to face contacts. In fact we should emphasize that teleconferencing with video is superior to telephone contact which has been an essential part of standard of care for providing medical services for almost as many years as the technology has existed.
Jacob Sperber, MD spoke next on "The Impact of Interactive Digital Social Media on Psychiatry." However, most of the several authors he quoted have published in other fields, like media and sociology, and it soon became clear that he talked not about psychiatry in general but rather about psychoanalytic psychotherapy. He argued that psychiatry, as though it were some kind of monolithic organization, espouses intimacy as a value, and that psychiatrists should oppose activities, such as social networking, that threaten to impair our capacity for intimacy. I strongly disagree with this position. Social networking clearly has potential for good as well as harm, but psychiatrists should stick to treating mental illness rather than promoting values which, at least in this case, are probably based on psychoanalytic views of what should be considered normal. With his views Dr. Sperber would likely have risen to a high position in the old Soviet Union.
Sperber also argued that digital social networking promotes "multiplicity," in that users portray themselves in different ways in different settings on the Web. That may be true, but we would be pretty boring if each of us always acted the same regardless of the situation. And you don't need the Internet to act differently just for fun, or for some other purpose. I guess if Dr. Sperber's mother told him she cried for the cop to get out of a traffic ticket he would want her to sign up for a several years on the couch.
After lunch VA psychiatrist Kenric Hammond, MD described the electronic medical record system that has evolved over many years at the VA. He focused on the problem of copying and pasting of text and encouraged increased use of narrative vs. check boxes. He also suggested hypertext technology might provide a superior alternative, allowing the provider to refer elsewhere in the record rather than copying the same text. Having reviewed many pages of records from VA clinics and hospitals myself I agree the system begs for improvement. I might suggest a system in which each provider could select modules to customize data entry. It appears to me that the tail too often wags the medical dog. EMR's should bend to the style of the physician rather than dictate how the physician works. On the other hand the EMR, properly designed, might also lead to improved care. The proposed use of hypertext, however, will create change in how forensic record reviews proceed. If the reviewer wants an accurate picture the linked document must be readily accessed from the link. This could apply pressure for abandoning paper copies in favor of electronic. This could be good.
Finally librarian Valerie Lawrence told us how to access journals and other resources available to all WA licensed physicians, and attorney Jacqueline Melonas described risk management considerations in communicating with patients via digital media.
Tuesday, April 20, 2010
Wednesday, April 14, 2010
iPad. Ho Hum.
I have been using a tablet PC for over 7 years.
I can write on it.
It even recognizes my handwriting.
It's really a computer.
I can read books with it, watch movies on it, surf the Web with it.
iPad? Not.
I can write on it.
It even recognizes my handwriting.
It's really a computer.
I can read books with it, watch movies on it, surf the Web with it.
iPad? Not.
An Ethics Odyssey III
(Continued from An Ethics Odyssey II)
Meanwhile, Back in Washington State
After returning from a vacation I contacted the WSPA office hoping for a status report. In an August 24 email the WSPA executive office acknowledged receipt of my inquiries and reported passing them on to the president, Dr. Williams, and, in a later email, to Dr. Adler. I wrote to Dr. Williams on September 4 asking if I should attend a meeting since there had been no response to my contacts via email and telephone.
In a September 13 email Dr. Adler reported, “…in their present incarnation, [the company's] business agreements do not appear to be consistent with ethical medical practice. It is our hope that [the company] will elect to revise the agreements.”
The Martini Doctrine
Dr. Adler wrote in an email dated September 18, 2007, “… our committee has adopted a stance that we term ‘The Martini Doctrine.’ In short, it de-emphasizes punitive approaches in favor of education and advocacy. It may be the view of the committee to update the named WSPA members on the status of this issue, the concerns raised and invite them to contact us to discuss the situation.”
On September 24 the WSPA office wrote me via email that Dr. Williams had received the “USPS documentation” I sent in April, apparently referring to my letter of April 16. It appears that the office received my letter, but it remains unclear whether the executive director forwarded it to the ethics chair, the president, neither or both.
The WSPA Committee Analyzes the Agreements
In a letter dated October 5, 2007 Dr. Adler wrote an attorney for the company to express “concerns about two issues.”
According to Dr. Adler “Although there is not tacit [?] ‘fee splitting’ reflected in the business arrangement, close review… gives the appearance that your arrangements are an elaborate method to achieve ‘fee splitting’ within the letter of the law, but not the spirit of appropriate medical practice.”
