Ethical considerations in dermatology residency

Ethical considerations in dermatology residency

Clinics in Dermatology (2012) 30, 202–209 Ethical considerations in dermatology residency Amit Garg, MD a,⁎, Jane M. Grant-Kels, MD b a Department o...

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Clinics in Dermatology (2012) 30, 202–209

Ethical considerations in dermatology residency Amit Garg, MD a,⁎, Jane M. Grant-Kels, MD b a

Department of Dermatology, Boston University School of Medicine, 609 Albany St, J207, Boston, MA 02118, USA Department of Dermatology, University of Connecticut Health Center, Farmington, CT, USA


Abstract There are a number of ethical considerations relevant to dermatology training that are worthy of dialogue. In this contribution, social networking, relationships with mentors, relationships with patients, and moonlighting are discussed with the goal of encouraging ongoing discourse and reflection on these and other ethical considerations relevant to dermatology training. © 2012 Elsevier Inc. All rights reserved.

Introduction Although few training programs have focused curricula on professionalism, there is a renewed emphasis in this content area in undergraduate and graduate medical education.1 A number of ethical considerations relevant to dermatology training merit discussion, and we have chosen to elaborate on 4 topics, each introduced by real world case scenarios. These topics include social networking among residents, resident relationships with mentors, resident relationships with patients, and resident moonlighting. There are indeed debatable points and counterpoints to be made for the many ethical dilemmas faced by dermatology residencies. Our emphasis, herein, is on illustrating ethical dilemmas relevant to dermatology trainees, faculty, and patients from various perspectives as a vehicle for enduring discussion on professionalism.

Social networking: staying professional in a digital era Case: A male resident who is single actively engages in online social networking in an effort to meet women outside

⁎ Corresponding author. Tel.: +1 617 638 5523; fax: +1 617 414 1363. E-mail address: [email protected] (A. Garg). 0738-081X/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2011.06.008

of the workplace. He posts his photograph, states that he is a dermatology resident at the university clinic, and asks potential viewers if they would like a full skin exam from a qstudq like him. One of his clinic patients comes across the post and files a complaint with his residency director, the department chair, and the dean of the medical school. Counseling is arranged for the resident, and he is asked to deactivate all of his social networking accounts. Discussion: The rapid growth in popularity of Internet applications based on user-generated sharing of content, collectively termed Web 2.0, has changed ease, frequency and the spontaneity with which people communicate information about their personal and professional lives. The use of online social networking forums has become ubiquitous, particularly among a younger generation of physicians,2,3 and this has created new challenges for the professionalism component of medical training. The newer generation of medical students and physicians, raised in the information era, use online forums for social and professional networking. Such online applications include social networking sites (eg, Facebook, Twitter, LinkedIn, MySpace), media-sharing sites (eg, Flickr, YouTube), blogs, wikis, and podcasts among others. According to the Pew Internet and American Life Project, 4 46% of online American adults use social networking sites, up from 8% only 4 years earlier. Facebook, developed in 2004, alone boasts more than 400 million active users worldwide who update their Facebook status 35 million times each day.5 Approximately 100 million active users access Facebook

Ethics in dermatology residency from a mobile device, making this and other social networking forums continuously accessible. Social networking sites allow users to communicate and share information with peers via status updates and personalized online profiles. On Facebook, registered users can choose to join individual or group networks by mutual agreement. By becoming a “Friend” of another registered user, one may be granted access to that user's personal profile pages, which include information such as e-mail address; home address; telephone number; place of employment; personal photographs; political and religious affiliations; favorite book, movie, and music; relationship status; sexual orientation; membership with virtual groups; social events attended; and a searchable list of all other Friends in the user's profile. Additionally, Friends have real-time access to each others' status postings—personal communications of any nature and, often, of little discretion. These online conversations may be recorded indefinitely, searched, replicated, altered, and accessed by others who may have differing views on what is socially acceptable.6 Although social networking sites may facilitate social and also professional relationships, controversy surrounds their ethical application in medicine as health care users risk privacy, safety, and professional reputations. Without sensible and precautionary use of social networking, the delineation between professional and personal boundaries may become instantaneously obscured. Patients may come across or search for information about their doctors that is not disclosed in usual doctor-patient communication, and this may compromise the professional relationship and reflect poorly on individual professionals and affiliated institutions, as well the medical profession. Online friendships between physicians and patients have the potential to become problematic, because they may open the door to types of interactions, romantic or otherwise, that are inappropriate to the patient-doctor relationship. Social networking interactions between physicians and patients also risk leaving the patient vulnerable to loss of medical confidentiality and the physician subject to disciplinary action because of unprofessional behavior online with a patient. What trainees perceive as innocuous and risk-free online networking communications among friends and coresidents may be perceived entirely differently by faculty, patients, and current or potential employers. Several instances of unwanted consequences resulting from the use of social networking sites by health professionals have been documented anecdotally in the press and academic literature.2,7-11 In one survey, 60% of responding medical schools reported social networking incidents of unprofessionalism by students, which included profanity, discriminatory language, depictions of intoxication, sexually suggestive material, and violations of patient confidentiality.7 In another study among medical students and resident physicians, several postings of subjectively inappropriate content were noted, and many trainees belonged to groups

