Physician Patient

Archive for January 8th, 2011

Doctor-Patient Boundaries: Road Rules and Red Flags

Saturday, January 8th, 2011

Boundaries are the “rules of the road” that define and secure professional, trusting, therapeutic relationships between doctors and patients. Respecting and understanding boundaries between professionals and patients are essential for optimal therapeutic outcomes. And defining and enforcing professional-patient boundaries are key to assuring the public that doctors seek to do no harm to patients.

Establishing and maintaining professional roles and interpersonal boundaries are the sole responsibility of the physician and other treating clinicians. The time-honored doctor-patient relationship first described in Hippocratic texts 2,500 years ago framed expectations that the patient must be able to be truthful with the doctor; and that the doctor will safeguard the patient’s confidences, know and respect the patient’s beliefs and expectations about his illness, and be caring and nonjudgmental in treating the patient. [See the American Medical Association’s “Principles of Medical Ethics,” on the AMA Web site, www.ama-assn.org.]

Likewise, patients are to refrain from asking the doctor to be dishonest or unethical; and if they do, the doctor must resist temptations to engage in unethical conduct with a conviction that to do otherwise will impair the patient’s recovery or best possible outcome. Moreover, patients are obligated to tell the doctor their fears and report when they have not taken the doctor’s advice.

Doctors have the responsibility to avoid and interrupt potential conflicts of interest between their professional duty to their patients and their personal interests. This cornerstone of medical ethics justifies the physician’s privileged access to very personal information about the patient’s physical and mental condition, and permits the patient to trust that the physician will act in the patient’s best interests. Only when people feel safe in a professional relationship can they entrust the doctor with their most private emotional, psychological and physical secrets.

Patients need to be aware of “red flags” that may indicate breaches of their doctor’s professional duty to them. For example, when a doctor engages in a substantial outside business relationship or invites or has an intimate relationship with a patient, the doctor’s emotional, personal or financial interests present a conflict of interest and impair his or her ability to provide optimal care. If a doctor is intoxicated or impaired when practicing medicine, he or she is violating medical ethics. Moreover, how the doctor is paid, by whom, and for what can skew the doctor’s focus away from the patient’s best interests; for example, if the doctor is rewarded for not seeing patients, gets bonuses for withholding care, or is paid extra for tests and procedures that he or she does not personally provide, supervise, or authorize.

Supporting and clarifying boundaries

Careful tending of a doctor-patient relationship by both the patient and the doctor will improve the quality of care the patient receives and flag inappropriate behavior. Rather than being barriers to care, healthy professional treatment boundaries greatly enhance the healing power of the doctor-patient relationship. Toward the goal of empowering patients and doctors to build and maintain healthy doctor-patient relationships, the sidebar gives some tips for patients and questions for them to ask their doctors and clinicians when improving their doctor-patient relationships.

There are times when doctors or patients should disqualify themselves from a relationship. Adhering to the principle of “once a patient, always a patient” preserves the clinician’s role and fosters patient safety, independence, privacy, and autonomy. A prior intimate personal relationship with a patient presents ethical problems for the doctor, depending on the intensity, nature and duration of the relationship. Medical practitioners may engage in friendships with their patients, but caution always should be a guide when doctors and other clinicians consider treating a friend, just as most doctors do not treat family except in urgent circumstances. This is because their past and present personal involvement could cloud their professional judgment.

Regulating professional misconduct

A vital and lawfully mandated function of all Minnesota clinician licensing boards is to protect patients from harm caused by licensees under their regulatory scrutiny. Minnesota licensed psychologists, clinical social workers, nurses, and chiropractors are responsible to their respective state boards, and the Minnesota Department of Health has overseen unlicensed mental health therapists.

The Minnesota Board of Medical Practice (BMP) (www.bmp.state.mn.us) oversees 18,000 physicians. The board is authorized by Minnesota law to identify and deal with physicians and other licensees who show “unprofessional conduct” (defined as departures from minimal standards of acceptable and prevailing medical practice) and “unethical conduct” (behavior likely to deceive or defraud patients). The medical board also seeks to identify doctors who are “incompetent,” e.g., as a result of illnesses, including alcoholism and substance abuse. Importantly, unlike the case for malpractice suits, it is not necessary for the patient to have suffered damages in order for the BMP to justify a finding of “unprofessional” or “unethical” conduct for a licensee doctor.

Many complaints to the BMP concern perceived or real complaints of professional boundary violations. In the year ending June 2004, the BMP received 941 complaints. Thirty-three percent were from aggrieved patients, 13 percent from family members, 14 percent from professional liability malpractice settlements (based on presumption of damage due to the negligence of the doctor), and 13 percent from other physicians, nurses, or health care personnel. The specific charges in the 941 FY 2004 BMP complaints included unprofessional conduct (34 percent); incompetency/unethical conduct (34 percent); and sexual misconduct (2 percent).

