Federal health reform is the front page news, but states and businesses are the laboratories for change. Next to Governors, who have to deal with hideous budget problems driven by declining revenues and escalating Medicaid costs, employers who offer health insurance to their employees are most directly concerned about health care costs.
Health reform requires three ingredients: (1) facing facts, (2) thinking strategically and (3) embracing individual and population concerns. Given the virulent divisiveness of current U.S. politics, employers who offer health insurance are the most promising venue for applying this triad in a "businesslike" manner!
In previous posts I've written about how IBM promotes primary care and encourages employees to find a medical home (here), how Foundation Coal and Peabody Energy understand and act in accord with comparative effectiveness concepts (here), and how the Hannaford supermarket chain rewards employees who have surgical procedures like joint replacement in Singapore, where high quality services are available at lower cost (here). An article in yesterday's New York Times - "Health Care Savings Could Start in the Cafeteria" - describes a pilot collaboration between employers, a health plan, and The Full Yield, a start up health improvement company.
Starting in January, employees at John Hancock and the City of Boston will be able to enroll in a year-long Full Yield program that will provide access to healthful prepared meals, nutrition coaching, and other self-management tools. At John Hancock participants will get $100 worth of coupons that can be used at the office cafeteria and at local supermarkets that carry the Full Yield products. At the City of Boston, participants will have a series of biometric measurements taken at least three times during the year. The Full Yield is partnering with Harvard Pilgrim Health Care, the not for profit insurance company for which I run the ethics program, to administer and evaluate the program.
The Safeway company has apparently achieved the near-miracle of keeping its employee health insurance costs level since 2005. Steven Burd, the CEO, attributes its success to "creating a culture of health," part of which involves incentives for managing tobacco use, healthy weight, blood pressure and cholesterol levels. For achieving targets in those four areas, employees can reduce their contribution to health insurance premium, by up to $780 per year for individuals and $1,560 per year for families. (see here)
Incentives - especially if they're guided by insights from behavioral economics - work. (See, for example, this article in JAMA by Kevin Volpp and colleagues.) And, since obesity is a highly stigmatized condition that tracks closely with socioeconomic status, the wrong kinds of incentives could reinforce prejudice and discriminate unjustly. But those risks are reasons to use incentives carefully and monitor for negative impacts as well as success - just as good clinicians do for the treatments they administer - not reasons to avoid incentives altogether.
I continue to believe that employer/employee collaboration on behalf of promoting health and constraining health care costs within the workplace "family" is an extremely promising approach to transforming our national health non-system!
Monday, November 30, 2009
Wednesday, November 25, 2009
Doctor-Patient Sex: Why is it Unethical?
Earlier today I responded to the following anonymous response to a post I wrote in April about doctor-patient sex:
Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.
What is the actual harm to the patient? I have found countless articles and sites that claim dr. patient sex is "obviously harmful to the patient." Well, I am not a medical professional and not all the reasons are obvious to me. I am however somewhat of a victim in this sort of case (with a diagnostic consultant) and am trying to understand what happened. All I know is he gave me hope and then killed it through abandonment, etc. He made lots of promises and didn't keep them.
The comment got me thinking. To the best of my knowledge, every medical specialty in all of the countries whose medical ethics I'm familiar with finds doctor-patient sex unethical. But as the questioner noted, it's not clear what the basis of that ethical condemnation is.
I did some on line browsing in the literature and came upon an excellent article - "Arguments for Zero Tolerance of Sexual Contact between Doctors and Patients" - by R.M. Cullen, a GP in New Zealand.
Dr. Cullen examines four common justifications of the zero tolerance view of doctor-patient sex and finds them all inadequate to the task:
- Sex with patients is always harmful. Cullen points out that the evidence base for this conclusion is skimpy. There are no surveys of large numbers of patients who have had sex with their physicians to see how many have been harmed. What we have is powerful case reports of individual situations that were harmful to specific individuals. These don't prove that doctor-patient sex is inevitably harmful.
