Thursday, January 27, 2011

Why Psychiatrists Should Enter the Blogosphere

A few weeks ago Shrinkrap Dinah posted Why Shrinks Don't Blog, quoting my earlier comment:

"The fact is, though you claim your blog is for psychiatrists, my impression is that few of us participate in any blog. What stops them? Snobbery? Hubris? Ignorance? Apathy? Fear?"

Despite a lively conversation I'm not sure we ever answered the question, but it occurs to me, now that I've been doing this since August 2009, to put the hard sell on my colleagues who have not yet jumped in.

Doctor, you are in control. You do not have to start your own blog and post to it every day. Just read someone else's when you get the urge. Read a few comments, too. Most of us isolate ourselves pretty completely. We put together a pretty narrow view of psychiatry. Reading blogs will not provide a complete psychiatry world view, but it will expand your horizons.

You will discover how some of your colleagues think and practice. Once in a while you may incorporate some of these ideas in your own approach. Better yet you will discover what some of our patients think about us, especially what they may not feel free to discuss during a visit. You will become more sensitive to their concerns.

Enter the fray by posting a comment. Most blogs allow you to post anonymously, so you need not worry that your patients or colleagues will discover your innermost secrets and opinions. Your opinion matters to the rest of us, and we want to learn from your experience. You can influence psychiatric thinking. Test your own ideas by provoking disagreement from others. It is not so terrible to discover that you were wrong. I know from experience.

Starting you own blog may be easier than you thought. Decide whether you want to remain anonymous or  use your blog as a vehicle to increase exposure for your professional identity, even to market your practice. You can make a commitment or not. Write as little or as much as you want. You will not spend every waking moment screening comments.

To paraphrase, "Doctor, blog thyself." You will make psychiatry better.

Thursday, January 20, 2011

Psychiatric Ethics of Publishing Cases

Publication of psychiatric cases in the media can benefit the public, patients, and psychiatry in general. It can also benefit the author and the publisher, but such publication raises the question of whether, and how, we can ethically make patient treatment information public.

Do we as psychiatrists want prospective patients to wonder whether they might end up in the same positions as Dr. Spork and his patient Barbara?:

In the past week or so two psychiatrists appear to have described real cases in national media. In neither was there any indication that the author had made up the case; in neither was there indication that the psychiatrist obtained permission from the patient; and in neither was there any indication of the extent, if  any, to which the author might have disguised the case. In both the level of detail seemed sufficient that the patient might be identified:

Depression On The Rise In College Students
In fairness to the Dayton, Ohio psychiatrist, Jerald Kay, MD, who did not author the story, I can find only one sentence in which he seems to have supplied the information. Perhaps the author obtained the story elsewhere and Kay just added to it.

When Self-Knowledge Is Only the Beginning
New York psychiatrist Richard A. Friedman, MD authored this story.

In each of these articles:
  • Does potential benefit to the public outweigh risk of damage to the patient?
  • What constitutes adequate disguise?
  • Can a psychiatrist ethically ask a patient to allow publication without damaging the treatment relationship?
An author can attempt to disguise patient information, but what constitutes adequate disguise? In a private communication a chair of the American Psychiatric Association ethics committee pointed me to the standard used by a professional journal. The sole criterion was whether the patient herself could recognize her case. But, in my opinion the most critical piece of information in determining whether a case describes oneself is the name of the treating psychiatrist who will generally be the author. Regardless of the criteria used, the author should make note of the fact that a case has been fictionalized or disguised.

When it seems likely that any reader can identify the patient from published information, and even perhaps when there seems to be little such danger, one might consider obtaining the patient's consent to publish their case. However, this raises the additional question of whether a patient can freely consent. In most situations where it is desirable to release patient information the patient benefits directly, and often the patient initiates the request. In this case however the author, publication, and perhaps the public -- not the patient -- stand to benefit. The physician asking for consent risks placing the patient in a difficult position where he might feel pressured to consent against his will, damaging the treatment relationship. If the patient did consent to publication, the author should state this fact in the article.

Relevant sections of 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.”

Section 4.11 “It is ethical to present a patient or former patient to … the news media only if the patient is fully informed of enduring loss of confidentiality, is competent, and consents in writing without coercion.”

