- Email: [email protected]
The ethics of the consultation process
Temptations of consultant
request for his consultation, positive evidence of a psychiatric illness is needed. Psychiatrists have been successful in establishing liaison services with general medicine through which we hope to heighten our colIeagues' awareness of the importance of the patients' personalities as they react to the stresses in their lives and as their personalities are reflected in the symptoms and problems that they bring to their physicians. Psychiatric consultations have been found to be useful and, therefore,
are frequently requested. The two points that I hope to have made are (I) the symptoms and the circumstances that may have stimulated the request for the consultant's assistance are not necessarily identical with those on which his final conclusion should be based; and (2) there are a number of subtle forces that may tempt the consultant to lean in the direction of a functional diagnosis, a temptation which must be avoided if the liaison between the primary physician and the psychiatrist is to be truly beneficial to the patient. 0
PRESIDENTIAL ADDRESSES Academy of Psychosomatic Medicine 33rd Annual Meeting
The ethics of the consultation process WILLIAM L. WEBB, JR., M.D.
Dr. Martin's discussion of diagnosis in the consultation process raises an even more important issue, namely, professional integrity in the consultation process. Ethics may seem a rather esoteric subject in the frantic pace of daily consultation practice, but I think you will agree that value judgments are very much a part of what Lipowski I has identified as the fundamental process in consultation-the reconceptualization of the clinical problem. Further, our ethical integrity with our colIeagues and patients is an essential ingredient in the establishment of trust, which is so vital to the diagnostic and therapeutic relationship. As Clouser' points out, the values and traditions of medi- . cine are derived from the moral imperative, "do your duty. " He eloquently states, "This is a moral rule because it involves expectations; it involves what others have come to count on and have every reason to believe will be forthcomRead as the President-Elecrs Response. 33rd Annual Meeting of The Academy of Psychosomatic Medicine. November 14. 1986. New York. Dr. webb is Psychiatrist-in-Chief at the Institute of Living. Reprint requests to him there. 200 Retreat Ave.. Hartford, CT 06106.
278
ing; that is, they realIy count on the health professional doing his duty to them~r what they believe to be his duty. The crux of the moral issue is that the patient knows what to count on-to fail him in his expectations is to cause him suffering. " Our professional integrity is at risk in the 1980s. Not only do we face diminishing health care resources that may present us with serious ethical dilemmas, we continue to receive criticism from the public that we have abandoned our professional ideals. Gartland,' in a recent discussion at the Council of Medical Specialty Societies, notes, "Even though most opinion polls show that the public continues to be greatly satisfied with the quality of care it receives from doctors, and medicine remains the institution in which the greatest amount of public confidence exists, disturbing undercurrents have appeared. We hear that we spend too little time with patients, that we do not listen, that we are becoming medical technicians, and that we make too much money for the time and effort given to patients. In short, the perception exists that medicine is drifting away from its noble goal of improving the human condition and its primary responsi-
PSYCHOSOMATICS
bility of healing the sick and helping to maintain good health." I would submit that the correction of these very ills has been the philosophical backbone of the psychosomatic movement, and that it is incumbent upon us to pay special attention to our own professional behavior lest we fall heir to the same malaise. I would like to examine four areas of ethical concern of special importance to the psychiatric consultant: competence, confidentiality, informed consent, and abandonment.
symptom for a good many years, knew that he did not have cancer or he would be dead, had had negative skin tests for fungus and tuberculosis, had undergone three previous bronchoscopies, thought his diagnosis was probably bronchiectasis with bronchitis, and would be damned if he would undergo another bronchoscopy.
I Abandonment
Patients trust us to keep their confidences to ourselves. Appelbaum and associates' confirmed this in a study of psychiatric outpatients. The essence of consultation involves the patient's system of care. We gather information from relatives, nurses, social workers, physicians, and other patients. Correcting the problem usually involves sharing information within the patient care system. How much concern do we exercise in protecting the patient's confidences? Some information must be shared, while some belongs only to the patient and you because he chose to share it with you. Particular care should be exercised in what we write down. We must communicate clearly with our colleagues but protect our patients-a tough assignment.
