One of our course participants had a vignette case on his Psychiatry Oral Board Exam in which a patient disclosed that she had sexual relations with her previous psychiatrist.

How would you handle this situation? Read what the AMA and the APA recommend.

Throughout our careers, we may receive information from another person or witness firsthand information suggesting unethical or impaired behavior of a physician-colleague. What do you do when confronted with such information? Let’s run through the different scenarios, starting with unethical behavior.

(NOTE: Please be clear that I am not a trained ethicist or lawyer. So, please seek professional advice if you confront such challenges in your work. My focus in this blog is to make sure you have something sensible to say on your board exam.)

Both the American Medical Assocation (AMA) and the American Psychiatric Association (APA) hold that sexual contact between a psychiatrist and patient or ex-patient is unethical in all cases. Following is the pertinent statement from the AMA "Principles of Medical Ethics" with the Annotation Especially Aplicable for Psychiatry.

"The requirement that the physician conduct himself/herself with propriety in his/her profession and in all the actions of his/her life is especially important in the case of the psychiatrist because the patient tends to model his/her behavior after that of his/her psychiatrist by identification. Further, the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctorpatient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical."

Regarding unethical behavior of whatever type, the APA has guidelines stating that the complaint against a psychiatrist needs to be put in writing, signed by the complainant, and submitted to the district branch, in which a hearing takes place. If the charges against the psychiatrist are sustained, that psychiatrist may be reprimanded, suspended, or expelled from the APA. The investigation takes place in secrecy.

However, if an APA member is expelled because the charges for unethical behavior were sustained, disclosure of that expulsion and the nature of the unethical behavior is authorized to be disclosed. Disclosure includes notifying the state licensing body in which that member holds medical licenses.

Many states require reporting to the licensing board or another government agency concerning the physician who has been found to have engaged in unethical conduct. The level of detail and the time frame in which the reporting needs to take place, differs from state to state, however.

Now, you may be thinking, "My gosh, if a professional may be taking advantage of or abusing a patient, it seems reprehensible to wait while these slow wheels of investigation grind out at some APA district branch." The APA recognizes this moral imperative and gives us the following statement.

"Apart from these specific guidelines, public safety considerations may justify reporting before completion of formal proceedings. If a complainant, deemed highly credible, alleges unethical conduct on the part of a member that would pose a serious danger to the safety of patients, the district branch could report the allegations to an appropriate state agency, following consultation with legal counsel."

I would take this to include the case of a clinician engaging in sexual or other intimate contact with a patient – I would consider the risk of harm to the patient to be grave in such a circumstance.

Changing focus from unethical to impaired conduct, the APA Ethics Guidelines state the following: "Special consideration should be given to those psychiatrists who, because of mental illness, jeopardize the welfare of their patients and their own reputations and practices. It is ethical, even encouraged, for another psychiatrist to intercede in such situations."

My recommendation for the ABPN Psychiatry Part 2 Exam, is to know the disclosure guidelines for your state. (This may be easier said than done. I’m still trying to figure out how to find out the exact requirements in Illinois. Our Dept of Professional Regulation website does not have the information readily accessible on their website. I will continue to investigate this for myself in Illinois.)

In any case, my bottom line recommendation is, if you have evidence, or even clear suspicion, of unethical or impaired behavior of a colleague, you need to state on the exam that you will notify the APA district branch as well as the state medical licensing body. If you don’t know the details of level of disclosure, you can say that you would obtain a written copy of your state’s guidelines.

Last point. One interesting aspect that is included in the APA Ethics Q-&-A is why would a complainant make false accusations. The answer is to seek revenge towards a clinician. Thus, the need for formal investigation.

Here is the link to the APA webpage:

http://www.psych.org/psych_pract/ethics/medicalethics2001_42001.cfm

I would appreciate your comments and further recommendations. Please leave comments below. Include additional scenarios and additional resources if you have any to recommend.