On the issue of informed consent Dr. Adler wrote, the agreement appears “… to inhibit the process of providing appropriate Informed Consent to the patient” and “Review of your materials suggests that the patient at the time of consulting with the physician would not be permitted to receive information about the dosage of medication(s) they would be receiving, without the possible delay of the process of written consent by [the company] to do so.”
Adler then suggested the company might want to “… revise its Agreements to conform with the tenets of good medical practice so as to help physicians avoid running afoul of possible ethical violations.”
Don’t Tell.
Perhaps under pressure from the company, or perhaps embarrassed about his earlier mention of The Martini Doctrine, Dr. Adler asked me in an October 19 email to “be kind enough to commit to making no secondary use of communications sent to you regarding this case (prior communications and those going forward)?” I declined after he agreed I was under no obligation to do so.
In a November 27 email Dr. Adler reported, “However, it is [the company’s] assertion that NONE of the named WSPA members were contractees with them. Thus, the only issue ‘on the table’ concerns contractual impingements/restrictions to the provision of proper Informed Consent.” This assertion is interesting in that it leaves the impression that the committee has relied on the company rather than the members for information critical to the determination.
On December 10 2007 a physician with the company emailed to assure me, the “license agreement and its practices have always taken these issues into account. However, your raising them has allowed the company to further strengthen its License Agreement and to make even clearer its requirement of licensees’ conformance with the AMA and APA ethical guidelines. It further demonstrated [the company’s] long-standing commitment to adhere to patient disclosure and its compliance with law and ethics to preclude fee splitting.
“It occurs to me, though, that it is a tedious and inefficient way of having your questions and concerns addressed. I'd therefore like to meet with you for a collegial dialogue and educational exchange consistent with our respective obligations under those Principles.”
I was tempted, but only my own professional association could really answer my ethics questions. The company seemed to be trying to do the right thing, and I was glad for the expressed appreciation for my small role in helping to conform the agreement to ethical guidelines. I would have liked to be able to see the agreement without agreeing to non-disclosure, but the company physician did not make such an offer. I saw no purpose in a meeting, so I declined.
Company Representatives Meet with WSPA Ethics Committee
On December 11 Dr. Adler wrote an email to legal counsel an attorney for the company thanking her on behalf of the committee for her “… having flown in from the East Coast, and [the company doctor’s] trip from California.” He went on to ask her to provide “…the updated contract containing the newly added 9.3 element meant to specifically address our Informed Consent concerns.” He added, “We were very relieved to see the addition.” He mentioned her “…commitment to have the updated agreements endorsed by WSPA members who may have signed the prior contract.”
I had copied Dr. Adler on a November 29 email communication to a local radio reporter who had written a story on the protocol in the context of its use at a nearby clinic. I described my attempts to obtain an ethics opinion. Dr. Adler added in a subsequent message to the company attorney, “Despite assurances that our committee was actively pursuing this issue and making concrete steps forward to resolve the concerns raised, [the author] has made inquiries to the Washington State Psychiatric Association (WSPA) and to a news reporter.”
Ordinarily I would have expected the ethics committee to consider my communications as the “complainant” confidential. On the other hand the complainant should not be obligated to keep anything secret. Although this would seem particularly critical in handling a complaint from a patient I believe a member of the Association should be accorded the same privilege. I remain confused as to Dr. Adler’s need to report this fact to the company. My understanding of the ethics process is that the committee’s duty is to the Association, its members, and the public rather than to a corporation.
A New Licensing Agreement
On January 5, 2008 an attorney from the company wrote an email to Dr. Richie (the “lead investigator”) with a copy to me:
“… the confidentiality restrictions in the agreement in no way limit a physician's ability to disclose information about the Licensed Technology to patients. That new section provides in relevant part:
"Notwithstanding any provision to the contrary in this Section 9 or otherwise in this Agreement, nothing in this Agreement is intended to or shall restrict any Group treating physician’s ability to disclose fully to patients the details of treatment with the Licensed Technology or to provide any and all relevant information necessary to obtain any patient’s informed consent to that treatment, and Group agrees to provide patients with informed consent in accordance with the requirements of controlling law and ethical guidelines as set forth in the American Medical Association’s Opinion Of The Council On Ethical And Judicial Affairs CEJA Opinion 2-I-06 E-8.08.” and…
“We are grateful to you and your committee for the opportunity to further clarify this issue and avoid any future confusion about the restrictions imposed by the license agreement.”