203 that likely would be considered unprofessional in nature. Most accounts in this study listed at least one form of personally identifiable information associated with such posts. In another study, Facebook accounts among new physicians publically revealed sexual orientation, religious views, relationship status, photographs of users' alcohol consumption, and intoxication at alarming frequencies.8 The study in 2008 2 indicated that the use of privacy settings restricting posted content to only Friends was relatively infrequent compared with the frequency of use in a 2010 study,8 which may reflect an increasing savvy among trainees using social networking sites; however, by virtue of being tantalized by social networking, many users are nondiscriminating when initiating and accepting Friend requests. As such, posts may be broadcast to unintended parties, such as patients, colleagues, or authority figures. Consequences of inappropriate Facebook posts have resulted in various forms of discipline, and even dismissal.7,12 Medical school applicants and young physicians have been declined positions due to compromising personal information identified on social networking sites.13 The illustrated case in which a dermatology resident was reprimanded and counseled was also a true occurrence. Although repercussions of unprofessional online behavior may be severe in some instances, many medical schools and training programs still have no policies that guide trainees on the appropriate uses of social networking.7,14 Given the widespread and increasing use of social networking applications, the current generation of physician trainees must consider the ethics surrounding use of social networking applications so as to minimize the risk of insult or harm to themselves, patients, and to our profession. The Accreditation Council for Graduate Medical Education15 requires professionalism as a core competency and includes in it a number of domains such as integrity, respect for others, respect for patient privacy and autonomy, and accountability to patients, society, and the profession.15 Professionalism, however, remains difficult to define and even harder to measure16-18; moreover, definitions of “e-professionalism”10 are at present inadequate in medicine, as medical educators have little evidence on which to establish standards of professional conduct in the use of social networking applications. The current generational trend of new users is likely to result in an ever-increasing use of social networking sites among Internet-savvy young physicians, who will ultimately comprise the health care workforce. As such, there exists the need for expansive discussion on ethical and professional social networking guidelines across organizational medicine in conjunction with accrediting bodies, including the ACGME.19,20 It has been suggested that educating trainees on the ramifications of posting negative material may be more effective than implementing institutional policy that strictly regulates online behavior and practice.9 Although medical professionalism curricula strive to maintain pace with the evolving nature of the physician-patient relationship,

204 there may be few if any established curricula among dermatology training programs that offer instruction on sharing user-generated information and managing the “digital footprint.” Inception of such e-professionalism curricula and field-specific counseling for online professional behavior consistent with the ACGME framework on the professionalism core domains should be a near-term focus for dermatology residency programs. Curricula on social networking should discuss in broad and specific terms several considerations pertinent to online professional behavior including the following: (1) discussing the public nature of posts and other shared information on the Web21-23; (2) applying safeguards that protect the professional “digital image”, such as adopting a “think-before-you-post” attitude, applying strict privacy settings on social networking sites, as well as searching for one's own name to identify unsanctioned posted material9; (3) assessing the potential risk associated with merging personal and professional lives online in the context of the medical profession's accountability to society,9 and the potential consequences to career and profession of digital behavior that demonstrates poor judgment24; and (4) demonstrating an online persona that is characteristic of a young professional10 and an ambassador of medicine. Trainees must recognize the risk of interacting with patients through online social networking and the risks of posting any information that might bring into question their professionalism. At a minimum and until clearer guidelines are established, young physicians should make every attempt to protect patient privacy, avoid problematic dual relationships, and carefully consider self-disclosure content before sharing personal information. A conservative approach would further prohibit under any circumstance a trainee from initiating or accepting a social networking invitation from patients.

