Tuesday, March 13, 2012

Canadian Psychiatric Code of Ethics - II

Code of Ethics
I. Consider first the well-being of the patient.
II. Honour your profession and its traditions.
III. Recognize your limitations and the special skills of others in the prevention and treatment of disease.
IV. Protect the patient's secrets.
V. Teach and be taught.
VI. Remember that integrity and professional ability should be your only advertisement.
VII. Be responsible in setting a value on your services.

This is the full list of the Canadian Medical Association Code of Ethics. The CMA has written a short explanation related to each. Dr. Cliver Mellor prepared an 'annotated version" for the Canadian Psychiatric Association showing the relevance to psychiatry with some specific and general examples.
In my blog Canadian Psychiatric Code of Ethics part I I've address I. Consider first the well being of the patient and stated that I believe this should be the starting point for all 'codes of ethics' for all working in the health care field.
II "Honor your profession and it's traditions.  I have tremendous gratitude for the medical and psychiatric profession. I consider my training as a physician one of the greatest priviledges I could have in this life. I have further thoroughly thankful for the time I've spent as a physician and psychiatrists serving with patients in rural and urban communities.  The profession of medicine and psychiatry are to me truly grand and magnificent in their achievements and work.  The traditions of the profession are more complex. I will leave discussion of the 'traditions' of the professions to another time of writing.
III Recognise your limitations. This is to me obvious. I'm thankful that I work in a community of physicians and specialists and when I'm consulted I know that if I don't have an answer there is commonly a subspecialist who has more experience with a particular condition that I do.  I am a subspecialist and when I've been stymied by a case I've had the benefit of consulting colleagues in England, Australia and the United States personally as well as taking advantage of local resources including the College of Physicians and Surgeons excellent library and PuB Med literature search.  When faced with a difficult case I've had personal support from fellow psychiatrists who have helped me through difficult personal and practice issues. I have always felt a part of a greater and helpful collective even alone treating a patient in the wilderness as I've so often been called upon to do.
IV Protect the patient's secrets. I've considered this utterly important and gone to extreme lengths protecting files guarding against the 'loose lips that sink ships.'  Having worked in small towns, reservations and on islands with limitted population I've had to be extremely careful about patient confidentiality and information. Despite all this effort I made the error in hiring a staff person who despite being specifically educated and warned about confidentiality released patient information to a boyfriend and disclosed patient information to government organizations for her own personal profiit.  It didn't matter that I didn't recognise her sociopathic tendencies and did my very best to limit damage control by contacting police and notifying those people she had violated.  The experience did make me appreciate the Medical Office Assistants I had had who were collectively responsible and trustworthy in comparison.  I had personally approached two hospitals about their grossly inferior record keeping services and with the Dean of Medical Schools had both these hospitals security improved to minimum standard levels. In both hospitals I had walked in off the street and asked for senior colleagues personal files without showing credentials or having specific care responsibilities for the patient. I was not wearing a name tag, did not need to present identification, and was not known by the clerical staff.  I did not open the files but took the files to the senior personnel and explained the story and told them that I did not feel that I could ethically take the information that I was required to take from patients and have that information stored in this manner. The Winnipeg General Hospital Administrator wanted to phone the police. I am very thankful to the brilliant Dr. Arnold Naimark who essentially 'saved my ass' from the 'evil hospital administrator'  having been apprised of this situation, shocked by the shoddy service,  demanded that the standards be brought up to minimal levels ie requiring signing out and identification notification. It was an early in my career and despite 25 years of experience I continue to see the secular and non medical administration first response to notification of their inadequacy as 'kill the messenger'.  The clerical staff at a another major hospital required to "ID" everyone who took out files condemned me for making their work more difficult.
As a proto hacker I noted there were no 'firewalls' on early filing systems in provincial and federal government storage systems.  Recent cyber attacks by presumbly Chinese military indicate that no information is 'safe' in public filing systems .  There is a tendency to 'keep up the appearances' but there hasn't been any real attempt ot reasonably address the problem. I have at different times had thousands of dollars of cyber security for my office files but know that "a lock only keeps an honest man out'.
Given the difficulty of security ethically doctors are concerned about their 'notes' however legally and from insurance companies there's a trend to all information being made available to third parties and the 'space' in the traditional 'doctor patient' relationship has become increasingly narrow.
V: Teach and be taught.  That's been my way for decades and I have said that my patients are often my best teachers. An administrative doctor who was most peculiar thought that doctors shouldn't be 'taught' by their patients but their patients teacher. I didn't know what planet she came from but every clincian I know learns from each patient 's presentation and passes this learning on to how they deal with the next patient. The gap between clinical physicians  and beaurocratic physicians has never been wider and I fear that there is grave concern that increasingly a controlling managerial sort who wants to keep their hands clean will try to 'jump the queue' with devastating consequences for the profession. This has already been seen in RCMP a once great organization with tendency to promote from the ranks. Recently there has been increasing political appointments 'parachuted in' with the result that the 'administrators' may well not know how to find their arse with both hands in the service. (to quote one RCMP)
VI Remember integrity and your professional ability should be your only advertisement. This requires further discussion elsewhere as it really has been affected by what has been called the 'americanization" 'f the Canadian public health system. it's further affected by the ability of almost everyone to find out almost everything about anyone with the least effort in the cyber reality world.  What was once only available at high cost from a Private Investigator is available in a program from the local computer store as well as all the 'spy' ware tools from the local 'spy' store.  I'm rarely not being observed by some form of camera in the street or satellite coverage.  When is a 'celebrity doctor' 'advertising' or just hawking his or her wares.
VII Be responsible in setting value on your services. I believe this once had more to do with high prices being asked so that people couldn't afford medical or surgical services. Today 'for profit hospitals' and private 'fee for services' approaches come with 'whatever the market can bear' style capitalism.  In contrast I've been criticized repeatedly for 'giving it away for free' .  When I signed forms for my patients others hearing of it threatened their doctors to do the same.  As a result, not wanting patients threatening colleagues, I began to religiously follow the professions fee guides with regard to a number of things which I'd not really considered that importnat. I know my profession is wiser usually than me in terms of 'valuing service'. Even here "I blog" and give 'information' for free in a society where 'information' is bought and sold.  Many colleagues think that my doing 'pro bono' work is questionalbe and a judge recently criticized me for my belief that when I did 'pro bono' work it mad the work less subjct to negative motives and bias. He was right as those doing pro bono work might well be seeking 'status' rather than 'finances'.  I am continuing to learn about market factors and group process issues in the profession which senior colleagues often seemed to have learned long ago. Some of the senior medical administrators have over the years helped me immensely in understanding issues from a broader base than I'd originally seen them.  I have been very fortunate to have such colleagues.

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