Case closed? Not quite
Dr. Richie wrote me via email on January 16, 2008: “This is the first communication to you since our last ethics committee meeting on January 8th. I had hoped to be able to tell you that the… matter was closed. Unfortunately some investigation remains undone and the case will have to remain open. I will update you and Dr. Adler weekly. You may call me at 253.879.7944 or if you prefer, we can continue these updates by e-mail.”
This was the last I heard from Dr. Richie. There were no further updates. Not weekly. Not ever. The elusive Dr. Richie disappeared from the case without a trace. On the same day (January 16) I received a copy of an email from Dr. Williams: “Regarding the ‘Martini Doctrine’, this is an informal term named after a very proactive WSPA Ethics Committee member, Dr S. Martini, who advocates that the committee always attempt to apply the most corrective approach in a specific situation as opposed to a more punitive approach. Any ambiguities in the term “martini” are strictly coincidental; please do not interpret this as a cavalier attitude on the part of the relevant parties.”
Sure.
I had recently communicated my concerns about Dr. Adler’s use of the expression “Martini Doctrine” to APA along with my concern regarding the propriety of the committee working so closely with a for-profit corporation, almost seeming to be assisting the company in crafting a contract. This is not an appropriate role for a professional association ethics committee.
Dr. Williams went on to say that I “helped us identify weaknesses in our operations which we are working to correct.” Let us see to what extent WSPA worked to correct those weaknesses.
Continued: An Ethics Odyssey IV
Meanwhile, Back in Washington State
After returning from a vacation I contacted the WSPA office hoping for a status report. In an August 24 email the WSPA executive office acknowledged receipt of my inquiries and reported passing them on to the president, Dr. Williams, and, in a later email, to Dr. Adler. I wrote to Dr. Williams on September 4 asking if I should attend a meeting since there had been no response to my contacts via email and telephone.
In a September 13 email Dr. Adler reported, “…in their present incarnation, [the company's] business agreements do not appear to be consistent with ethical medical practice. It is our hope that [the company] will elect to revise the agreements.”
The Martini Doctrine
Dr. Adler wrote in an email dated September 18, 2007, “… our committee has adopted a stance that we term ‘The Martini Doctrine.’ In short, it de-emphasizes punitive approaches in favor of education and advocacy. It may be the view of the committee to update the named WSPA members on the status of this issue, the concerns raised and invite them to contact us to discuss the situation.”
On September 24 the WSPA office wrote me via email that Dr. Williams had received the “USPS documentation” I sent in April, apparently referring to my letter of April 16. It appears that the office received my letter, but it remains unclear whether the executive director forwarded it to the ethics chair, the president, neither or both.
The WSPA Committee Analyzes the Agreements
In a letter dated October 5, 2007 Dr. Adler wrote an attorney for the company to express “concerns about two issues.”
According to Dr. Adler “Although there is not tacit [?] ‘fee splitting’ reflected in the business arrangement, close review… gives the appearance that your arrangements are an elaborate method to achieve ‘fee splitting’ within the letter of the law, but not the spirit of appropriate medical practice.”
On the issue of informed consent Dr. Adler wrote, the agreement appears “… to inhibit the process of providing appropriate Informed Consent to the patient” and “Review of your materials suggests that the patient at the time of consulting with the physician would not be permitted to receive information about the dosage of medication(s) they would be receiving, without the possible delay of the process of written consent by [the company] to do so.”
Adler then suggested the company might want to “… revise its Agreements to conform with the tenets of good medical practice so as to help physicians avoid running afoul of possible ethical violations.”
Don’t Tell.
Perhaps under pressure from the company, or perhaps embarrassed about his earlier mention of The Martini Doctrine, Dr. Adler asked me in an October 19 email to “be kind enough to commit to making no secondary use of communications sent to you regarding this case (prior communications and those going forward)?” I declined after he agreed I was under no obligation to do so.
In a November 27 email Dr. Adler reported, “However, it is [the company’s] assertion that NONE of the named WSPA members were contractees with them. Thus, the only issue ‘on the table’ concerns contractual impingements/restrictions to the provision of proper Informed Consent.” This assertion is interesting in that it leaves the impression that the committee has relied on the company rather than the members for information critical to the determination.
On December 10 2007 a physician with the company emailed to assure me, the “license agreement and its practices have always taken these issues into account. However, your raising them has allowed the company to further strengthen its License Agreement and to make even clearer its requirement of licensees’ conformance with the AMA and APA ethical guidelines. It further demonstrated [the company’s] long-standing commitment to adhere to patient disclosure and its compliance with law and ethics to preclude fee splitting.