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 of public education.”

Wednesday, January 12, 2011

Dr. E. Fuller Torrey Unethical?

The January 10 New York Times quoted psychiatrist Torrey with regard to accused Arizona mass murderer Loughner: “I’d say the chances are 99 percent that he has schizophrenia.” (Red Flags at a College, but Tied Hands)

According to Section 7.3 of the Ethics Code of The American Psychiatric Association, "On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."

Are we to believe that Dr. Torrey conducted an examination and obtained authorization? Was he acting ethically when he made the statement (assuming that's what he actually said)?

Thursday, January 6, 2011

More New Ways to Communicate

A few weeks ago I asked, Is It Time to Give up on the Phone?, bemoaning the challenges our increasingly complicated and varied modes of communication present. Here I add alternatives that arguably increase the complexity and opportunities for dysfunction, but at the same time allow workarounds when other modalities fail.

How did I forget? I use a fax service that, for a reasonable monthly fee, assigns my own private fax number and allows me to send and receive via Internet. Received faxes appear in my email inbox as .pdf files. I can even receive a document in .pdf format, print it to a .jnt (Windows Journal) file, sign it with the stylus on my tablet pc, print back to .pdf format with CutePDF Writer (a free download), and fax it back, all without paper. One patient who had lost his phone actually did cancel his appointment via fax.

Of course videoconferencing via Skype, Google Video Chat, or other such service makes for a nice alternative to the voice only phone, but users can also send text messages. The chief limitation for me comes from the fact that I usually do not leave Skype running unless I have scheduled a patient contact. The notifications whenever someone signs distract me. Phone-based videoconferencing services like Tango depend on an operating telephone, so they do not add much.

Google Voice
This free and flexible service offers the capability of customizing an outgoing message to an identified caller. I almost tested this a couple weeks ago with the patient I mentioned in the earlier post who apparently was unable to access voicemails I had recorded. I could have recorded a message specifically for him containing more or less the same information I had left on his voicemail. The same capability used to "block" unwanted callers. Once you have identified a caller you want blocked simply so indicate through your Google Voice contacts list. The caller then encounters a message that says something to the effect that the number is no longer in service. An accommodating DEA agent actually confirmed for me that this works very nicely. (I recorded a custom outgoing message for a patient yesterday after several failed attempts to contact him by phone.)

Another more mundane feature probably available in one guise or another to many cell phone users actually allowed me to communicate with the patient mentioned above. Between Google Voice, my software-as-a-service contact management vendor, and my Android phone I am able to send unidentified callers as well as selected identify callers (usually all of my patients) directly to voicemail without ringing the phone. However, in the case of this particular patient I had not yet set his contact for immediate forwarding, so shortly before I intended to record a special outgoing message for him the phone rang identifying him, and, of all things, I actually picked up the phone and answered the old-fashioned way.

Google Wave
Google has indicated it plans to abandon the service in the near future. However, just yesterday it occurred to me that it might offer a solution to a different problem. I like to be able to hand my patients information at the end of a visit. Most commonly this would relate to a new medication I have just prescribed. However, I also like to be able to provide a business card when I refer someone to a psychotherapist or primary care physician. (I could write down the name and phone number, but the patient could never read it, and I always seem to run out of cards.) Since these kinds of information, as well as information about specific mental disorders, reside on Web pages, I would like to be able to efficiently provide the patient with a link. Google Wave appears to offer the capability of establishing a private forum for myself and the patient where I might post URL's for future reference by the patient. Since one can also leave messages or use a Wave for real-time text and even video chat, it could also serve in place of the telephone in a pinch. Furthermore, I can envision, with the patient's permission of course, inviting the patient's psychotherapist and primary care provider into the Wave.

Each of these modalities carries risks and benefits. In particular I wonder about the privacy and security of Wave. However, like with other modalities, we can always manage the content of the conversation in such a way as to maximize privacy. And as with other modalities such as e-mail, a written agreement can go a long way toward assuring that patient and physician understand rules and expectations.

After all, as far as I know it's still okay, even under HIPAA, to smile at the patient when you see him in public.