Saturday, January 30, 2010

Proposed Additions to a PCSS Guidance

A physician associated with the Physician Clinical Support System for prescribing methadone and buprenorphine has asked me, "do you have an edit or rewrite of the proposed guidance?  I would be very interested in what you would propose that would benefit our members as they are included in an audit."

My response follows:

  • Doctors are not accustomed to audits or investigations by law enforcement and are therefor vulnerable.
  • Doctors are unaware of their rights.
  • Doctors are easily intimidated by implied threats of criminal prosecution or revocation of licenses.
  • DEA agents are not accustomed to conducting audits or investigations of physicians.
  • DEA agents are not trained in how to conduct themselves in a way that respects the rights and privacy of patients.
  • DEA agents will base their conduct of audits on erroneous assumptions about medical practices.
  • Patients are at a disadvantage and unlikely to protest because of stigma and fear of loss of privacy
  • Patients are vulnerable to disruption of medical care.
  • These audits constitute fertile ground for violation of due process.
  • Unannounced and unscheduled intrusion of DEA agents will disrupt medical practice.
In many, if not most, jurisdictions there has been no written notice of impending audits. Different DEA field offices appear to have freedom to conduct audits in whatever manner they choose. There may be no national standard.

Questions arise even before the audit begins. If agents approach a physician outside the office, how must the physician respond? Must the agent identify himself/herself as such. Must the physician respond at all? What must agents do to properly identify themselves and demonstrate that their visit is proper. Can agents demand a physician provide identification if confronted in a hallway or parking lot?

Does the administrative order provide for more protection such that it may be preferable to unannounced audit? What does it entail? By whom must it be authorized? A judge? Must investigation under administrative order be scheduled?

How should a physician who uses electronic medical records handle the situation in which computer files cannot be accessed temporarily or permanently due to technical problems? May the physician postpone the audit until the problem can be corrected?

PCSS should offer guidance as to whether physicians can refuse to answer questions agents may ask that may not relate to buprenorphine records, for example:
  • Do you prescribe other scheduled drugs?
  • Any other “do you” question, not to mention Did you or Have you ever...?
  • Do you dispense other scheduled drugs?
  • Do you count pills?
  • Do you require patients to submit to random drug tests?
  • How often do you see patients?
  • Are you licensed to carry a concealed firearm?
  • Do you keep a weapon in your office?
  • Where do you live?
  • Do you have family members or colleagues who suffer from substance use disorders?
  • Have you ever been diagnosed with hepatitis? Opiate addiction? AIDS?
  • With whom do you live?
  • Have you ever used marijuana?
There may be a statute that specifies that agents may not ask about clinical matters. How is the boundary determined, and what are the consequences to the agent for crossing the boundary or the physician for refusing to answer? What recourse do physicians have for inappropriate conduct on the part of agents?

Physicians need to know whether we can decline investigation at a particular time because:
  • Office staff are not present
  • A witness is not present
  • Patients need attention
  • Records cannot be readily accessed
Can the physician terminate an investigation (and require agents to vacate the premises) if:
  • The witness or office staff must leave.
  • Patients need attention.
  • The physician believes the mission is completed and agents are extending their stay in order to intimidate.
  • Physician or staff becomes ill or incapacitated.
Will physicians be obligated to provide:
  • Copies
  • Access to a copier
  • Telephone
  • Seating (If we do not providing seating agents may be less likely to dally.)
How much will agents likely know about the physician before they arrive?
  • Criminal record?
  • Whether physician owns registered firearms?
  • Whether physician is licensed to carry a concealed weapon?
  • Whether physician has worked in the criminal justice system?
  • Whether physician has testified as an expert witness in criminal court?
  • Physician's immigration status?
Must physicians perform at the agents command, e.g. counting patients, or can we advise agents they must do that themselves? (Of course we must show them certain records as I fully expect to be asked.)

Agents may use audits as a pretext to investigate further matters they believe may lead to criminal charges, possibly subverting due process protection such as Miranda laws?

Buprenorphine patient count:

What determines whether a patient should be counted toward the 30/100 limit? Is it based on:
  • Date of last contact
  • Date of last prescription
  • Date when last prescription should have run out
  • Whether patient is alive or dead
  • Whether patient has been discharged
  • Whether patient has disappeared
  • Whether patient responds to phone calls
  • Whether patient has declared intention to stop using the drug, but may still have a supply
What about a patient who missed the last appointment, did not respond, has not obtained new prescriptions, but has scheduled an appointment in the future?