“It occurs to me, though, that it is a tedious and inefficient way of having your questions and concerns addressed. I'd therefore like to meet with you for a collegial dialogue and educational exchange consistent with our respective obligations under those Principles.”
I was tempted, but only my own professional association could really answer my ethics questions. The company seemed to be trying to do the right thing, and I was glad for the expressed appreciation for my small role in helping to conform the agreement to ethical guidelines. I would have liked to be able to see the agreement without agreeing to non-disclosure, but the company physician did not make such an offer. I saw no purpose in a meeting, so I declined.
Company Representatives Meet with WSPA Ethics Committee
On December 11 Dr. Adler wrote an email to legal counsel an attorney for the company thanking her on behalf of the committee for her “… having flown in from the East Coast, and [the company doctor’s] trip from California.” He went on to ask her to provide “…the updated contract containing the newly added 9.3 element meant to specifically address our Informed Consent concerns.” He added, “We were very relieved to see the addition.” He mentioned her “…commitment to have the updated agreements endorsed by WSPA members who may have signed the prior contract.”
I had copied Dr. Adler on a November 29 email communication to a local radio reporter who had written a story on the protocol in the context of its use at a nearby clinic. I described my attempts to obtain an ethics opinion. Dr. Adler added in a subsequent message to the company attorney, “Despite assurances that our committee was actively pursuing this issue and making concrete steps forward to resolve the concerns raised, [the author] has made inquiries to the Washington State Psychiatric Association (WSPA) and to a news reporter.”
Ordinarily I would have expected the ethics committee to consider my communications as the “complainant” confidential. On the other hand the complainant should not be obligated to keep anything secret. Although this would seem particularly critical in handling a complaint from a patient I believe a member of the Association should be accorded the same privilege. I remain confused as to Dr. Adler’s need to report this fact to the company. My understanding of the ethics process is that the committee’s duty is to the Association, its members, and the public rather than to a corporation.
A New Licensing Agreement
On January 5, 2008 an attorney from the company wrote an email to Dr. Richie (the “lead investigator”) with a copy to me:
“… the confidentiality restrictions in the agreement in no way limit a physician's ability to disclose information about the Licensed Technology to patients. That new section provides in relevant part:
"Notwithstanding any provision to the contrary in this Section 9 or otherwise in this Agreement, nothing in this Agreement is intended to or shall restrict any Group treating physician’s ability to disclose fully to patients the details of treatment with the Licensed Technology or to provide any and all relevant information necessary to obtain any patient’s informed consent to that treatment, and Group agrees to provide patients with informed consent in accordance with the requirements of controlling law and ethical guidelines as set forth in the American Medical Association’s Opinion Of The Council On Ethical And Judicial Affairs CEJA Opinion 2-I-06 E-8.08.” and…
“We are grateful to you and your committee for the opportunity to further clarify this issue and avoid any future confusion about the restrictions imposed by the license agreement.”
Case closed? Not quite
Dr. Richie wrote me via email on January 16, 2008: “This is the first communication to you since our last ethics committee meeting on January 8th. I had hoped to be able to tell you that the… matter was closed. Unfortunately some investigation remains undone and the case will have to remain open. I will update you and Dr. Adler weekly. You may call me at 253.879.7944 or if you prefer, we can continue these updates by e-mail.”
This was the last I heard from Dr. Richie. There were no further updates. Not weekly. Not ever. The elusive Dr. Richie disappeared from the case without a trace. On the same day (January 16) I received a copy of an email from Dr. Williams: “Regarding the ‘Martini Doctrine’, this is an informal term named after a very proactive WSPA Ethics Committee member, Dr S. Martini, who advocates that the committee always attempt to apply the most corrective approach in a specific situation as opposed to a more punitive approach. Any ambiguities in the term “martini” are strictly coincidental; please do not interpret this as a cavalier attitude on the part of the relevant parties.”
Sure.
I had recently communicated my concerns about Dr. Adler’s use of the expression “Martini Doctrine” to APA along with my concern regarding the propriety of the committee working so closely with a for-profit corporation, almost seeming to be assisting the company in crafting a contract. This is not an appropriate role for a professional association ethics committee.
Dr. Williams went on to say that I “helped us identify weaknesses in our operations which we are working to correct.” Let us see to what extent WSPA worked to correct those weaknesses.