After investigating the FY 2004 complaints, the board issued 204 formal orders including reprimands, fines, educational programs (e.g., completion of a course on professional boundaries), supervision, and (rarely) license suspensions. Twenty-three percent of the orders were for clinician chemical dependency; 20 percent for illness; 15 percent for unprofessional conduct; 14 percent for unethical conduct; and 2 percent for sexual misconduct with a patient.

The BMP also supports an independent diversion program, the Health Professional Services Program (HPSP), to evaluate and rehabilitate physicians who self-report misconduct and agree to supervised conditions of treatment and monitoring. HPSP protects the public from impaired physicians, who do often regain their competency, self esteem, and can return to ethical clinical practice. A doctor or clinician in HPSP may practice with degrees of supervision and monitoring while undergoing psychiatric, medical, or chemical dependency treatment.

Doctor-patient sex

Doctors who serve as reviewers and consultants for the Minnesota Board of Medical Practice ponder the patterns and characteristics of those physicians found guilty of sexual misconduct by the medical board. Of particular note is the slippery slope of escalating interpersonal boundary violations, which may ultimately result in doctor-patient sex. This process may begin with hugs in the office, holding hands, or end-of-day, unusually long, or off-hours appointments, and may progress to a rendezvous outside of the clinic setting. In many cases, these physicians have abused alcohol, illicit drugs, or prescription medications, and/or had untreated mental disorders. A small number, the rare sociopathic doctors, sexually exploit patients simply because they believe they can get away with this behavior.

Doctor-patient sex is against the law in Minnesota, and doctors can go to jail for this behavior. The rationale for criminal status is the inherent imbalance of power in the clinical doctor-patient relationship. Consenting sex, by law, is therefore not possible (similar to the case for statutory rape involving minors).

Dealing with questionable behavior

The paragraphs below deal with situations that concern potential “red flag” situations involving patient-physician boundaries.

  • What should patients do or say if a physician asks to see them away from the office or after regular office hours? Ask the doctor about the purpose of the meeting. If the purpose is nonprofessional, decline the request and promptly contact the clinic manager or another doctor in the clinic to report the incident. In response, the clinic manager or professional colleague will validate your concerns, address the incident with the physician, and meet personally with you soon afterwards. The doctor and clinic must address your concerns about safety and professionalism. You may decide to see another doctor or transfer to another clinic, and you may decide to report the incident to the BMP.
  • How should patients respond if a physician touches them in an inappropriate way? In the clinic setting, ask to have a nurse or attendant come into the examining room. Then, state your concern to the nurse and also notify the clinic administrator. File a complaint with the BMP.
  • What should a patient do if a physician appears to have been drinking or is high on drugs? Ask a nurse or other staff person to come into the treatment setting. Notify the clinic administrator. Register a complaint with the BMP.

Lee H. Beecher, M. D., is a psychiatrist in private practice in St. Louis Park, president of the Minnesota Physician-Patient Alliance (MPPA), a clinical associate professor of psychiatry at the University of Minnesota, and a trustee of the Minnesota Medical Association.

Tips on improving your doctor-patient relationships

  • Don’t mix professional relationships with intimate ones. Doctors are rewarded by doing the work of being physicians and are paid for this professional privilege. Combining sex and doctoring is bad medicine for both patients and doctors. Sigmund Freud called the prohibition on doctor-patient sex the “Rule of Abstinence” necessary rule for professional relationships.
  • When you feel embarrassed or puzzled by your doctor’s questions, say so. Ask the doctor to explain why the information is needed.
  • Inquire about data privacy and confidentiality of your medical/clinical records. Ask your doctor to record the following statement in the clinical record: “Except in emergencies, no paper or electronic medical records are to be released to any party outside of the clinic organization without my expressed written consent.” Ask that no records be released to any party in non-emergencies without your explicit written consent. Don’t withhold information that will likely affect your diagnosis and treatment. Ask to see your medical records and keep your own file, including lab tests and medications.
  • Know and document the training and licensing credentials of key clinicians involved in your care. If you have concerns about unethical or unprofessional conduct from your clinician, talk to your doctor or clinic administrative personnel. You can also contact the Minnesota Board of Medical Practice or the clinician’s professional licensing body to consider filing a complaint.
  • Be clear about the expected length and content of treatment sessions and recommended methods and plan of care (including medications).
  • The fee is a proper and necessary ingredient of the doctor-patient contract. Ask your doctor to disclose all insurance arrangements (e.g., capitation, case rate caps, payment withholds and pay-for-performance incentives) involved in your case. Such financial facts directly impact the nature of the doctor-patient alliance and are not only the insurance company’s concern.
  • Discuss expectations for treatment, including scientific evidence and treatment rationale with your doctor and treatment team. What treatments have worked and what didn’t? What are the pros and cons of specific treatment recommendations? Tell your doctor exactly what you have and haven’t done (including taking medications or not) to allow assessments of your adherence to doctor’s recommendations.