According to a recent article in Psychiatric News "agents will ask to see three months of records." If this is true, will the want the last three months counting backward from the day of the examination, the last three full months, or any three months. Will agents want to see records of any patient for whom the physician wrote a prescription during that period or for only those patients currently active?

Suggestions for strategy:

We cannot assume that DEA will answer any of the questions above. If DEA does answer the questions, we cannot assume that individual agents will abide by any answers provided. We must find alternatives means to collect information about how agents actually conduct themselves. We need to ask anyone who is audited to debrief, perhaps by developing a questionnaire which can be completed (anonymously) online, and perhaps modified as we learn more. We need to find out whether there is any covert, implied or overt threat that might result in physicians fearing to describe the experience, especially if agents inform them of any irregularity. We need to know whether any physician has initiated disciplinary action against an agent.

Each physician not yet audited should write a letter to the local DEA field office (return receipt requested) as follows:

I am writing to formally request that you schedule my audit of buprenorphine records. [Give date and time when patients will not be present, but physician and needed staff will be present.]

Please be advised that if your agents arrive unannounced, I will only be able to allow the audit if:
  • I have been able to confirm by telephone with your office that the agents are legitimate.
  • I am present
  • My office staff are present
  • No patients are present
  • There is no reason to believe that other practices sharing my office will be disrupted.
  • I will expect the agents to leave when asked and will allow them to schedule another encounter to complete any unfinished business.
Patients in my practice may work in state, local or federal law enforcement or related fields, or relatives of such. Because of this I need you to provide me with the identities of agents who will perform the audit at least thirty days before the audit. I will provide these names to my patients so they can determine whether they wish to risk being identified.

If individuals appear claiming to be DEA agents but have not been previously identified to me by you, I will contact your office by telephone and give you an opportunity to confirm their legitimacy. If I am unable to positively identify the agents as legitimate, I will ask them to leave. If they do not leave, I will contact local law enforcement. Anyone appearing at or remaining at my office without proper authority will be charged with criminal trespass.

Please be advised that no information that identifies a patient will be provided.

Even though DEA will not likely schedule the audit, evidence the agency received the letter will weaken any claim that the physician did not cooperate with the audit. 

More strategies:

We should establish a buddy system whereby physicians available will be notified by text (Twitter?), phone, or email when a colleague in the community faces an audit so they can travel to the office to provide support from a less threatened perspective, then gather and report on what they have observed.

We should suggest that all OBOT physicians abide by a complete or at least partial moratorium on new patients until DEA begins to schedule audits as I have done, and make sure that all concerned agencies know. This will underscore the likelihood that this policy has already discouraged many physicians from providing this treatment while preventing DEA from claiming that our protest is financially motivated. So far I have turned away 3 new potential buprenorphine patients.

I cannot imagine that this listing could cover all possibilities. Since I do not keep buprenorphine or other controlled substances in my office I have not attempted to include questions or strategies that might arise in relation to that aspect of the investigation. Perhaps someone even more paranoid than myself could add more items. Better yet, I invite comments from those physicians who have experienced audits already.

Telemedicine and Standard of Care

A recent NY Times article quoted Humayun Chaudhry, DO, President of the Federation of State Medical Boards:

“It should be the same exact standard as if the patient was in your examining room. You can’t cut corners."

He seems to imply that an audio/video contact (such as with Skype) must equal a face to face visit. I wonder whether he would say the same thing about telephone contact between patient and physician which has been part of the standard of care for years, and which suffers from lack of any visual contact.

Should not "standard of care" be applied to the entirety of the patient-physician relationship rather than to an isolated component of that relationship?

Saturday, January 23, 2010

Restriction of Practice: Fear or Anger?

I recently suggested to the leadership of my local branch of the American Society of Addiction Medicine that as a way of protesting the DEA's unnecessarily disruptive and wasteful methods of conducting audits, that we encourage members to do as I have done: I have made a decision to stop accepting new opiate addicted patients for treatment with buprenorphine and to make that fact known. One of them replied,

"I'm not sure I understand your recommendation to stop accepting patients(?) We are fully within our rights to treat patients. It is unnecessary to curb our professional activity unless any individual MD is exceeding the 100 patient limit; or if, of course, a given physician simply wants to discontinue for their own purposes such as retirement or the pursuit of other professional goals.