Continued: An Ethics Odyssey IV
Thursday, April 8, 2010
Smokin' Joe Califano
If I recall correctly, Joseph Anthony Califano, Jr., who served as Secretary of Health, Education, and Welfare during the Carter Administration, felt obligated to quit smoking in order to set an example in his new post, given the emerging evidence of adverse health effects of tobacco. I was on the medical staff of Gracie Square Hospital, a private psychiatric hospital in New York City, at the time, and an anti-tobacco activist myself, so I was not about to miss the opportunity to hear him speak at the hospital where there was still a cigarette vending machine in the patients' day room upstairs, and patients smoked freely during their hospital stays.
Mr. Califano told a story of driving through suburban Maryland with his teenage son soon after his appointment. He said his son knew of his dad's frustration in attempting to get Americans to give up smoking. Attempting to console him as they passed a high school, his son drew attention to a group of youngsters sitting on the steps at the school entrance. He said something like this, "Don't feel so bad, Dad. A few years ago every one of those kids would have been smoking a cigarette. Now they just have one, and they're passing it around."
Mr. Califano told a story of driving through suburban Maryland with his teenage son soon after his appointment. He said his son knew of his dad's frustration in attempting to get Americans to give up smoking. Attempting to console him as they passed a high school, his son drew attention to a group of youngsters sitting on the steps at the school entrance. He said something like this, "Don't feel so bad, Dad. A few years ago every one of those kids would have been smoking a cigarette. Now they just have one, and they're passing it around."
Wednesday, April 7, 2010
An Ethics Odyssey II
(Continued from An Ethics Odyssey I)
Other State Associations, District Branches
By the middle of April I reasoned that the only way to solve the problem of potential disagreements among the various state associations and district branches might be to refer the same question to each of those where I found more apparent APA members listed on the company Web site as providing the protocol. On April 17, 2007 I sent letters to state associations and district branches in Texas, Hawaii, Georgia, Florida, New Jersey, and Queens County in New York. In each letter I provided the name or names listed on the company Web and described the financial arrangement.
WSPA
By May 1, 2007 there was still no determination. I asked Dr. Williams about the letter I had written him to formalize my request, including the names of four psychiatrists listed on the company Web site as providing the protocol in the state of Washington. He responded two days later that the WSPA office had forwarded the letter directly to Dr. Adler and, “The Ethics Committee is meeting tonight and this is the main item on the agenda.”
Months passed with no response from WSPA, but other district branches and state associations began to respond.
Queens County, NY
Stanley Brodsky, MD, Chairperson of the Queens County Psychiatric Society, was the first to respond. In a letter dated May 12, 2007 he asked if I could provide more information. I wrote him a letter and put him in touch with Dr. Adler. He also provided his direct phone number. In our last conversation he told me the Society’s attorney had attempted to review the matter with the APA ethics committee but with no response. In a telephone conversation with Dr. Brodsky on September 10, 2008 he told me, “They dropped it.” When I asked about a written response, he told me the district branch would get back to me.
New Jersey
The New Jersey Psychiatric Association completed the investigation first with a letter dated June 18 indicating that the named member was indeed licensed with the company “through affiliation with the [a clinic in] NJ” but that he “is no longer affiliated with them and in fact did not accept any fees for any treatments using the… protocol.” The physician later called me to inquire about my letter and explained that he had severed his relationship with the company.
Georgia
Peter Ash, MD, chair of the Georgia Psychiatric Physicians Association Ethics Committee responded with a letter dated September 17, 2007 indicating the committee determined the member there “administered the … protocol [as a] full-time salaried employee of a clinic” and had “no contract” or “other financial arrangement” with the company.
Texas
In a letter dated November 14, 2007 Milton Altschuler, MD, Chairman of the ethics committee of the Texas Society of Psychiatric Physicians wrote that the committee had found no ethical violation. When I telephoned Dr. Altschuler he explained that the committee believed “informed consent” to the financial arrangement obviated any ethics concerns. It was not clear whether anyone on the committee had actually looked at the agreement or whether the committee even determined that either of the psychiatrists named had been involved in the arrangement described above.
I questioned whether otherwise unethical conduct could be made ethical simply by informed consent, so I appealed the decision to the APA ethics committee. The Texas decision was upheld with little further explanation. This determination raised more questions than it answered. First, the committee offered no evidence that they had determined the nature of the financial arrangement between the company and the named members. Second, the committee offered no evidence to support the assertion that informed consent was obtained. Finally, the notion that an action that would otherwise be considered unethical might be rendered ethical simply by obtaining informed consent seems unprecedented. This might mean, for example, that pursuing a sexual relationship with a patient might be ethical provided there is informed consent.