- Sex with patients always violates the principles that define an ethical sexual relationship: trust, equitable power balance, and consent. Cullen quotes a position paper by the College of Physicians of Ontario that concludes that because of the inevitable power imbalance between physician and patient, valid consent is never possible. But here too it is possible to imagine doctor-patient relationships that do not violate the principles.
- Sex with patients is always inconsistent with the virtues that characterize the ethical physician. Here Cullen cites an argument that to be ethical a physician must be self-effacing and self-sacrificing, and that these virtues rule out deriving sexual satisfaction with a patient. Once again Cullen concludes that we can imagine circumstances in which a self-effacing and self-sacrificing doctor falls in love with a patient and is loved in return.
- Finally, Cullen considers the argument that the intrinsic nature of medicine may forbid sexual contact with patients on an a priori basis. Edmund Pelligrino makes the strongest argument of this kind, in "Toward a Reconstruction of Medical Morality" and elsewhere. Pellegrino argues that three phenomena – the fact of illness, the act of profession, and the process of care – if understood properly, provide a coherent basis for professional ethics, including the prohibition of doctor-patent sex. But here, too, Cullen finds it possible to postulate examples that could evade this perspective.
Cullen's own argument for the zero tolerance position is simple and practical:
It first attempts establish that, as a matter of policy, sexual contact between doctors and patients ought to be prohibited. Then, [it asserts] that doctors have a moral obligation to comply with such a prohibition. If this is true then it follows, as a matter of definition, that doctors who have sexual contact with patients have behaved immorally.Cullen argues - in my view correctly - that it is not necessary to prove that every instance of doctor-patient sex will be harmful, contrary to principles and virtues, or inconsistent with the fundamental nature of medicine, to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero tolerance ethical stance based on (a) the potential for harm to the patient with (b) no offsetting potential benefits for the patient, combined with (c) the inevitable harm to trust in the medical profession itself, and via that loss of trust, loss of healing capacity.
[This] counterfactual argument may be summarised as:
Proposition. If sexual contact between doctors and patients were allowed then there would be unacceptable consequences.
Conclusion. Sexual contact between doctors and patients should not be allowed.
Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.
Monday, November 23, 2009
Drew Altman on President Obama's Leadership
There's been lots of debate as to whether the President has been a wise leader or a wimpy neophyte in the health reform process. I've felt that as discombobulated as things have been, we couldn't realistically hope for a more linear unfolding, and that the President is doing things right.
In his superb series of "Pulling it Together" columns, Drew Altman, President and CEO of the Kaiser Family Foundation, nailed the leadership issue earlier today. He argues that President Obama has been wise to keep his cards close to his chest so far, and that the time to come on strong about his detailed positions will be "when there is a bill in conference; then again when that bill moves from conference to the floor of the House and the Senate and is the focus of intense lobbying and national debate." It's a (short) column well worth reading.(See here for the column.)
In his superb series of "Pulling it Together" columns, Drew Altman, President and CEO of the Kaiser Family Foundation, nailed the leadership issue earlier today. He argues that President Obama has been wise to keep his cards close to his chest so far, and that the time to come on strong about his detailed positions will be "when there is a bill in conference; then again when that bill moves from conference to the floor of the House and the Senate and is the focus of intense lobbying and national debate." It's a (short) column well worth reading.(See here for the column.)
Death Panel Plots and Mammogram Conspiracies
A number of friends are in despair over the possibility of rational political and public reflection about health policy.
I'm not.
Perhaps I'm a cockeyed optimist, but I see the summer's folly about death panels and the eruption about the Preventive Services Task Force recommendations as part of a societal learning process.
In the teaching I do about health care limits I often point out that limits are part of sharing finite resources within a population and that the way we learn about sharing as children teaches important political lessons.
Sharing toys doesn't come naturally. Parents (a) give cognitive messages ("it's fair that Johnny gets a turn with the toy") (b) provide emotional succor for the tantrums that follow, while (c) being firm about the need to share in order (d) not to raise selfish monsters. This process takes lots of time.