"I think that it is also important to underscore (to you) that treatment access remains a problem, and to the extent we magnify the impact of this situation, it may have the effect of discouraging physicians from pursuing this path in a manner that is disproportional to the regulatory risk of the prescribing activity. We have an ethical obligation to both our patients and our colleagues to not let our fear or [sic] audit translate into excessive fear of obtaining a SAMHSA DATA Waiver."

Doctor, it is not fear, but anger, and the wish to draw attention to, and possibly solve, a larger problem that motivates my decision. I still recall sitting in a lecture hall in medical school in the early 70's when one of my classmates briefly spoke out to challenge a legitimate wrong, but quickly withdrew. Out of fear. Since then it has seemed to me that medical schools, whether intentionally or not, select for conformists and cowards. Surgeons may represent an exception. Most physicians seem to fear that rocking the boat or taking action or an unpopular position will threaten their status or income. The rest might cite the rationale that we must fulfill an ethical obligation to treat all those people in need. And the legislators and regulators take full advantage. I can hear them now: "Let's just add a few more regulations. The doctors will just suck it up."

I chose not to risk being accused of Medicare fraud: I opted out. The result: I care for few older patients who enjoy more privacy because I am not required to bill Medicare for my services to them.

I dislike the terms of insurance contracts, including managed care: I enter into no such contracts. The result: Patients either pay cash or go elsewhere. And my patients do not need to worry that I will compromise their care to enhance my standing with the insurer.

I prefer not to be bound by HIPAA: Because I do not bill electronically, HIPAA does not apply to me. The result: State law, case law, and ethical considerations, not govern most of my privacy practices. The rest is between myself and my patients.

I choose not to be subject to the FCC's Red Flag Rules by not meeting the FCC definition of a "lender." The result: I cannot let my patients carry a balance.

For most physicians these and other distractions from patient care already lead to limitations of practice, increased time spent on non-clinical duties, and manipulation of physicians to "fill out forms" many of which address questions with which physicians should not be involved. Some doctors retire when they've had enough. Others stop accepting any new patients. For still others a patient may have to wait six months to get an appointment. Some become administrators, forensic experts, journalists, or legislators, or learn how to inject Botox. At the same time we hear that we as doctors should take better care of ourselves, spending more time with family, getting "therapy", or working shorter hours. You cannot have it both ways. You don't want rationing of health care? You already have it.

Of all specialties a physician in addiction medicine should recognize "enabling," a core concept in Alanon, in action. By continually giving in to these encroachments on patient care we become responsible for their perpetuation. The ultimate consequence for this obedient acquiescence to over-regulation is reduced access to care, which I read recently may have contributed to the deaths of 40,000 people. A doctor has a choice: She can spend 10 minutes treating a patient or she can obediently, and without charging, complete a preauthorization for a drug so an insurer can make more profit. He can perform a medical procedure or spend two hours reading about how to avoid going to jail for improper coding.

The net result for me is that while I could probably care for 100 patients per week I may care for 10. After all the public invested in my education and training I spend my time writing blog posts when I could be practicing medicine. You cannot hold a gun to my head to force me to practice. If you convict me of a crime and/or revoke my license, who will care for those patients? Send me to jail, and I have a right to medical care. For free. Make my day.

Perhaps we cannot ethically go on strike. Or perhaps ethically we should. You can certainly limit your practice. But if you do, do it out of anger, not out of fear, and make it known. I would stop practicing altogether today if I could, and when I think of how many other docs probably feel the same way, that scares me, and makes me angry.

And what about the doctor who says I should not stop accepting new buprenorphine patients? He also mentioned he's on sabbatical.

Wednesday, January 20, 2010

DEA Suboxone Audit: Worst Experience of My Career as a Physician

Continued from: DEA Suboxone Audit Update VI

You prescribe Suboxone. You know a DEA agent will "unexpectedly" appear in your waiting room to audit your records of treatment of opiate addicted patients under DATA 2000. You figure you have done nothing wrong, so why worry? It couldn't be too bad. I'll deal with it when it happens.