Florida
Karen Teston, MD, Chair of the Florida Psychiatric Society Ethics Committee, wrote in a letter dated December 3, 2007 that she had identified two of the three psychiatrists I had listed as members. She then described a Florida statute (Section 456.054 of Chapter 456) prohibiting “kickbacks.” She suggested I refer the matter to the Florida Attorney General and indicated that only if a member were convicted of violation of such a law the committee would proceed with an investigation.
Kickback?
It had never occurred to me that this arrangement might constitute a kickback, but the label sounded as fitting as fee-splitting. I contacted both the Attorney General and the Florida medical licensing board. Each agency declined to pursue the matter but referred me to the other. I hoped that since there appeared to be little likelihood of a criminal or licensure investigation the ethics committee might look into the matter from a purely ethics perspective, but there was no further response.
Hawaii
If not the most prompt, Hawaii was perhaps the most courteous and diligent. Soon after receiving my letter the Hawaii Psychiatric Medical Association informed me theirs is a small association and that their President who also acted as chair of their ethics committee had died. When they finally regrouped and considered the matter they quickly found that the member I had named had no relationship whatsoever with the company. It was a simple case of mistaken identity, a doctor with a similar, but not identical, name.
Continued: An Ethics Odyssey III
Other State Associations, District Branches
By the middle of April I reasoned that the only way to solve the problem of potential disagreements among the various state associations and district branches might be to refer the same question to each of those where I found more apparent APA members listed on the company Web site as providing the protocol. On April 17, 2007 I sent letters to state associations and district branches in Texas, Hawaii, Georgia, Florida, New Jersey, and Queens County in New York. In each letter I provided the name or names listed on the company Web and described the financial arrangement.
WSPA
By May 1, 2007 there was still no determination. I asked Dr. Williams about the letter I had written him to formalize my request, including the names of four psychiatrists listed on the company Web site as providing the protocol in the state of Washington. He responded two days later that the WSPA office had forwarded the letter directly to Dr. Adler and, “The Ethics Committee is meeting tonight and this is the main item on the agenda.”
Months passed with no response from WSPA, but other district branches and state associations began to respond.
Queens County, NY
Stanley Brodsky, MD, Chairperson of the Queens County Psychiatric Society, was the first to respond. In a letter dated May 12, 2007 he asked if I could provide more information. I wrote him a letter and put him in touch with Dr. Adler. He also provided his direct phone number. In our last conversation he told me the Society’s attorney had attempted to review the matter with the APA ethics committee but with no response. In a telephone conversation with Dr. Brodsky on September 10, 2008 he told me, “They dropped it.” When I asked about a written response, he told me the district branch would get back to me.
New Jersey
The New Jersey Psychiatric Association completed the investigation first with a letter dated June 18 indicating that the named member was indeed licensed with the company “through affiliation with the [a clinic in] NJ” but that he “is no longer affiliated with them and in fact did not accept any fees for any treatments using the… protocol.” The physician later called me to inquire about my letter and explained that he had severed his relationship with the company.
Georgia
Peter Ash, MD, chair of the Georgia Psychiatric Physicians Association Ethics Committee responded with a letter dated September 17, 2007 indicating the committee determined the member there “administered the … protocol [as a] full-time salaried employee of a clinic” and had “no contract” or “other financial arrangement” with the company.
Texas
In a letter dated November 14, 2007 Milton Altschuler, MD, Chairman of the ethics committee of the Texas Society of Psychiatric Physicians wrote that the committee had found no ethical violation. When I telephoned Dr. Altschuler he explained that the committee believed “informed consent” to the financial arrangement obviated any ethics concerns. It was not clear whether anyone on the committee had actually looked at the agreement or whether the committee even determined that either of the psychiatrists named had been involved in the arrangement described above.
I questioned whether otherwise unethical conduct could be made ethical simply by informed consent, so I appealed the decision to the APA ethics committee. The Texas decision was upheld with little further explanation. This determination raised more questions than it answered. First, the committee offered no evidence that they had determined the nature of the financial arrangement between the company and the named members. Second, the committee offered no evidence to support the assertion that informed consent was obtained. Finally, the notion that an action that would otherwise be considered unethical might be rendered ethical simply by obtaining informed consent seems unprecedented. This might mean, for example, that pursuing a sexual relationship with a patient might be ethical provided there is informed consent.
Florida
Karen Teston, MD, Chair of the Florida Psychiatric Society Ethics Committee, wrote in a letter dated December 3, 2007 that she had identified two of the three psychiatrists I had listed as members. She then described a Florida statute (Section 456.054 of Chapter 456) prohibiting “kickbacks.” She suggested I refer the matter to the Florida Attorney General and indicated that only if a member were convicted of violation of such a law the committee would proceed with an investigation.
