Monday, June 4, 2018

Doctor-patient sex and professional self-regulation

The topic that has attracted the largest readership on this blog is doctor-patient sex. In the past 10 years the 29 posts I've written on the topic have received 75,000 hits. An article in today's Boston Globe focuses on an aspect I've discussed only briefly thus far - professional self regulation.

The story concerns a complaint from Ms. Lisa Grover that Dr. Melvin Rabin, the psychologist she sought out when her marriage broke up, drew her into a sexual relationship. Grover's allegations dramatize the way "boundary crossings" like calling the patient at home "just to talk," calling the patient a "special person," and hugging at the end of the appointment, can lead, over time, to "boundary violations" like sex. Apparently Grover brought a malpractice action against Rabin which, the article reports, was "settled for an undisclosed sum."

In February 2016 Grover complained to the Massachusetts Board of Registration of Psychologists, but the case is still "open" and Dr. Rabin's license is still unrestricted.

A core component of the implicit contract between the health professions and society is that in exchange for the autonomy and trust society gives to the professions, the professions will regulate themselves with regard to quality and integrity. Two years is much too long for a professional board to leave a serious complaint like Ms. Grover's unsettled.

In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:

First and foremost, safety for patients. If the board believes Ms. Grover's accusations, it should have suspended Dr. Rabin's license. A therapist who acted as Ms. Grover describes should not have an unrestricted license, which allows unrestricted, unmonitored access to patients. What Ms. Grover describes, if true, is very serious misconduct.

But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.

I know this first hand.When I joined the Harvard Community Health Plan practice in 1975, one of my first patients was a sensitive and vulnerable young woman with a mild autism spectrum disorder. The treatment was proceeding well until I cancelled an appointment because I was going away. My patient contacted the psychiatry board to complain that I had molested her. Psychologically my cancellation felt to her like a "molestation." By the time I heard from the board my patient and I had resumed meeting and the treatment was again on track. She explained that she had been upset by the cancellation and apologized for what she said to the board. I didn't appreciate at the time just how serious a threat a false accusation could be.

To the credit of the Boston Globe, the headline to the article refers to an "alleged betrayal." But if the Board does not believe Ms. Grover, it should have closed the case by now. Two years is too long for the case to be in limbo. A false accusation is a serious injury to the clinician.

Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the Boston Globe does the opposite.

(In addition to the Boston Globe article describing Ms. Grover's allegation, readers may be interested in an interview with Dr. Rabin in which he describes himself and his approach to therapy.)

Wednesday, May 30, 2018

Loneliness and Health

It's easy to make jokes about the British "Minister of Loneliness," as Steven Colbert did when Theresa May announced creation of the new position this winter. But for several decades we've known that loneliness isn't a joke - it's a significant risk factor for poor health and premature death.

Here's how Vivek Murthy, the former Surgeon General, explains the health impact of loneliness:

...Over thousands of years, the value of social connection has become baked into our nervous system such that the absence of such a protective force creates a stress state in the body. Loneliness causes stress, and long-term or chronic stress leads to more frequent elevations of a key stress hormone, cortisol. It is also linked to higher levels of inflammation in the body. This in turn damages blood vessels and other tissues, increasing the risk of heart disease, diabetes, joint disease, depression, obesity, and premature death.

Understanding the toxicity of loneliness has implications for public policy and health care practice. The UK ministry exemplifies a public policy action. But my interest for this post is health care.

Physicians are overburdened with requirements, but asking about our patients' social connectedness is central to understanding them. Loneliness is often the result of illness. People who are ill may withdraw from the social world, and sometimes others may withdraw from them. And loneliness can cause vulnerability to illness and diminish the resilience we need to recover.

In my psychiatric practice I sometimes took out my prescription pad and wrote instructions like "talk with a friend at least once every day" to dramatize my belief that in many circumstances, persons could be more effective than pills. And I kept a file with resources patients mentioned: AA and NA groups, Alliance for the Mentally Ill support programs, and more. Over time this helped me suggest venues that aligned with my patients' temperaments for those who might benefit from the right kind of peer support.