Some of the death panel madness was fomented by duplicitous politicians and talk radio hosts, just as we saw during the Bush years at the end of Terri Schiavo's life. But some people truly experienced the idea of end of life counselling as an assault on life and freedom by a death-dealing government. If 2 year olds could speak as adults I expect that they would respond to being asked to share their toys in similar fashion - "This toy means my whole life to me - you're killing me by asking me to share it - this idea of sharing is worse than a death panel!" We don't expect the child to learn all at once, and we can't expect the same from the body politic.
Unfortunately, the duplicitous politicians and audience-hungry talk show hosts are like bystanders who would rush up to the child having a tantrum to say - "you're right - it's outrageous that you've been asked to share your toy - your parent is a socialist!" This will make the learning harder and slower.
The mammogram furor is related, but different. The ever-changing recommendations are genuinely confusing, and people of intelligence and integrity can reasonably disagree. But seeing a government plot in the very idea of the new recommendations has to be understood in light of Kubler Ross's stages of grief theory. Recognizing that mammograms are not a magic bullet that can be counted on to ward off breast cancer confronts us with mortality. Denial of the epidemiological facts about the limitations of the test, combined with our suspicion that the government is a harsh parent insisting that we share all that is important to us with others, underlies some of the backlash we are seeing.
For those who understand the need for limits and for evidence-based health policy, what's needed is the patient persistence that good parents have in teaching us to share. This doesn't mean that fellow citizens who understand end of life counselling to mean death panels or see epidemiology as government conspiracy are childish. Surprising as it is to those of us who obsess about health policy and health system ethics, not everyone has been wonkishly immersed in these issues. Societal learning takes time.
The differential diagnosis between between an honorable person on a learning trajectory and a duplicitous politician can be difficult. But it's hard to believe that people as smart as Newt Gingrich and John Boehner really believe the death panel drivel they indulged in. I leave it to Rahm Emanuel to devise the best responses to duplicitous opportunism. But for all those who are open to learning, President Obama's ability to explain and inspire are what's needed. And as wise parents know, he'll have to do it again and again!
(For an excellent discussion of playground learning, see Steve Almond's op ed here. And for an important analysis of the death panel madness, see a discussion by Representative Earl Blumenauer here.)
I'm not.
Perhaps I'm a cockeyed optimist, but I see the summer's folly about death panels and the eruption about the Preventive Services Task Force recommendations as part of a societal learning process.
In the teaching I do about health care limits I often point out that limits are part of sharing finite resources within a population and that the way we learn about sharing as children teaches important political lessons.
Sharing toys doesn't come naturally. Parents (a) give cognitive messages ("it's fair that Johnny gets a turn with the toy") (b) provide emotional succor for the tantrums that follow, while (c) being firm about the need to share in order (d) not to raise selfish monsters. This process takes lots of time.
Some of the death panel madness was fomented by duplicitous politicians and talk radio hosts, just as we saw during the Bush years at the end of Terri Schiavo's life. But some people truly experienced the idea of end of life counselling as an assault on life and freedom by a death-dealing government. If 2 year olds could speak as adults I expect that they would respond to being asked to share their toys in similar fashion - "This toy means my whole life to me - you're killing me by asking me to share it - this idea of sharing is worse than a death panel!" We don't expect the child to learn all at once, and we can't expect the same from the body politic.
Unfortunately, the duplicitous politicians and audience-hungry talk show hosts are like bystanders who would rush up to the child having a tantrum to say - "you're right - it's outrageous that you've been asked to share your toy - your parent is a socialist!" This will make the learning harder and slower.
The mammogram furor is related, but different. The ever-changing recommendations are genuinely confusing, and people of intelligence and integrity can reasonably disagree. But seeing a government plot in the very idea of the new recommendations has to be understood in light of Kubler Ross's stages of grief theory. Recognizing that mammograms are not a magic bullet that can be counted on to ward off breast cancer confronts us with mortality. Denial of the epidemiological facts about the limitations of the test, combined with our suspicion that the government is a harsh parent insisting that we share all that is important to us with others, underlies some of the backlash we are seeing.
