Saturday, October 24, 2009
Boundaries, Ethics and Professionalism
I just completed the two day workshop on Boundaries, Ethics and Professionalism offered by the College of Physicians and Surgeons of BC. Dr. Glen Gabbard, internationally reknown psychiatrist and author of Psychotherapeutic Treatments and the classic work Boundaries in Psychoanalysis and Dr. Maureen Piercy, Deputy Registrar of the CP&SBC chaired the meeting with facilitators from colleges across Canada. About 50 doctors attended and the workshop took place in the very pleasant offices of the College.
If one gets around the idea that everyone in our society now needs a lawyer and an administrator to accompany them in every human interaction to avoid complaint or lawsuit, (accepting these normally socially immature professionals ie lawyers and administrators ,who without their professional power couldn't 'relate' their way out of a wet paper bag,) then the workshop was very good. The idea however that these "protected" and "priviledged personnel" who make the laws and are commonly above the laws are needed in 99% of relationships between doctors and patients to protect the 1% of patients from the much fewer than 1% of doctors who have problems is central. Further the type of problem is rarely anything of great significance to the patients life and overall well being. But then police are more often tax collectors than chasers of murderers and thieves.
Metaphorically, if we accept that Saddam Hussein's poor treatment of the Kurds justified the invasion of a soveriegn country, overall destruction of that country and the removal of their oil and wealth then perhaps its understandable the many must suffer for the few. So line up 10 random people from the village on the hour and shoot them because there's a bad one withholding information and helping terrorists somewhere. The fallacy of this argument is 'the ends against the middle". It's the great poison of our present times.
My tendency therefore was to see Dr. Gabbard and Dr. Piercy as the problem, capitalizing on this new industry which costs physicians onerously and ruins collectively the doctor patient relationship. I had chosen to attend the workshop as a necessary evil in these insane times. Boundaries and such ideas promised to replace natural and well accepted "norms" with new codified and 'artificial' agendas based on political correctness (ie social communism) and often driven by radical feminism. As one sexist leader commented, "we're past the days of patriarchy" and I had to object to that language, saying I personally refer to the 50's as the age of "parentalism" and our present day as the age of 'individualism". Sexism cuts both ways and the College actually did a very good job of being gender neutral as well as acknowledging the Gay Lesbian and Trangendered person specific issues.
However I have a tendency to paranoia when it comes to the State these days after they developed weapons to wipe out the whole of human race, are jailing everyone willy nilly and have an army of brownshirts called 'homeland security'. Freud did say, "maybe the paranoids are right."
That said the conference was excellent in advising physicians of the new "laws" and the new "guidelines" and warning us collectively how to avoid what Dr. Gabbard aptly called the 'daily minefields." This included how to avoid entrapment by patients, how to recognise sexual advances of patients as well as how to protect patients, how to recognise personal risk factors and how to ensure patients got the best care intended. It was clear throughout that everyone there was a doctor and that individually and collectively that we'd gathered here for this workshop to help patients get the best care, and help us as physicians to help them. Dr. Piercey did a superb job of keeping this idea central when it must be remembered that the College of Physicians and Surgeons is in many ways like Internal Affairs of Police. We all know from cop shows what cops feel about Internal Affairs. They're usually in bed with the corrupt mayor's office and screw up the anti heros like Clint Eastwood.
A major part and extremely valuable set of lessons lay in the prevention strategies and the early recognition of being at risk. Times had changed a great deal since I started medicine 25 years ago and multiculturalism, media induced fear mongering, increasing costs, decreasing resources, long waitlists, and the internet had all impacted on the practice of medicine.
Unfortunately discussions of perfectionist doctors and doctor burn out and doctors cherry picking patients while the rest of the doctors did the lion's share of difficult work didn't offer any real strategies for change but more of the usual platitudes. One always has the feeling that people are out of touch with the trenches when they say "refer patients to other doctors," 'refuse referrals', "tell patients you're uncomfortable and unwilling to do certain things", "refuse services" , "talk softly with patients threatening your life" and "tell women who are walking about in lacey bras to put their clothes back on." It all sounds so 'academic' but I couldn't help but remember how much more difficult it was disarming a big guy swinging an axe at my head and how angry the psychotic woman became when I asked her to put her clothes back on and said I couldn't 'accept the shirt off her back' as a gift. Further there's no one else to see patients and when you refuse to see a patient you're often the 'end resource' since so many patients in Canada can't see a family physician and waitlists for psychiatric consultations are months. Sometimes patients can wait years before a psychiatrist is available to do therapy and no one is arresting the administrators and politicians who are taking the money that tax payers are giving for health care but which goes anywhere but.
The critical factor was that this meeting was 'blame the doctor' in only that sense. More so it addressed how the doctor could survive in a nightmare war zone of high patient expectations and horrendous lack of health care resources.