Healthy relationships with mentors: drawing the lines between professional and personal relationships Case: Abigail is an older resident who develops a friendship with Mary, a new procedural attending of similar age. The two spend time socializing together outside of work, and Abigail facilitates a social date for Mary with one of her friends. Other residents in the class have feelings of resentment toward Abigail, because they perceive her to be receiving special treatment from Mary, and because she is more often exposed to cosmetic procedures. Discussion: An ethical faculty-resident relationship is an essential component of the educational experience that in addition to facilitating proper clinical training also serves, in the best cases, to inspire excellence in all facets of a trainee's professional development. Although the focus of established boundaries in professional relationships in medicine has centered on the physician-patient relationship,25 there has been little comment on the ethical and professional

A. Garg and J.M. Grant-Kels limits around the relationship between faculty and trainee, and few training programs discuss the consequences of “inappropriate” relationships between teaching staff and residents.26 Given the inequities in position and authority inherent in the faculty-resident relationship, there exists the potential for abuse in any such relationship, especially when supervisors place personal goals ahead of trainees. High-achieving trainees accustomed to impressing and, in many instances appeasing, their faculty supervisors may have difficulty in recognizing and managing professional boundaries. Personal relationships between mentor and mentee, such as close friendships as described in the opening vignette, may result in disparate treatments of others in the training environment. Whether friendly or abusive, ethical lapses in the facultyresident relationship have the potential to disrupt individual professional relationships as well as the training environment for other residents. In the psychiatry literature, a boundary is defined as the “edge” of appropriate or professional behavior.27 Behaviors falling outside the scope of the usual teacher-learner relationship qualify as 1 of 3 degrees of boundary indiscretions. Boundary-straddling behavior refers to conduct that is atypical in the context of a standard teacherlearner relationship but does not reach the level of a boundary crossing. These behaviors do not qualify as misconduct, although they reflect the potential for the emergence of a harmful behavior pattern. An attending who socializes with a specific trainee on a one-to-one basis with some regularity outside of the workplace engages in a boundary-straddling behavior. Boundary crossing represents a deviation from the usual supervisory behavior even if it is nonexploitative and may even be potentially constructive for the trainee.28 For example, the exchange of a personal gift, such as a textbook, from a supervisor to one trainee and not others implies exclusivity and differential treatment but does not reflect exploitation. Boundary violation refers to behavior that is exploitive or harmful to the trainee,28 such as making overt sexual contact or engaging in verbal or physical abuse. Examples of boundary transgressions between mentor and mentee are documented in the medical literature. In a study surveying the nature of supervisor-medical trainee interactions, a high incidence of inappropriate behaviors related to academic/professional, personal, and dating boundaries were reported by trainees.29 Other studies report similar, and sometimes unsettling examples of boundary transgressions, such as acts of discrimination, abuse, and sexual intimacy or harassment.30-34 Although it is not likely that such boundary violations are common or go unresolved in present day medicine, the occurrence of boundary straddling and crossing may be underappreciated. The specialty of dermatology offers a unique training environment in which a relatively small group of trainees and faculty, some of whom may be proximate in age, have long contact hours as part of a close and cooperative working

Ethics in dermatology residency environment in which building collaborative relationships and mentoring opportunities are encouraged; moreover, Facebook, Twitter, and other cyber venues increase the likelihood and overall frequency of resident-faculty social interaction within and outside the academic institution. Taken together, the dermatology learning environment is conducive to establishing close relationships that have the potential to transcend the typical teacher-learner relationship. Implicit to these types of personal relationships is the inevitability of boundary transgressions, subtle more often than overt, which may compromise equity and the overall integrity of the educational environment. Friendships between attendings and trainees that involve unequal socializing or the exchange of valuable or highly personal gifts may be common within the specialty. Such a relationship may for example result in actual or perceived favoritism, as illustrated by a loss of objectivity at the time of formal evaluation, and additionally, disclosure of sensitive faculty-specific issues or discussions. Of course, even the mere perception of peerlike relationships that involve intimacy creates an uncomfortable and potentially damaging learning and working environment for all departmental personnel. There is little skepticism that a friendship between teacher and learner may enhance the learning experience while further facilitating mentorship and collaboration; however, such friendships should emulate good judgment, discretion, and, when necessary, restraint, so as to avoid compromising the integrity of the training experience. Programs should encourage discussion among faculty and residents on maintaining healthy professional relationships with colleagues, and should further develop professionalism curricula to include as a component the ethical boundaries of the mentor-mentee relationship.