For those who understand the need for limits and for evidence-based health policy, what's needed is the patient persistence that good parents have in teaching us to share. This doesn't mean that fellow citizens who understand end of life counselling to mean death panels or see epidemiology as government conspiracy are childish. Surprising as it is to those of us who obsess about health policy and health system ethics, not everyone has been wonkishly immersed in these issues. Societal learning takes time.
The differential diagnosis between between an honorable person on a learning trajectory and a duplicitous politician can be difficult. But it's hard to believe that people as smart as Newt Gingrich and John Boehner really believe the death panel drivel they indulged in. I leave it to Rahm Emanuel to devise the best responses to duplicitous opportunism. But for all those who are open to learning, President Obama's ability to explain and inspire are what's needed. And as wise parents know, he'll have to do it again and again!
(For an excellent discussion of playground learning, see Steve Almond's op ed here. And for an important analysis of the death panel madness, see a discussion by Representative Earl Blumenauer here.)
Wednesday, November 18, 2009
In Defense of "Bean Counters"
I've been speaking about health reform and managed care in different venues around the country. With regard to cost containment I often hear the phrase "bean counters" - as in "Do you want bean counters controlling your life by reducing your medical care to a set of numbers?"
This post is in praise of the much abused act of "bean counting."
When I first began to practice at the not-for-profit Harvard Community Health Plan HMO in 1975 I had a young patient with severe alcoholism. While drunk he got into a fight and was admitted to a psychiatric hospital. I'd been in charge of a psychiatric hospital unit before coming to the HMO and I knew that my patient would be better served by an alcohol treatment program, which would also, it happens, be cheaper. That's the basic definition of win/win.
But when I called the attending psychiatrist about my patient, to urge discharge to my care, I heard him say to the chief of the unit, who had been a teacher of mine during residency - "I have Sabin on the phone...he used to care about patients, but now he cares about money!"
I was really p - - - - d off by the comment, but it led to many years of thinking about how our health system can do a better job of caring about patients and caring about money. (See here for an article I wrote with that title 15 years ago.) I've come to use a framework that encourages all participants in health care to embrace two core values – compassionate fidelity to the needs of individual patients and responsible stewardship of the resources we place in public and private insurance pools.
Fidelity is about individuals. Stewardship is about populations. These two values are the pillars of an ethical health system.
Fidelity - the commitment to seek benefit for the patient and to avoid doing harm - has been at the heart of medical ethics since the time of Hippocrates. As long as health care was a transaction between a single patient and a single physician paid for by the patient’s own funds (or by barter), there was no need for insurance. Population concerns and stewardship were not important considerations.
But as health care became more complex and vastly more expensive societies created insurance mechanisms through which people pool funds to help them pay for care when they need it. In countries like Canada and England, where coverage is universal and paid for by taxes, the ethical importance of stewardship is easy to understand. As important as health care is the public has many uses for its funds. These societies see responsible stewardship as a moral requirement
In the complex U.S. health system it is much harder for the population and its leaders to understand how insurance funds are created. As a result, our society has not recognized stewardship as an ethically justifiable process. That's how we've come to demean attention to the cost of care as “bean counting.”
In the mind of the public (and some political leaders) “stewardship” is often confused with “rationing.” In health care, rationing refers to withholding beneficial services, such as very expensive cancer therapies, because of their cost. In reality, stewardship is the best way to avoid a need to ration! Responsible stewardship by insurers involves (a) seeking elimination of interventions that are not needed but can cause harm (as by side effects), (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly but unnecessary test today, and (c) careful contracting. The more insurers do (a) - (c) the less need society will have to (d) ration - in the sense of deliberately choosing not to provide interventions likely to be beneficial.
Stewardship isn't just a job for public and private insurers. It's best seen as a responsibility for all who are concerned with health and health care. As individuals we are stewards of our own well-being, even if most of us do a poor job. The provider community - physicians, nurses and other clinicians - is in the best position to differentiate between efficient and inefficient health care and to provide what patients need in the right way, at the right place, at the right time. And the employers who pay for insurance would rather invest more in employee wages and research and development than in ever-increasing health care costs.