That's what our colleague assumed, until a woman and a man claiming to be DEA agents appeared in his office.

It wasn't the first time they had staked out his office. Since they hope to catch physicians in the act of committing unspeakable narcotics crimes, these dedicated public servants eschew appointments. This also affords them the luxury of a morning or afternoon where "work" on the taxpayer's dimes consists of traveling to a doctor's office, discovering the doctor is out, and then what? Maybe a doughnut and a cup of coffee. Hazardous duty in law enforcement. Of course now and then these intrepid guardians of public safety will face an evil physician, risking life and limb to audit records of buprenorphine prescriptions.

Having already wasted one trip these lions of law enforcement pounced on this wayward health care provider with claws bared. First they sat in the waiting room discussing his case in front of his patients. One of the patients left without seeing the doctor. Then they asked him to sign a form permitting them to proceed with the "audit."

"You don't have to sign it doc. We can come back with a search warrant."

He signed.

They cleverly engaged him in casual conversation, ensnaring the unwitting villain. Then they showed him the water board. Just kidding.

The doctor described the agents' approach as hostile and intimidating, treating him like a criminal. He told me it was the worst experience of his career. Good work, agents. We can all sleep better knowing these guardians of public safety will protect us from all those dangerous docs trying to help people recover from substance use disorders.

The physician has hired an attorney and was told to expect an "exit interview."

The DEA has little cause for worry. Most doctors are too afraid to rock anybody's boat to even speak out, much less take action, and besides, if they put the other guy out of business, it means more patients for the rest of us!

Above all, remember that treating opiate addicts with buprenorphine results in less diversion of pharmaceutical opiates and in a reduced market for heroin, both major threats to job security for DEA workers. And some of us addiction docs actually were naive enough to think that law enforcement was on our side in the war on drugs.

If you believe our law enforcement agents can make more of a difference by chasing criminals instead of doctors, demand that professional associations like ASAM, AMA, AAAP and APA take action. Write your legislators and your local DEA field office.

DEA Suboxone Audits: The Video

Monday, January 18, 2010

Medical Practice at a Distance May Be Illegal

I am grateful to Jeff Neimark, MD for adding to our knowledge of licensure problems in practicing across state lines (Boundary Violation J Am Acad Psychiatry Law 37:95–7, 2009), but this article should have been published where all American physicians (and perhaps patients as well) might read it. Dr. Neimark has revealed that some states consider that if a physician talks by telephone to her patient temporarily traveling in another state, where the physician does not hold a license, the physician might be committing a felony.

Patients should have reasonable access to their physicians when traveling, not only across state lines, but internationally as well, and risk of both criminal and civil sanctions extends to practice across international lines as well as across state lines. But in many cases courts and licensing boards deem that practice of medicine occurs where the patient – not the physician – is located at the time.

Dr. Neimark’s analysis appears to assume that the physician knows the patient’s location, but we must depend on the patient for that information unless made obvious, for example by request to order a prescription from a pharmacy. Perhaps the physician should ask the patient their location at the outset of every telephone conversation. But a savvy patient will soon learn to say he is located nearby in the same state if he wants help from his physician. (Physicians can sometimes avert this problem by suggesting that the patient transfer the prescription to a nearby pharmacy.)

Even if the physician knows the patient’s location at that instant the patient might maintain legal residence in North Dakota, own a vacation home in Texas where they reside for only a few months every year, but spend most of the year traveling abroad or living in yet another state. Such ambiguity further increases uncertainty about jurisdiction. Americans who reside in two or more states should not have to split their medical care between two or more sets of physicians because of irrational licensure laws.

Civil courts might hold a physician responsible for providing for patient access to emergency medical care or admission to hospital even when the patient’s location is far away. But even when the patient’s location is close to the physician’s patients should call 911 to obtain emergency assistance of any kind.

Physicians often provide in states where they are not licensed in order to better serve the patient, but by ignoring these archaic laws and assuming risk of prosecution to help patients traveling out of state we only enable a defective system. Before attempting to provide consultation in a state where she is not licensed a physician should contact that state’s licensing board and demand written confirmation of applicable law. Patients who travel to states like Missouri may do so at their peril. Only by drawing negative attention to such states can we hope to rectify this problem, but lawmakers, not physicians are responsible.