When I was asked to start an HMO outpatient program for patients with chronic mental illness I surveyed the literature for guidance. While the term "loneliness" wasn't used, the most promising models were group-based programs with an informal, friendly and welcoming atmosphere. For several years I had the privilege of being the psychiatrist who met with the group. Patients could come as often or as rarely as they wished. When a patient had a question about medication of some other aspect of treatment, I could usually direct the question to another patient with first hand experience of the treatment in question. Patients often became friends.

The widening recognition of loneliness as a toxic state and meaningful social connection as a health promoting factor is a positive step for health care. But, unfortunately, valuable insights can be drowned in bureaucratic regulations. Reducing inquiry about loneliness to a required checklist of questions risks coming across to patients as sterile and perfunctory, and to physicians as one more requirement in the ever-lengthening list of externally driven expectations.

But when interest in the social texture of our patients' lives is part of the clinician and patient coming to know each other as human beings and collaborating in service of health, both parties will gain.

Monday, January 8, 2018


Dear Readers
This is a belated post to explain that I'm taking a hiatus from the blog. My plate has been rather full in recent months and there have been some health matters to deal with. I look forward to returning to regular posting in the spring.
Best to all

Wednesday, July 26, 2017

Encouraging democratic values in English class

On July 21 I conducted a workshop with a group of teachers who are students at the Bread Loaf School of English, a Middlebury College program in which they can get a Master's degree in English in the course of 4-5 summers. We'd set as the topic the question of whether and how teachers should bring their own moral and political perspectives into the classroom.

To my surprise we didn't address the question head on. After the session I realized that we'd stepped back from the explicit question to discuss the issues that underlie it and from which it arose. Unfortunately, I wasn't smart enough to recognize what was happening during the session, so I couldn't connect the discussion we had with the question we'd posed.

In retrospect I believe the question we posed arose from a sense on the part of a number of teachers that self-disclosure was necessary (a) to advance important goals for the class or (b) to counter what the teachers saw as seriously "wrong" student values. The National Conference of Teachers of English (NCTE) statement on Academic Freedom presents fostering democratic values as a central objective for English teachers:
NCTE maintains that students have the right to materials and educational experiences that promote open inquiry, critical thinking, diversity in thought and expression, and respect for others. [Academic freedom] not only serves the common good but also enhances academic integrity and the overall quality of education  
But the statement warns teachers and schools against indoctrination:
Educators and educational institutions must not require or coerce students to modify their beliefs or values. Efforts to convince students to modify their beliefs or values must be academically justifiable.
If promoting open inquiry, critical thinking, diversity in thought and expression, and respect for others is a central goal for English class, the question of whether to bring our own moral and political perspectives into the classroom should be judged by whether doing so is needed to promote those underlying goals. What happened in the workshop is that the teachers jumped past the question of self-disclosure to focus on techniques that promote the democratic values. They referred to the Kipp School approach, the Quest to Learn Schools, and others. The implicit message was - if we can develop a classroom environment that encourages the values of democratic deliberation, self-disclosure is not required.

A teacher gave an example of a student who espoused highly discriminatory attitudes towards immigrants. The teacher was tempted to offer his own different values as a "corrective" to the student's views, but over time the student came to recognize that some painful experiences of his own had led him to views he could no longer accept. In this way the aim the teacher contemplated pursuing via self-disclosure was achieved without self-disclosure.

A comment made by one of the participants - "I think less about what I’m saying and more about what structures I’m setting up" - reminded me of a key lesson I learned many years ago from Irving Yalom's superb book Theory and Practice of Group Psychotherapy. According to Yalom the most valuable contribution by group therapists was fostering a culture of inquiry, diversity of thought and expression, and respect for others, not their insights into psychodynamics. I took from Yalom's teaching that if a therapy group developed and maintained a constructive therapeutic culture, the healing process would, in effect, take care of itself.

The teachers in the workshop suggested that something similar was true for English class. With regard to the character development goals for the class, a constructive democratic ethos would generally lead to the desired results.

Although we did not discuss the initial question at any length, one participant strongly supported the view that teachers could bring their own moral and political perspectives into class discussion without squelching students in their independent reflection or violating the NCTE guardrail against indoctrination. This is a question I've thought about a lot from the perspective of medical ethics. Perhaps we'll come back to it in another workshop next summer.