Ideally, the health reform process would move our society along a learning curve towards better understanding and appreciation of the moral importance of stewardship. But so far the voices changing "bean counters - up against the wall!" have been the loudest.
This post is in praise of the much abused act of "bean counting."
When I first began to practice at the not-for-profit Harvard Community Health Plan HMO in 1975 I had a young patient with severe alcoholism. While drunk he got into a fight and was admitted to a psychiatric hospital. I'd been in charge of a psychiatric hospital unit before coming to the HMO and I knew that my patient would be better served by an alcohol treatment program, which would also, it happens, be cheaper. That's the basic definition of win/win.
But when I called the attending psychiatrist about my patient, to urge discharge to my care, I heard him say to the chief of the unit, who had been a teacher of mine during residency - "I have Sabin on the phone...he used to care about patients, but now he cares about money!"
I was really p - - - - d off by the comment, but it led to many years of thinking about how our health system can do a better job of caring about patients and caring about money. (See here for an article I wrote with that title 15 years ago.) I've come to use a framework that encourages all participants in health care to embrace two core values – compassionate fidelity to the needs of individual patients and responsible stewardship of the resources we place in public and private insurance pools.
Fidelity is about individuals. Stewardship is about populations. These two values are the pillars of an ethical health system.
Fidelity - the commitment to seek benefit for the patient and to avoid doing harm - has been at the heart of medical ethics since the time of Hippocrates. As long as health care was a transaction between a single patient and a single physician paid for by the patient’s own funds (or by barter), there was no need for insurance. Population concerns and stewardship were not important considerations.
But as health care became more complex and vastly more expensive societies created insurance mechanisms through which people pool funds to help them pay for care when they need it. In countries like Canada and England, where coverage is universal and paid for by taxes, the ethical importance of stewardship is easy to understand. As important as health care is the public has many uses for its funds. These societies see responsible stewardship as a moral requirement
In the complex U.S. health system it is much harder for the population and its leaders to understand how insurance funds are created. As a result, our society has not recognized stewardship as an ethically justifiable process. That's how we've come to demean attention to the cost of care as “bean counting.”
In the mind of the public (and some political leaders) “stewardship” is often confused with “rationing.” In health care, rationing refers to withholding beneficial services, such as very expensive cancer therapies, because of their cost. In reality, stewardship is the best way to avoid a need to ration! Responsible stewardship by insurers involves (a) seeking elimination of interventions that are not needed but can cause harm (as by side effects), (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly but unnecessary test today, and (c) careful contracting. The more insurers do (a) - (c) the less need society will have to (d) ration - in the sense of deliberately choosing not to provide interventions likely to be beneficial.
Stewardship isn't just a job for public and private insurers. It's best seen as a responsibility for all who are concerned with health and health care. As individuals we are stewards of our own well-being, even if most of us do a poor job. The provider community - physicians, nurses and other clinicians - is in the best position to differentiate between efficient and inefficient health care and to provide what patients need in the right way, at the right place, at the right time. And the employers who pay for insurance would rather invest more in employee wages and research and development than in ever-increasing health care costs.
Ideally, the health reform process would move our society along a learning curve towards better understanding and appreciation of the moral importance of stewardship. But so far the voices changing "bean counters - up against the wall!" have been the loudest.
Sunday, November 15, 2009
Abortion and Health Reform
The current clash about abortion and health reform is a tragedy. It reflects the breakdown of civil national discourse.
Although I'm a strong supporter of accessible abortion services, I see abortion as a a sad human event, to be avoided as much as possible.
And I respect the views of the majority of the "pro-life" community who oppose abortion in a thoughtful, conscience-driven manner and who respect those who hold the "pro-choice" position in an equally thoughtful, conscience-driven manner. Unfortunately the hate-laden screamers and the madness of committing murder on behalf of purported "reverence for life" has tainted the anti-abortion position, just as suicide bomber-murderers have tainted the noble traditions of Islam.