A key discussion that was extremely useful was the ethical consideration of intent versus outcome. An interesting clinical example used in small group discussion was of a male Ear Nose and Throat Surgeon listening to a woman's heart under her blouse and her complaining he'd been sexual. All the doctors understood the need for the exam and none felt he was anything but a good doctor but we all equally understood a woman in for sinusitis examination wouldn't understand the need for stethescope auscultation under her blouse. (ie touching her left breast). As one doctor said, too many people were watching doctor shows where for family television the stethescope is placed over the clothing and besides to the patient what would a chest exam have to do with sinusitis. We knew but we understood very well how the poor patient would be confused. Collectively we all realized we needed to be more willing to explain as we went along what in fact was the reason for various procedures.
Dr. Piercy gave an excellent review of a kaboodle of such examples of physical examination mishaps which at times had the group of us laughing or crying considering the misperceptions implicit and how a complaint would arise.
Dr. Gabbard's presentation had excellent clips from movies showing problems that even Hollywood had picked up on. From my point of view his best recommendation though was ," When in doubt, act human".
In the end that was the key message that the College presentation was trying to get accross. A colleague recently said that he now had so much paper work that he hardly could look at the patient but the patient couldn't possibly know what expectations the College, the law and the clinical charting record required. Among the clinical doctors everyone expressed their sense of pressure and overwork and frustration with the payment schedules which didn't in any way acknowledge the increased 'documentation' demands by government. However one clinician did say that the salaried doctors were being given time and paid for these activities allowing them to focus once again on the patients. This hasn't translated to private practice yet but it certainly provided a ray of hope for us in the front lines.
Both Dr. Gabbard and Dr. Piercy covered well the concerns with impairment in physicians with regard to drug and alcohol abuse. It was clear that early warnings could lead to early prevention and appropriate intervention appreciated by the doctors and protective of patients. Dr. Gabbard, Dr. Piercy and the BC Physician's Health Program were all committed to keeping doctors working while clearly ensuring safety for the patients.
While discussion of the predatory sexually exploitative male doctor was addressed the course did an equally good job on looking at the more common female physician problem of material exploitation of patients, the acceptance of extravagant gifts, innappropriate business adventures etc.
It was made clear too that the fiduciary relationship of doctor and patient excluded sex entirely and that "love" wasn't ever enough despite the all the songs. As Dr. Gabbard made clear Ethics is about behaviour and while sexual relations (despite Clinton's idea on the subject) were behaviour, love wasn't.
The difficulties of the small rural practitioners were well addressed with everyone being their patients and all relationships being in many ways enmeshed. Some excellent guidelines came out of the lecture and small group materials, while physicians themselves had an opportunity to express their concerns and share ideas about solutions. I was delighted to hear how other psychiatrists and addictionists dealt with problems I'd thought at times I alone was facing.
Representatives of the Physician Health Program were present and gave some excellent suggestions as well. Dr. Gabbard encouraged consultation and colleagial discussions as well as mentorship and joining local physician focus groups. Both he and Dr. Piercy recommended early consultation with a colleague, even if just by phone or email, of any difficult situations or patients. Certainly I've phoned the College and the Canadian Medical Protective Association and found them to be extremely helpful in 'sticky' stituations. Belonging to 'cyberdocs' an on line international physician support group has been extremely beneficial for me as well. I was delighted to hear that the addiction doctor attached to Physician Health was wanting to locally form a group for those of us working with addicted patients.
Amazingly Dr. Piercy and Dr. Gabbard and all those on the faculty became less a part of the problem than a real source of solutions as the workshop went on. Both Dr. Piercy and Dr. Gabbard disclosed amusing stories of their own short comings and how they'd handled difficult clinical situations, if not in the best way, at least humanly.
Society may well be going to hell in a handbasket with litigiousness and more than 60% of health care costs being legal and administration. Alot of the ideas presented however were just good medicine and got to the crux of difficulties that arose between patients and doctors. Dr. Piercy won us all over when she finally described a pair of predatory patients working in tandem to hustle doctors and the talk moved to the male patient masturbating on the female physicians. I remembered my hostile patient threatening me and me thinking there must be limits on what a doctor is expected to do in psychiatry. 50% of psychiatric residents were still being physically injured in their training. One day soon it appeared that patients would be more accountable and responsible for their health and behaviour when they weren't acutely ill or psychotic but just bullying or behaving rather badly. The one sided idea of the all powerful doctor and the poor little female waif patient may one day be more balanced.
As it stands the message is that the doctor must act professionally and humanely. Considering that in psychiatry often the "behaviour is the disease' it's well warranted but that doesn't get around the profit motives and hidden agendas of some patients who are more sociopathic than sick and the complaints process costs physicians dearly in time and resources that otherwise would be put to patient care.
I suspect this will come when there are more complaints against lawyers and administrators and they get their own back.
Dr. Piercey and the College of Physicians and Surgeons are to be congratulated for putting on a really fine workshop. It's always great to hear Dr. Gabbard. The organization was terrific and interactive small groups very well facilitated. The catering was superb with great soups and sandwiches, lots of fruit, yogurt and finally Hagen daz ice cream bars. Not one participant was taken into a side room and tortured to rat on other physicians and the taster I employed assured me that the food did not contain any salt petre or long acting psychiatric medications. Indeed it was a most helpful workshop and would benefit most doctors working with patients today.