If you have experience of state licensure jurisdiction interfering with patient care, please leave comments here.

More: Medical Practice at a Distance May Be Illegal II

Thursday, January 14, 2010

Commentary on Opinions of APA Ethics Committee III

Continued from:  Commentary on Opinions of APA Ethics Committee II

With societies around the world grappling with questions of how to pay ever increasing costs of medical care and who should receive how much care for what without having to pay, the ethics of money and psychiatry continues to evolve. But APA too often neglects to address conflicting principles and sometimes gives non-ethical considerations excessive weight.

The Opinions of the Ethics Committee on The Principles of Medical Ethics

The new opinions document may not have addressed a case in point at all: Section 9 of the code states that, "A physician should support access to medical care for all people." Talk about a feel good principle. Who could possibly speak against such an ideal? Perhaps those who realize that someone must pay for that care. This principle smacks of politics. I wondered whether a psychiatrist who voted for a public official who opposes universal access to medical care might face charges of ethical misconduct: Democrats, ethical, Republicans, unethical.

When I submitted this question to the Ethics Committee the chairman suggested I ask the AMA. AMA (of which I am not a member) failed to respond. Perhaps we need a test case. Volunteers? I believe this "principle" has no relevance to practice of medicine, including psychiatry, and should be removed. I believe it would be unethical to discipline a physician based on a political view or party alignment.

If Section 9 does apply to the physician - patient relationship, does it imply that all physicians must treat all comers regardless of their ability, or intention, to pay? That might be a slippery slope. Would it apply to physician executives? to cosmetic surgeons?

So here comes the conflict: The ethics guideline document argues against professional courtesy,  the tradition of physicians providing treatment for other physicians or their families at low or no charge so that physicians will not try to treat themselves or members of their own families in order to save money. The guideline cites "give and take" as critical to the transaction, indicating that without payment the patient might harbor doubts as to whether the treatment provided measures up to that for paying patients. But any patient might harbor such doubts about low or no fee treatment. And what about the psychiatrist on salary to a clinic or health system or whose fee is paid by a friend or relative of the patient, an insurer or HMO, or an employee assistance program?

K.2.g. (page 46, 1981)
Now we move to the opposite extreme: the ethics of charging an "exorbitant" (but unspecified) fee. According to this answer from almost 30 years ago (before managed care) an ethical psychiatrist can charge a "reasonable" fee. What constitutes an unreasonable fee, and who might determine this? According to the answer such a person must be "knowledgeable as to current charges made by physicians." An unreasonable fee would leave such a person "with a definite and firm conviction that the fee is in excess of a reasonable fee" after considering factors such as "difficulty and uniqueness of services performed and the time, skill, and experience required," "customary" fees charged by other physicians for similar services, the amount (There's a surprise.), the "quality of performance,"  and the "experience, reputation, and ability" of the psychiatrist. So we need someone who knows the local fees, and her conviction must be firm AND definite. No soft or fuzzy convictions allowed. And how does this person judge these factors? Some of them overlap. The skill required, quality of performance, and ability of the physician might seem very similar. And how does one judge the quality of a medical management visit, let alone a psychotherapy session? How about shock therapy? How skillfully did she press that button or set the voltage?

This discussion ignores the matter of price fixing addressed by anti-trust statutes, which might even prohibit such a process of price determination by this mythical knowledgeable person. Today many physicians accept less than the actual fee anyway in order to contract with insurers or Medicare. But the most glaring omission in this discussion comes from basic economics. Supply and demand determine price. If patient and third party payer refuse to pay, the psychiatrist must lower the price or find another occupation. The opinion makes no mention of the patient's ability to pay. A destitute patient might not have $10 to spend on treatment, while for a wealthy patient might barely notice the financial impact of a $10,000 fee for the same service.