If Representatives Stupak and Pitt, their supporters, and the Conference of Bishops, were simply trying to ensure that health reform would continue the 33 year history of the Hyde amendment in prohibiting direct federal funding of abortion, I would be with them. (See here for the wording of the Stupak-Pitt amendment.) Abortion is currently an unresolvable moral conflict in the U.S. about which people of conscience cannot agree. Protecting access to abortion when states wish to fund the services or private insurance contracts include them while not allowing federal tax money to pay for abortion is a fair resolution. It won't leave anyone fully happy. That's something a mature democracy must be able to accept.
But Stupak-Pitt appears to have a much wider scope than the Hyde amendment, including prohibiting abortion in private insurance sold through any "exchange" created by the legislation. If the amendment is trying to extend constraints on abortion by hijacking health reform to achieve that aim the supporters ought to put their cards on the table and acknowledge that blackmail is their aim: "We think further restraint of abortion is more important than reforming our health system, so unless we get our way we'll block any legislation." If that's not their intent they should work with leadership to achieve a fair resolution.
Threatening to kill health reform unless abortion constraints are extended would be a misguided way of witnessing one's conscience. If abortion opponents take this path "pro-choicers" will take an equally hard line. The U.S. would miss a rare opportunity to tip toe towards greater social justice in health care.
Although I'm a strong supporter of accessible abortion services, I see abortion as a a sad human event, to be avoided as much as possible.
And I respect the views of the majority of the "pro-life" community who oppose abortion in a thoughtful, conscience-driven manner and who respect those who hold the "pro-choice" position in an equally thoughtful, conscience-driven manner. Unfortunately the hate-laden screamers and the madness of committing murder on behalf of purported "reverence for life" has tainted the anti-abortion position, just as suicide bomber-murderers have tainted the noble traditions of Islam.
If Representatives Stupak and Pitt, their supporters, and the Conference of Bishops, were simply trying to ensure that health reform would continue the 33 year history of the Hyde amendment in prohibiting direct federal funding of abortion, I would be with them. (See here for the wording of the Stupak-Pitt amendment.) Abortion is currently an unresolvable moral conflict in the U.S. about which people of conscience cannot agree. Protecting access to abortion when states wish to fund the services or private insurance contracts include them while not allowing federal tax money to pay for abortion is a fair resolution. It won't leave anyone fully happy. That's something a mature democracy must be able to accept.
But Stupak-Pitt appears to have a much wider scope than the Hyde amendment, including prohibiting abortion in private insurance sold through any "exchange" created by the legislation. If the amendment is trying to extend constraints on abortion by hijacking health reform to achieve that aim the supporters ought to put their cards on the table and acknowledge that blackmail is their aim: "We think further restraint of abortion is more important than reforming our health system, so unless we get our way we'll block any legislation." If that's not their intent they should work with leadership to achieve a fair resolution.
Threatening to kill health reform unless abortion constraints are extended would be a misguided way of witnessing one's conscience. If abortion opponents take this path "pro-choicers" will take an equally hard line. The U.S. would miss a rare opportunity to tip toe towards greater social justice in health care.
Tuesday, November 10, 2009
A Psychiatrist's Reflections on Dr. Hasan
I'm not going to speculate publicly about Dr. Hasan's psychological state, about which, of course, I know nothing. The American Psychiatric Association Principles of Medical Ethics very clearly - and in my view correctly - prohibit armchair psychoanalysis:
A central component of clinical education in psychiatry is that we clinicians need to observe ourselves as carefully as we observe our patients. Our thoughts and feelings are important sources of "data" - they can give information about our patients. In my residency the training director told us that "no human being is truly boring. If you feel bored while you're with a patient it's either because the patient is talking to hide what's important, which makes what he's saying an empty shell, or what he's saying threatens you, and your boredom is a defense."
In more than 40 years of practice since hearing that precept it has served me (and fellow residents) well. Whenever I felt bored I went into action - which of the two alternatives was going on?