Boundary transgressions in the physicianpatient relationship Case: A male resident notes that one of his continuity patients is becoming more flirtatious with him over time. At the end of one of the visits, the patient slips the resident physician her phone number. The resident also feels a connection with the patient, and they eventually begin dating. The resident did not inform anyone of this relationship out of concern for discipline, and he continues to evaluate the patient whenever she follows up in one of his assigned clinics. Discussion: Maintaining appropriate boundaries in the doctor-patient relationship is recognized as a core principle in medical ethics.35-37 In this context, boundaries represent mutually appreciated physical and emotional limits between the trusting patient and the caring physician.38 In dermatology, patients entrust their doctors with their unique vulnerabilities (the complete skin exam), as well as sensitivities (an exposed, chronic dermatitis). It is in this context

205 that dermatologists have the sometimes challenging responsibility of balancing clinical objectivity with establishing an empathic and platonic bond with patients. Maintaining such boundaries is requisite to establishing durable fiduciary relationships with patients in dermatology, whereas transgressions in such boundaries have the potential to affect the dermatology trainee's judgment and undermine the ability to focus solely on the needs of the patient. A friendship or intimate relationship with a patient may make it difficult for the physician to confront noncompliance with treatment, perform a proper informed consent, facilitate independent informed decision making, or consider diagnoses inconsistent with what one would consider possible in an intimate partner (eg, sexually transmitted disease or substance abuse), as examples.38 Although establishment of an intimate relationship between doctor and patient is among the most serious violation of ethical boundaries in medicine, prevalence estimates of sexual contact between physicians and their current or former patients from national surveys have varied from 3% to 11%.39-49 Psychiatrists, gynecologists, and general practitioners were overrepresented among physician transgressors,50-52 perhaps in part because of the nature of ongoing or intense therapeutic relationships in these specialties. Although some instances result from the predatory behavior of doctors,53,54 many may culminate from a series of seemingly naïve or inoffensive boundary crossings, sometimes consensual, that occur as the patientphysician relationship matures.55,56 In some instances, these boundary violations represent indiscretions on the part of patients. Violations by physicians appear more likely when they are under stress with insufficient emotional support or when there is little self-awareness for companionship needs or other psychological vulnerabilities.57,58 Sexual or improper emotional relationships between a doctor and a current patient are prohibited by existing codes of ethics,35 although physicians may vary widely in their beliefs about the effect of these personal relationships on their professional behavior.41,59,60 Less obvious to both physician and patient are the more subtle crossings that occur when the relationship between the physician and patient becomes personal but not sexual. Moreover, the ethical validity of personal relationships with former patients or within limited therapeutic encounters (ie, episodic care in the dermatology clinic), distinguished from either psychotherapeutic or ongoing therapeutic relationships, has been debated.39,61 In dealing with patients who attempt to engage in sexual contact with the physician, the trainee should be clear about the boundaries within the relationship and the professional nature of the interaction. Referral to another doctor, even though the patient might be reluctant, can be in the best interest of both parties. Faculty mentors should make known their availability as nonjudgmental consultants to trainees who find themselves conflicted about how to manage such complex situations. Ultimately, education forms the basis for

206 averting professional boundary violations with patients, although medical training has provided little information to physicians about interpersonal boundaries and potential transgressions with patients.45,62 Professionalism curricula under development for trainees in dermatology have an opportunity in this regard.

Moonlighting in dermatology residency Case: A second-year dermatology resident moonlights weekly with the intent of earning additional income and gaining autonomous clinical experience. The patients are delighted to be able to see “the dermatologist” who has more availability than the university clinic. The training program feels the resident is performing adequately, although he is not reaching his full potential and appears less engaged in the residency curriculum than in the previous year. Discussion: Moonlighting has engendered a range of opinions about the safety and appropriateness of the practice.63-67 Although this provocative controversy has been debated in the radiology and emergency medicine literature most robustly, moonlighting among dermatology residents remains discussed only in informal forums. Practices and attitudes toward moonlighting among dermatology trainees and program directors have not been surveyed, and overall support and acceptance of external moonlighting appears to vary. Some consider moonlighting to be a right that also enhances the educational experience, whereas many others regard moonlighting as a privilege that ultimately detracts attention from training and study. For the purposes of the following discussion, moonlighting is defined as providing independent clinical services in dermatology outside of the required assignments of the training program. The most often cited and immediately tangible benefit to moonlighting from a trainee's perspective is a significant increase in earning potential.68,69 It is not uncommon for trainees to nearly double their yearly salary through moonlighting. This incentive is perhaps more compelling today than ever before, as the average financial debt of resident physicians exceeds $150,000.70 In addition to the burgeoning costs of college and medical education, resident physicians also bear the formidable costs of licensing and certification fees, multiple textbooks, review courses, digital cameras and dermatoscopes, along with maintaining the typical personal and family-related living expenses on relatively modest salaries. Higher debt level, lower salary, lower spousal income, and fewer work-related hours during residency have been shown to correlate with increased likelihood of moonlighting.71-73 Gaining independent longitudinal clinical experience that imparts high educational value, particularly in an era of diminished autonomy within an increasingly regulated