Kickback?
It had never occurred to me that this arrangement might constitute a kickback, but the label sounded as fitting as fee-splitting. I contacted both the Attorney General and the Florida medical licensing board. Each agency declined to pursue the matter but referred me to the other. I hoped that since there appeared to be little likelihood of a criminal or licensure investigation the ethics committee might look into the matter from a purely ethics perspective, but there was no further response.
Hawaii
If not the most prompt, Hawaii was perhaps the most courteous and diligent. Soon after receiving my letter the Hawaii Psychiatric Medical Association informed me theirs is a small association and that their President who also acted as chair of their ethics committee had died. When they finally regrouped and considered the matter they quickly found that the member I had named had no relationship whatsoever with the company. It was a simple case of mistaken identity, a doctor with a similar, but not identical, name.
Continued: An Ethics Odyssey III
Tuesday, April 6, 2010
Medical Practice at a Distance May Be Illegal II
Follow up to: Medical Practice at a Distance May Be Illegal
State medical boards will likely continue to change policies regarding the legality of "practice" from outside the state, but I wanted to share with you the responses I have collected from a few states in the past few days. We will start with several assumptions that may not apply to other physicians, but will likely always apply to myself:
In this case the patient might actually be located on a vessel either docked in CA or in CA waters. In response to my inquiry of the CA board regarding these questions I received only a letter indicating that I would have to seek the advice of legal counsel.
HI
The HI board responded the same day by email:
"We are in receipt of your message.
"Your patient may want to check with the pharmacy, but I believe the Pharmacy Board's laws allow pharmacists to fill one out of state prescription.
"With regard to your other two questions, the Hawaii board generally looks at the practice of medicine as occurring where the patient is. As the patient will be in Hawaii, the practice occurs here and so the physician should be licensed.
"However, this is an informal opinion and is not legally binding.
"Thank you for your inquiry.
"sincerely,
Constance I. Cabral
Executive Officer
Board of Medical Examiners"
NY
I spoke with a lady at the NY board by telephone. She indicated that the board would likely consider a teleconference with a patient located in the state to be practicing without a license. When I asked her about ordinary telephone contact she asked me how anyone would know. But when I pressed her for a statement of policy she indicated that even telephone contact might be considered practice without a license.
Conclusions
I find it interesting that in CA and HI responses were couched as opinions. If provided in writing perhaps NY would have as well. Why can this not be stated as a matter of current policy? Perhaps the boards want to avoid any possibility of appearing to give a green light to, to what? Could it be that they just feel they must act tough but would never prosecute?
Telephone "practice" across state lines occurs routinely near state lines. Some states may have reciprocity agreements. But no physician should have to break the law to avoid malpractice, and patients in this country should be able to travel freely without concern that their physicians might not be available to them by phone, and better yet by teleconference, regardless of whether the physician bills them for the service.
The reality is that physicians break the law every day because they are unwilling to stand up to irrational regulations. It's just easier to go with the flow. These laws serve no purpose and should be changed. Perhaps the next time we practice without a license in a state where a patient is traveling we should turn ourselves in and see whether prosecution follows.
It may or may not be good that laws prohibit a physician located in state A from initiating and maintaining care of a patient never examined in person from state B. But every state, if not every country, should immediately enact laws to allow physician-patient contact by phone or teleconference when the patient travels to another state.
State medical boards will likely continue to change policies regarding the legality of "practice" from outside the state, but I wanted to share with you the responses I have collected from a few states in the past few days. We will start with several assumptions that may not apply to other physicians, but will likely always apply to myself:
- Practice takes place where the patient is located and is governed by the laws of that jurisdiction.
- Patients reside in my state.
- Patients temporarily travel to states in which I am not licensed.
- Patients may need to contact me by telephone to ask for prescription orders or to discuss clinical matters such as symptoms, side effects, and dosing strategies.
- Patients may benefit from conducting a single contact via teleconference (eg, Skype) if traveling during a time when a visit would ordinarily occur in state. (As of now routine teleconference contacts will occur only alternating with in office contacts.
In this case the patient might actually be located on a vessel either docked in CA or in CA waters. In response to my inquiry of the CA board regarding these questions I received only a letter indicating that I would have to seek the advice of legal counsel.
HI
The HI board responded the same day by email:
"We are in receipt of your message.