The news reports suggest that the idea of criminal action entered Dr. Hassan's mind long before he carried it out. Honest human beings acknowledge that all manner of things come into their minds. The most notorious failing on the part of psychiatrists is sex with patients. The proper professional response to sexual thoughts about a patient is "differential diagnosis." Why is this reaction occurring? Is it telling me the patient is lonely, or making an erotic appeal? If so, that's the proper focus of therapeutic attention. But if the reaction is more about me, then the professional should ask - what is it telling me about myself? What do I need to do? The proper professional response is to ask for consultation when the answers aren't clear.
Psychiatric ethics are unambiguous about sexual involvement with patients - whether it is a current or former patient, sexual involvement is always unethical. If a psychiatrist found himself beginning to rationalize why the ethical principles do not apply to him it is as much of a danger signal as hearing about suicidal plans from a patient. Immediate consultation is required.
Similarly, it wouldn't be a sign of "pathology" if a thought of harming others were to enter a clinician's mind. The same training director told a story to make the point that aggressive thoughts were not in themselves unhealthy, and might even be constructive: "It was the minister's 50th anniversary of what looked like a very happy marriage. A mischievous parishioner asked 'Minsiter - tell the truth - in 50 years of marriage did you ever think of divorce?' After a moment of thought the minister responded - 'divorce, never....murder, often...'"
But if a fantasy about harming patients, colleagues or others took on a life of its own it would call for immediate consultation with a colleague and some form of corrective action. It's when aggressive and erotic fantasies are kept secret that they fester and turn dangerous.
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.Today's New York Times reported that Dr. Hasan was in contact with a jihad-supporting cleric in Yemen many months ago (see here) and that he bought the gun that was allegedly used in the crime at Fort Hood shortly after arriving in Texas. Those public reports lead me to these thoughts about psychiatric education and the ethical responsibility for self scrutiny.
A central component of clinical education in psychiatry is that we clinicians need to observe ourselves as carefully as we observe our patients. Our thoughts and feelings are important sources of "data" - they can give information about our patients. In my residency the training director told us that "no human being is truly boring. If you feel bored while you're with a patient it's either because the patient is talking to hide what's important, which makes what he's saying an empty shell, or what he's saying threatens you, and your boredom is a defense."
In more than 40 years of practice since hearing that precept it has served me (and fellow residents) well. Whenever I felt bored I went into action - which of the two alternatives was going on?
The news reports suggest that the idea of criminal action entered Dr. Hassan's mind long before he carried it out. Honest human beings acknowledge that all manner of things come into their minds. The most notorious failing on the part of psychiatrists is sex with patients. The proper professional response to sexual thoughts about a patient is "differential diagnosis." Why is this reaction occurring? Is it telling me the patient is lonely, or making an erotic appeal? If so, that's the proper focus of therapeutic attention. But if the reaction is more about me, then the professional should ask - what is it telling me about myself? What do I need to do? The proper professional response is to ask for consultation when the answers aren't clear.
Psychiatric ethics are unambiguous about sexual involvement with patients - whether it is a current or former patient, sexual involvement is always unethical. If a psychiatrist found himself beginning to rationalize why the ethical principles do not apply to him it is as much of a danger signal as hearing about suicidal plans from a patient. Immediate consultation is required.
Similarly, it wouldn't be a sign of "pathology" if a thought of harming others were to enter a clinician's mind. The same training director told a story to make the point that aggressive thoughts were not in themselves unhealthy, and might even be constructive: "It was the minister's 50th anniversary of what looked like a very happy marriage. A mischievous parishioner asked 'Minsiter - tell the truth - in 50 years of marriage did you ever think of divorce?' After a moment of thought the minister responded - 'divorce, never....murder, often...'"
But if a fantasy about harming patients, colleagues or others took on a life of its own it would call for immediate consultation with a colleague and some form of corrective action. It's when aggressive and erotic fantasies are kept secret that they fester and turn dangerous.
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