The determination of what consitutes a "reasonable" fee is in fact subjective. The committee should not pretend otherwise. For further, more recent, discussion of a related problem see my earlier post: The Best Treatment or Just the Most Expensive?
K.2.e. (page 45, 1978)
This one has stood the test of time. According to APA we can still ethically charge for missed appointments and raise our fees "in the middle of treatment" provided we inform the patient in advance. I suspect "treatment" here refers to psychotherapy rather than pharmacotherapy or ECT. Once more the opinion fails to specify this, probably because of the erroneous assumption that all psychiatrists practice psychotherapy. Again, recent changes in law may affect what we can do with fees, and third party payers generally consider a claim for a missed session as either fraudulent or not covered, depending on how we file the claim. Here the law may discourage professional courtesy. Government agencies may accuse us of fraudulent billing if we claim one fee on insurance forms, but charge a lower fee to other patients. I have been tempted at times to raise fees for new patients while keeping the fee constant for established patients, wishing to avoid imposing a hardship. But this implies that somehow the patient cannot make it without me, which may not be the best attitude with which to approach treatment of any kind. Few of us should consider ourselves indispensable. In fact I believe many patients can benefit from a fresh approach.

K.2.m. (page 48, 1986)
This psychiatrist allowed his patient to build a large balance. He sent the account to collection which succeeded, but only at a cost of one third of the total. When the insurance company did eventually pay, he wanted to keep the money to cover the collection agency fee. I agree with the committee that we cannot ethically do this. Avoid situations like this by requiring patients to keep accounts current. Don not trust insurance companies to pay you. By law they can demand that you repay them later if they decide they erred in paying you. If you allow your patient's account to build, the FTC considers you a "lender" and can subject you to identity theft rules. (See my earlier post: Need a Loan? See Your Doctor!)

L.5.a. (page 54, 1978)
Even more than 30 years later this still timely question stirs interest: Can we ethically use money provided by drug companies to pay for continuing education activities. The cowardly response and justification bother me: "Without advertising from drug companies our journals would be very expensive." Since when does a question of ethics hinge on the cost of publishing a journal?

N.1.5. (page 61, 1990)
Similar to the prior opinion, this one invokes realities of cost, perhaps with slightly more justification. The questioner wants to know whether she can ethically assume more responsibilities than salaried time allows her to complete effectively. The opinion states she can ethically do this because, "For us to declare otherwise might place an even greater burden upon our underfunded public institutions." I am glad the committee can allow reality to enter ethical discussions, but one could just as easily imagine declaring participation in executions ethical because to declare otherwise would result in overcrowded prisons.

I submitted the following two questions to the committee over the past few years. I wonder why the committee chose to omit them from the opinions document.

Question: What, if any, is my ethical responsibility to assist patients in obtaining insurance reimbursement for my services?  May I ethically charge a fee for such service?

Answer: "Our responsibility to patients (Section 8) and our need to maintain consideration for patients and their circumstances (Section 2, Annotation 6) suggest that such assistance, while not obligatory, is appropriate, and may be advisable. The contractual arrangement between patient and psychiatrist (Section 2, Annotation 5) should establish in advance whether a charge may be made for such service.  When this has been done, charging a fee is not inherently unethical.  However, when the time required is not unduly burdensome, the ethical psychiatrist may elect to waive a fee."

While I am glad the committee did not attempt to impose an ethical duty to an insurance company, possibly a commercial, for-profit organization, once more it seems they have subordinated ethical considerations to financial realities, potentially a slippery slope with role conflict implications.

Does this opinion not conflict with the earlier opinion included in the document: D.4.f. (page 24, 1990). Clearly predating my question, this opinion states that the ethical physician should "complete"  with no fee, a "simplified" claim form, but not necessarily multiple or complex forms to enable the patient to receive benefits. I believe it wrong to impose a duty on the physician to obtain money for a patient. I regularly see this lead to physician's attempting to meet patient expectations by stretching the truth to obtain disability funds, win custody disputes, or to prevail other legal disputes, often with little or no appreciation for the consequences. We should confine our activities to clinical duties.

The committee also seems to have employed this euphemism, completing the form, when they should have addressed the actual content or consequences of the form, considering whether the statements attested to are true or whether the physician can ethically opine on the issues presented in the form. The committee has also failed to address the possibility of role conflict where completing the form might imply duty to the insurance company.

Certain types of patients in my clinical practice demonstrate a propensity to obtain a prescription for a controlled substance then fail to continue in supervised treatment, leaving me liable for adverse outcomes, but with no control. I hoped to discourage this by having the patient pay in advance for the last visit ever, but I wanted the committee's opinion regarding ethical considerations.