Finally, the Principles make it clear that a physician has the right to choose whom he treats but also the responsibility not to abandon those who need his help. The consultation process is particularly fuzzy in this regard. Most often we are called to see another physician's patient, but as most of you know, a patient with predominantly psychological problems often becomes the consultant's responsibility. Making the transition from consultation to ongoing care, most likely with another therapist, presents a hiatus through which the patient can fall. This may be less of a problem in a private practice setting where the consultant and therapist are one and the same, but even busy practitioners get overloaded or wish to refer to another. It remains a difficult process for patients, and one to which there are not easy solutions. These are but a few examples of the many ethical dilemmas that we face in daily practice. I do not raise them to chastise or propose easy solutions. Rather, they should sensitize us to this critical aspect of our work. Our professional integrity will continue to be on the line, as it has been since the time of Hippocrates. In last year's Presidential Address," Richard Rada outlined the changes in the new delivery system that will move the patient toward having the attitude of a customer. All of these changes will tax our professional integrity and put us to the test to maintain a quality standard of practice. In the words of James Eaton, "We need to say to students and residents, 'Do as we do, not just as we say.' The psychiatric [consultation-liaison] service is a place where, before all of medicine, we psychiatrists can be seen doing."7 0
I Informed consent
REFERENCES
I Competence The Principles ofMedical Ethics" begins with the statement that the physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. Dr. Martin has made an important case for competency in diagnosis. Often the total direction oftreatment will change depending on the consultant's opinion. It is particularly important that he or she be knowledgeable both in his or her own speciality and in how that knowledge interacts with the medical realities of the case. With the advances in psychopharmacology, this becomes of critical importance.
I Confidentiality
In recent years, patients have come to expect more participation in the diagnostic and therapeutic process. They want to know about the risks of tests and treatments used in their care, and we are obliged to take the time to gain their informed collaboration. Most assuredly, patients cannot be all-knowing, but we have a responsibility to educate and, most important, listen to their concerns. I am reminded of being called by a medical colleague to see a "suicidal" patient. It turned out the patient had been labeled suicidal because he had turned down a bronchoscopy for a symptom of hemoptysis. The patient informed me that he had had the
MAY 1987' VOL 28' NO 5
1 Lipowski lJ Review of consultation psychiatry and psychosomatics. I, II. Psychosom Med29:153-171, 201-224,1967 2. Clouser KD: What is medical ethics? Annlnlern Med80:657-660, 1974. 3. Gartland J: Professionalism in medicine. a report of the workshop on profesrionalism to the council of medical speciality societies. Presented before the Annual Board of Directors Planning Meeting, Council of Medical Specialty Societies, Annapolis, Md. Jan 18-20,1986. 4. The Principles 01 Medical Ethics With Annotations Especially Applicable to Psychiatry. WaShington, DC, American Psychiatric Association, 1985. 5. Appelbaum PS, Walters B, Lidz C, et al: Confidentiality: An empirical test of the utilitarian perspective. Bull Am Acad Psychiatry Law 12:109-116. 1984. 6 Rada RT: The health care revolution: From patient to client to customer, Psychosomatics 27:276-279, 1986. 7. Eaton JS: Consultation-liaison psychiatry: Unfinished business. PsychosomatiCS 27:323-324,1986
279
request for his consultation, positive evidence of a psychiatric illness is needed. Psychiatrists have been successful in establishing liaison services with general medicine through which we hope to heighten our colIeagues' awareness of the importance of the patients' personalities as they react to the stresses in their lives and as their personalities are reflected in the symptoms and problems that they bring to their physicians. Psychiatric consultations have been found to be useful and, therefore,
are frequently requested. The two points that I hope to have made are (I) the symptoms and the circumstances that may have stimulated the request for the consultant's assistance are not necessarily identical with those on which his final conclusion should be based; and (2) there are a number of subtle forces that may tempt the consultant to lean in the direction of a functional diagnosis, a temptation which must be avoided if the liaison between the primary physician and the psychiatrist is to be truly beneficial to the patient. 0
PRESIDENTIAL ADDRESSES Academy of Psychosomatic Medicine 33rd Annual Meeting
The ethics of the consultation process WILLIAM L. WEBB, JR., M.D.
Dr. Martin's discussion of diagnosis in the consultation process raises an even more important issue, namely, professional integrity in the consultation process. Ethics may seem a rather esoteric subject in the frantic pace of daily consultation practice, but I think you will agree that value judgments are very much a part of what Lipowski I has identified as the fundamental process in consultation-the reconceptualization of the clinical problem. Further, our ethical integrity with our colIeagues and patients is an essential ingredient in the establishment of trust, which is so vital to the diagnostic and therapeutic relationship. As Clouser' points out, the values and traditions of medi- . cine are derived from the moral imperative, "do your duty. " He eloquently states, "This is a moral rule because it involves expectations; it involves what others have come to count on and have every reason to believe will be forthcomRead as the President-Elecrs Response. 33rd Annual Meeting of The Academy of Psychosomatic Medicine. November 14. 1986. New York. Dr. webb is Psychiatrist-in-Chief at the Institute of Living. Reprint requests to him there. 200 Retreat Ave.. Hartford, CT 06106.