A. Garg and J.M. Grant-Kels educational environment, is cited as an additional reason to pursue moonlighting.72,74 Some residents believe that moonlighting offers the opportunity to acquire important experience and skills that enhance personal growth and confidence, thereby supplementing residency training while not interfering with usual work and educational responsibilities69,74-78; however, the true educational value of unqualified or inadequate supervision for moonlighting in dermatology has not been evaluated. Trainees also believe that moonlighting exposes them to a variety of work environments, which may help in the decision of which career path or community practice setting to pursue. Through moonlighting, trainees also have the opportunity to demonstrate their clinical skills and ability to work with future partners. The duration of exposure needed to appreciate the community work environment may vary, although there may be low yield from such an exposure before the third year of dermatology training. The potential benefits of moonlighting should be weighed against several possible threats to patient care as well to the integrity of the training experience. Given the limited access to dermatology services relative to need in many communities, moonlighting by dermatology trainees offers the prospect of improved access to specialty care for patients. In these instances, however, dermatology residents are licensed to practice medicine, although they are not yet board-certified or even board-eligible to provide specialty care to patients with dermatology-specific chief complaints; moreover, residents do not customarily introduce themselves as dermatologists in training, even though these patients are expecting a standard of care offered by “the dermatologist.” Whether the dermatology resident is better equipped to manage patients with dermatologic complaints than a general physician untrained in dermatology is debatable. In instances of limited trainee experience and judgment, there exists a divergent interest between trainee intent and patient expectations, the balance of which may not fully benefit the patient and which may potentially result in harm. Trainees may be held liable to the same measure as a certified physician in the event of a breach in standard of care.79 Although conflicting viewpoints exist among state courts on the issue of whether specialty trainees are held to the same standard of medical care as certified physicians in the same specialty, trainees must not be complacent on the issue of medical liability.80 Along with creating a possible construct in substandard patient care, moonlighting has the potential to adversely affect activities germane to the the individual and collective training experience, including responsible patient care, commitment to independent study and the didactics program, participation in scholarship and research, and overall engagement in and enthusiasm for training. Most dermatology trainees log an average 45 to 55 (estimated) duty hours weekly and thus have an ample cushion of time with which to moonlight and still stay within ACGME duty hour guidelines. Without program oversight, uncharted time spent

Ethics in dermatology residency on moonlighting may violate the spirit of the ACGME duty hour regulations, which are standard across all specialties and that were established to protect residents, their patients, and the general public. With an extended workweek related to regular moonlighting, trainees have more difficulty following-up on patient care issues, writing notes, finding time to read, completing projects on time, and getting to know resident and attending colleagues. These trainees may become disengaged and less motivated to contribute to the experiences of their patients, colleagues, and the profession. Given the relative lack of training in dermatology before residency and the limited experience of numerous trainees in their first and second years of dermatology residency, it may be prudent at least to restrict moonlighting until the resident's skill and medical judgment have matured. In addition, the training programs that permit moonlighting should approve and have oversight of each trainee's experience, including at a minimum the following: (1) number of hours and frequency of moonlighting, as well as the patient volume; (2) complexity of work being performed and ensuring it is commensurate with knowledge, skills, and experience; and (3) level and adequacy of supervision during moonlighting, not only to ensure safe patient care, but also to offer the trainee constructive feedback on performance. Although there exist practical and ethical arguments for and against moonlighting in dermatology, state licensing boards have not generally impeded moonlighting for trainees. Training directors and residents should engage in a thoughtful discussion that results in a position on moonlighting that balances the well-being of patients and the integrity of the training experience with the desires of residents to moonlight.

Conclusions We have offered dialogue on 4 controversial ethical considerations. These topics represent a sampling of a multitude that may ultimately comprise a curriculum on ethics in dermatology residency. Although the ACGME offers general ethical principles to which residents are expected to adhere, and while the Association of Professors of Dermatology has initiated a discussion on setting professionalism milestones, there appears to exist an unmet need to develop professionalism curricula outlining ethical roles and responsibilities of dermatology trainees. In the absence of curricula, the value of ongoing guided discussion on ethical dilemmas, such as the ones posed in this article, and of the self-reflective process that results from such a dialogue should not be understated. In addition, helping faculty teach and mentor around ethical dilemmas will facilitate transmission of skills and attitudes through effective role modeling.


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