Question: Is it ethical to require advance payment for the last or final visit at the start of treatment?

Answer: "I’ve spoken with [the chairman] and he’s indicated that this really isn’t an ethics issue. Section 6 of the Principles provides:  “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.”

"I followed up with our Office of Healthcare [sic] Systems and Financing and they provided the following advice:

“This question seems to be a practice procedure question. Any procedures a psychiatrist utilizes in day-to-day operations should be communicated in advance to all patients. If the doctor wants to implement this policy I would recommend that he add this to his information he provides to new patients. It is probably best that the information be provided in writing so there is no confusion. I would also suggest that the psychiatrist make at least a note in the chart that the patient received the information, the psychiatrist asked for any questions and that they understand all the office policies. If this change will affect his current patients I would suggest providing them the new office policy, have a discussion as to understanding, questions and document the discussion.”

The committee copped out. They imply my proposed practice meets ethical muster, but they should have stated as much. Many of the questions addressed in the opinions document might be considered "practice management" questions. The committee remains responsible for considering the ethical implications and providing guidance to members when requested.

Commentary on Opinions of APA Ethics Committee IV

Wednesday, January 6, 2010

Commentary on Opinions of APA Ethics Committee II

Continued from:  Commentary on Opinions of APA Ethics Committee I

Surely the Ethics Committee of the APA could have published this document free of jargon. It starts with my pet peeve, the term "therapist," and gets worse.

Somehow, probably thanks mostly to Sigmund Freud, who was a neurologist, not a psychiatrist, the primary treatment modality of psychiatrists, at least those practicing outside of hospitals, was historically psychotherapy. We were, and decreasing numbers of us still are, psychotherapists. Shorten that term, and you get "therapist." This ambiguous term also applies to massage therapists, physical therapists, and a host of others. It may seem trivial, but I have a lot of respect for psychotherapists and psychiatrists. The word "therapist" demeans us as well as those other kinds of -therapist professionals. Which would you rather be called, therapist or physician, therapist or psychiatrist, therapist or psychotherapist? We should drop "therapy" and "therapist" from use, and so should the APA ethics committee.

A.1.g. (2008, page 7)
The question, as simplified and incorporated into the opinions at least, refers to practice of psychiatry. The answer refers first to "doctor-patient relationship" then degenerates to "therapist," even though psychotherapy is not mentioned. The admonition to avoid mixing roles is correct, but the role should have been labeled psychiatrist, physician, or even psychotherapist, rather than therapist.

A.2.c. (1978, page 8)
In this case, also addressed in my last post, the question uses the term "therapy." It sounds as though the case occurred in the context of psychotherapy. Why not say so? To remain more general we might say "treatment," which may be the only term for which the term therapy might be appropriately substituted.

R.4.b. (1993, page 80)
In this case the questioner asks about presenting the patient's "therapy" in educational settings, presumably to other professionals. At least the question earlier referred to psychotherapy, but how much ink do we save by leaving off the first six letters?

L.5.b. (1990, page 55)
Even 20 years ago psychiatrists questioned the ethics of accepting gifts from drug companies. The answer to this one, citing an AMA ethics opinion (8.061), allows that an ethical psychiatrist can accept a "modest" meal with no cash, provided, however, that she adopts a "squinty-eyed attitude" toward the material presented. Since the quotes do not appear in the APA opinion I assume this esoteric term must have originated with the APA ethics committee. I did not read the original AMA opinion. Perhaps squinty-eyed attitude is some sort of arcane psychoanalytic term. I can imagine it means "with a skeptical attitude," but the committee wanted to have fun that day.

G.7.b. (1983, page 35)
Everyone knows what the Goldwater rule is, right? The APA ethics committee seems to think so. Regardless, the ethics committee should avoid using this label for an annotation which should not be associated with Barry, or anyone else named Goldwater. I understand that the committee adopted annotation 3 of Section 7 after a number of psychiatrists speculated publicly about Barry Goldwater's psychiatric status. Although the answer to this question claims consideration of potential damage to the reputation of an "unsuspecting public figure," the original annotation includes no such justification. I suspect the real object was to keep psychiatrists from looking silly.

Professional ethics is too important a subject to be addressed so unprofessionally in what should be a serous and unambiguous document.

Commentary on Opinions of APA Ethics Committee III