"Your patient may want to check with the pharmacy, but I believe the Pharmacy Board's laws allow pharmacists to fill one out of state prescription.
"With regard to your other two questions, the Hawaii board generally looks at the practice of medicine as occurring where the patient is. As the patient will be in Hawaii, the practice occurs here and so the physician should be licensed.
"However, this is an informal opinion and is not legally binding.
"Thank you for your inquiry.
"sincerely,
Constance I. Cabral
Executive Officer
Board of Medical Examiners"
NY
I spoke with a lady at the NY board by telephone. She indicated that the board would likely consider a teleconference with a patient located in the state to be practicing without a license. When I asked her about ordinary telephone contact she asked me how anyone would know. But when I pressed her for a statement of policy she indicated that even telephone contact might be considered practice without a license.
Conclusions
I find it interesting that in CA and HI responses were couched as opinions. If provided in writing perhaps NY would have as well. Why can this not be stated as a matter of current policy? Perhaps the boards want to avoid any possibility of appearing to give a green light to, to what? Could it be that they just feel they must act tough but would never prosecute?
Telephone "practice" across state lines occurs routinely near state lines. Some states may have reciprocity agreements. But no physician should have to break the law to avoid malpractice, and patients in this country should be able to travel freely without concern that their physicians might not be available to them by phone, and better yet by teleconference, regardless of whether the physician bills them for the service.
The reality is that physicians break the law every day because they are unwilling to stand up to irrational regulations. It's just easier to go with the flow. These laws serve no purpose and should be changed. Perhaps the next time we practice without a license in a state where a patient is traveling we should turn ourselves in and see whether prosecution follows.
It may or may not be good that laws prohibit a physician located in state A from initiating and maintaining care of a patient never examined in person from state B. But every state, if not every country, should immediately enact laws to allow physician-patient contact by phone or teleconference when the patient travels to another state.
Thursday, April 1, 2010
The Real Reasons Psychiatrists Want to Provide Psychotherapy
It takes fewer patients to fill your practice, which means:
If your patient does like you, you can pretend like that's a symptom of their illness which will require even more treatment.
Your patients were probably never really sick to begin with.
Patients won't notice you forgot everything you learned in med school.
It takes longer for patients to get better, which means:
More time to get work done if the patient doesn't show up.
You have more of an excuse for not answering the phone.
You have more of an excuse for not answering the door.
You don't have to split the money with a psychotherapist.
Your appointment book can have bigger spaces.
You get paid to chat with people who are more interesting than you are.
You get paid to tell the patient goodbye.
You don't have to worry about getting all the history in the first session.
Patients know better than to ask if you can "squeeze" them in.
Regular visits make for fewer missed appointments.
I may add to this over time.
If you're a psychiatrist who does psychotherapy or psychoanalysis (a sporkiatrist?), and you're offended by this, you probably just need to get more psychotherapy or psychoanalysis yourself, or at least more supervision.
- Less paperwork
- Less room taken up by file cabinets
- Fewer problems with pharmacies
- You don't have to keep up with so many different drugs
- Fewer phone calls
- You're more likely to get the patient's name right since there aren't that many other patients to mix them up with
- Fewer phone calls (because you might see them tomorrow anyway and talk about it in person)
- You're more likely to get the patient's name right since you haven't had as long to forget what they look like.
- to talk about problems with keeping appointments or being late
- to talk about paying bills
- for the psychiatrist to fill out forms (while still getting paid for the time)
If your patient does like you, you can pretend like that's a symptom of their illness which will require even more treatment.
Your patients were probably never really sick to begin with.
Patients won't notice you forgot everything you learned in med school.
It takes longer for patients to get better, which means:
- They'll probably get better regardless of the treatment, because time heals all wounds, or
- They'll pretend to get better and leave treatment eventually just because they're so tired of talking to you.
More time to get work done if the patient doesn't show up.
You have more of an excuse for not answering the phone.
You have more of an excuse for not answering the door.
You don't have to split the money with a psychotherapist.
Your appointment book can have bigger spaces.
You get paid to chat with people who are more interesting than you are.
You get paid to tell the patient goodbye.
You don't have to worry about getting all the history in the first session.
Patients know better than to ask if you can "squeeze" them in.
Regular visits make for fewer missed appointments.
I may add to this over time.
If you're a psychiatrist who does psychotherapy or psychoanalysis (a sporkiatrist?), and you're offended by this, you probably just need to get more psychotherapy or psychoanalysis yourself, or at least more supervision.
Subscribe to:
Posts (Atom)
Posts