278
ing; that is, they realIy count on the health professional doing his duty to them~r what they believe to be his duty. The crux of the moral issue is that the patient knows what to count on-to fail him in his expectations is to cause him suffering. " Our professional integrity is at risk in the 1980s. Not only do we face diminishing health care resources that may present us with serious ethical dilemmas, we continue to receive criticism from the public that we have abandoned our professional ideals. Gartland,' in a recent discussion at the Council of Medical Specialty Societies, notes, "Even though most opinion polls show that the public continues to be greatly satisfied with the quality of care it receives from doctors, and medicine remains the institution in which the greatest amount of public confidence exists, disturbing undercurrents have appeared. We hear that we spend too little time with patients, that we do not listen, that we are becoming medical technicians, and that we make too much money for the time and effort given to patients. In short, the perception exists that medicine is drifting away from its noble goal of improving the human condition and its primary responsi-
PSYCHOSOMATICS
bility of healing the sick and helping to maintain good health." I would submit that the correction of these very ills has been the philosophical backbone of the psychosomatic movement, and that it is incumbent upon us to pay special attention to our own professional behavior lest we fall heir to the same malaise. I would like to examine four areas of ethical concern of special importance to the psychiatric consultant: competence, confidentiality, informed consent, and abandonment.
symptom for a good many years, knew that he did not have cancer or he would be dead, had had negative skin tests for fungus and tuberculosis, had undergone three previous bronchoscopies, thought his diagnosis was probably bronchiectasis with bronchitis, and would be damned if he would undergo another bronchoscopy.
I Abandonment
Patients trust us to keep their confidences to ourselves. Appelbaum and associates' confirmed this in a study of psychiatric outpatients. The essence of consultation involves the patient's system of care. We gather information from relatives, nurses, social workers, physicians, and other patients. Correcting the problem usually involves sharing information within the patient care system. How much concern do we exercise in protecting the patient's confidences? Some information must be shared, while some belongs only to the patient and you because he chose to share it with you. Particular care should be exercised in what we write down. We must communicate clearly with our colleagues but protect our patients-a tough assignment.
Finally, the Principles make it clear that a physician has the right to choose whom he treats but also the responsibility not to abandon those who need his help. The consultation process is particularly fuzzy in this regard. Most often we are called to see another physician's patient, but as most of you know, a patient with predominantly psychological problems often becomes the consultant's responsibility. Making the transition from consultation to ongoing care, most likely with another therapist, presents a hiatus through which the patient can fall. This may be less of a problem in a private practice setting where the consultant and therapist are one and the same, but even busy practitioners get overloaded or wish to refer to another. It remains a difficult process for patients, and one to which there are not easy solutions. These are but a few examples of the many ethical dilemmas that we face in daily practice. I do not raise them to chastise or propose easy solutions. Rather, they should sensitize us to this critical aspect of our work. Our professional integrity will continue to be on the line, as it has been since the time of Hippocrates. In last year's Presidential Address," Richard Rada outlined the changes in the new delivery system that will move the patient toward having the attitude of a customer. All of these changes will tax our professional integrity and put us to the test to maintain a quality standard of practice. In the words of James Eaton, "We need to say to students and residents, 'Do as we do, not just as we say.' The psychiatric [consultation-liaison] service is a place where, before all of medicine, we psychiatrists can be seen doing."7 0
I Informed consent
REFERENCES
I Competence The Principles ofMedical Ethics" begins with the statement that the physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. Dr. Martin has made an important case for competency in diagnosis. Often the total direction oftreatment will change depending on the consultant's opinion. It is particularly important that he or she be knowledgeable both in his or her own speciality and in how that knowledge interacts with the medical realities of the case. With the advances in psychopharmacology, this becomes of critical importance.
I Confidentiality
In recent years, patients have come to expect more participation in the diagnostic and therapeutic process. They want to know about the risks of tests and treatments used in their care, and we are obliged to take the time to gain their informed collaboration. Most assuredly, patients cannot be all-knowing, but we have a responsibility to educate and, most important, listen to their concerns. I am reminded of being called by a medical colleague to see a "suicidal" patient. It turned out the patient had been labeled suicidal because he had turned down a bronchoscopy for a symptom of hemoptysis. The patient informed me that he had had the
MAY 1987' VOL 28' NO 5
1 Lipowski lJ Review of consultation psychiatry and psychosomatics. I, II. Psychosom Med29:153-171, 201-224,1967 2. Clouser KD: What is medical ethics? Annlnlern Med80:657-660, 1974. 3. Gartland J: Professionalism in medicine. a report of the workshop on profesrionalism to the council of medical speciality societies. Presented before the Annual Board of Directors Planning Meeting, Council of Medical Specialty Societies, Annapolis, Md. Jan 18-20,1986. 4. The Principles 01 Medical Ethics With Annotations Especially Applicable to Psychiatry. WaShington, DC, American Psychiatric Association, 1985. 5. Appelbaum PS, Walters B, Lidz C, et al: Confidentiality: An empirical test of the utilitarian perspective. Bull Am Acad Psychiatry Law 12:109-116. 1984. 6 Rada RT: The health care revolution: From patient to client to customer, Psychosomatics 27:276-279, 1986. 7. Eaton JS: Consultation-liaison psychiatry: Unfinished business. PsychosomatiCS 27:323-324,1986
279