Medications for Depression: a consumer guide

Saturday, January 8th, 2011

Depressive disorders affect people of all ages and walks of life, including children and elderly people. About one in ten of us will suffer with clinically significant depressive symptoms in a given year. Common symptoms of depression include trouble concentrating mentally, loss of energy and enthusiasm, waking frequently or not sleeping restfully, nervousness, excessive sadness, self-critical or angry preoccupations, feelings of worthlessness, and, not infrequently, suicidal thoughts in varying degrees. Depression decreases productivity at work and heightens conflicts in personal and work relationships.

The cause of depression is an imbalance of brain chemicals, but currently there is no blood test for depression. Skillful psychotherapy can help change brain chemistry for the better, as can antidepressant medications. Depression may be associated with stressful life events such as major disappointments, separations, deaths, job loss, financial stress, and conflict with relatives. Alcohol and illicit drug use are very frequently associated with depression, and should never be overlooked or minimized as a significant factor. Other medical conditions (e.g., low thyroid hormone levels, anemia, diabetes) and prescribed medications to treat them (e.g., steroids, sedatives, chemotherapy, and blood pressure–lowering drugs), as well as herbal products containing ephedrine, can cause or contribute to depression. Clinical depression frequently accompanies any chronic medical condition that causes significant disability or threatens length or quality of life.

Diagnosing and treating depression

Successful treatment of depression requires study of the patient’s history of depression and treatment. This means you and your treating health professionals need an accurate story of your depression. To treat you effectively, your doctor needs to know answers to questions such as these: When did the symptoms of depression start? Did they begin gradually or suddenly? Has your mood changed suddenly or gradually, or gone down and up, from sadness to agitation? Has the course of your illness been associated with the use of medications, alcohol, or illicit drugs, or with definable events in your life? Have you had thoughts of suicide, and, if so, what steps are needed and taken to prevent a suicide attempt? Does your family know you are depressed, or at risk for suicide? Do you or members of your family have a history of symptoms of or treatment for depression, mental disorders, or substance abuse?

Studies have shown that if a person has severe and recurrent depression, long-term antidepressant therapy (a year or longer) is often the best treatment recommendation. Psychotherapy, which involves talking-thinking-deliberating-planning in a professional-patient relationship, is usually a vital component of optimal treatment for depression.

Who sees patients with depression?

Medical and mental health treatment professionals have different types and degrees of training. Most licensed personnel have some familiarity with the training of others, and they often work collaboratively in clinic or hospital settings. In Minnesota, all prescriptions for antidepressants are written by physicians or persons under a physician’s supervision or scrutiny.

  • Psychologists (master’s degree or Ph.D.) have completed graduate school in psychology, do not have medical school training, and do not prescribe medications in Minnesota. They can diagnose depression and many provide psychotherapy.
  • Nurses specializing in mental health, nurse practitioners (N.P.s), and physician assistants (P.A.s) can prescribe antidepressants under supervision of a physician. Patients should contact their physician if they have unanswered questions or concerns about their prescriptions.
  • Clinical social workers (L.I.S.W., L.I.C.S.W.) have training in psychotherapy. Some are licensed as family therapists.
  • Primary care physicians prescribe most antidepressants in Minnesota. Primary care physicians include pediatricians, family practitioners, internists, obstetricians/gynecologists, and rehabilitation medicine specialists.
  • Psychiatrists are physician specialists who have completed training residencies of three to five years in adult or child psychiatry beyond medical school and internship. Most psychiatrists are board certified by the American Board of Psychiatry and Neurology; some have board certifications in addiction or geriatrics psychiatry. Child psychiatrists have special training and clinical experience in child psychiatry; fewer than 100 child psychiatrists are available statewide.

Most patients in Minnesota get their antidepressant medications from family physicians, pediatricians, internists, and clinic nurses. Most of the state’s 700 practicing psychiatrists see patients in hospitals, outpatient clinics, or private offices to provide diagnostic assessments and to prescribe or monitor psychotropic medications (including antidepressants). Medical consultants in alcohol and drug rehab programs can prescribe antidepressants for patients whose depressive or mood symptoms do not substantially improve during chemical dependency care or recovery programs.

Some psychiatrists, usually in private practice, provide a combination of psychotherapy and medication (integrated treatment) to treat depression. In split-treatment arrangements, the psychiatrist prescribes medications while others provide the psychotherapy, as is the rule in most large behavioral clinics and mental health centers. Coordination of care is very important.