and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Keywords
Ethical issuesCompetenceInformed consentConfidentiality“Do all the good you can, by all the means you can, in all the ways you can, in all the places you can, at all the times you can, to all the people you can, as long as ever you can.”
John Wesley
When thinking back on our journeys in PC, we both remember numerous moments of discomfort about new ethical challenges we discovered. We learned that PC as a practice setting—and the PCBH model itself—presents situations not encountered in traditional MH. For example, we encountered multiple relationships unique to PC, with its focus on team-based care, families, and community, and we had concerns about our competence practicing in this new model. The more experience we gained in PC, the more ethical quandaries seemed to arise. In this chapter, we use manufactured case examples followed by analysis to help a BHC anticipate ethical issues before they become a problem. We encourage the reader to try to identify the unique ethical issue(s) raised by each example before reading the subsequent analysis. We also suggest that readers explore the Four Boxes Approach (Jonsen, Siegler & Winslade, 2010). It may prove useful in sorting out ethical issues with other members of the PCMH team.
Because we authors are psychologists, our reference point for the case analyses is the Ethical Principles of Psychologists and Code of Conduct, which can be perused and/or downloaded (American Psychological Association, 2003; see Web Link 1). For each case we include relevant excerpts from the code, though we have edited out parts not directly pertinent to the case example. We do recognize the value of other discipline specific codes, including those provided by the National Association of Social Workers (see Web Link 2) and the American Medical Association (AMA, 2012), and encourage readers from those professions to apply their unique analysis to these examples. Additional information on ethical issues in the PCBH model is available in a special issue of the journal, Families, Systems, and Health (Runyan, Robinson & Gould, 2013). It includes case examples for specific clinical problems (e.g., chronic pain, end-of-life issues) and information on special clinic settings (e.g., rural clinics, military clinics), along with research issues.
Common Quandaries in PCBH Work
Some of the most commonly encountered ethical dilemmas in PCBH work concern competence, confidentiality, and informed consent. These may arise especially often for new BHCs because of the novelty of work in the PCBH model and because of the profound differences in the practice cultures of PC and specialty MH. While reading through each case, take time to pause and consider the ethical implications and conundrums.
Competence: The Case of Dr. Feelgood
Dr. Feelgood, a clinical psychologist who had previously worked in specialty MH care, was hired to develop a new PCBH service. Despite a reasonably strong health psychology background, Dr. Feelgood had never worked in a PC clinic. Similarly, despite some experience with consultation-based work, this had never been the focus of Dr. Feelgood’s work, and only rarely had he needed to make rapid decisions as a consultant. Most of his consultation experience involved administering traditional, lengthy psychological evaluations of medical patients and providing detailed reports to medical providers. Curbside consultations, a common PC occurrence in which he was asked for advice on patients he had never met or only barely knows, had not previously been a part of Dr. Feelgood’s clinical repertoire. Most of Dr. Feelgood’s experiences in MH clinics had involved the usual combination of diagnostic assessments, hour-long therapy visits on a weekly or every-other-week basis, and psychoeducational groups. Before leaving his previous job, Dr. Feelgood had attended a workshop on the PCBH model and had read a few journal articles about it, but this was the extent of his exposure to the field prior to beginning in PC. Thus, Dr. Feelgood’s specialty MH experiences hadn’t prepared him well for what he faced in his new job.
The characteristics of Dr. Feelgood’s new patients were also quite different from those he had encountered in specialty MH care. Previously, in his private practice, Dr. Feelgood’s clients were usually middle class, English speaking, and basically healthy. However, with the move to his new community health center job, Dr. Feelgood discovered an entirely different patient population. Suddenly he was presented with patients addicted to heroin and methamphetamine, psychotic patients unwilling or unable to get specialty care, and patients with multiple chronic and complex medical problems. He was often asked to help with problems with which he had little familiarity, such as diabetes and autism. The majority of patients in his clinic spoke primarily Spanish, necessitating the use of interpreters and challenging his understanding of different cultures.
Initially, PCPs weren’t sure how to utilize Dr. Feelgood, and they peppered him with questions about medications. Questions such as, “What’s the maximum dosage for this medication?” and “What medication should we use for this patient?” were common. Patients also didn’t understand Dr. Feelgood’s background and, owing to his title of “Doctor,” assumed he could answer questions such as the following: How will my diabetes medication interact with my antidepressant? Is my blood pressure ok now?
In short, Dr. Feelgood was surprised by how different the challenges of his PC job were from those of his private practice job. He faced a new and diverse patient population with a range of ages and clinical problems he had not encountered before, and his new position required that he respond to situations where his knowledge and training was lacking. Dr. Feelgood was surprised to find that the transition to PC was more challenging than he had imagined it would be.
What Ethical Issues Can You Identify?
The case of Dr. Feelgood will probably sound very familiar to many readers. Most who enter PC and use the PCBH model will have had little if any experience with this type of work before starting. Further, given the incredible variety of behavioral problems and patient backgrounds encountered in PC, no novice BHC could claim to be experienced in every clinical problem sent her way. Thus, the issues raised in this example, and faced by many new BHCs, pertain mostly to Boundaries of Competence Standards (APA Ethics Standard 2.01).
In Dr. Feelgood’s case, his experience with brief consultation, specifically in PC, and training within the PCBH model was very limited. To add to his ethical concerns, this practice model is in many ways an emerging area that lacks recognized training standards or care guidelines. This makes for some difficulty defining “competent care,” which Dr. Feelgood worried might leave him vulnerable to charges of incompetent care. Finally, Dr. Feelgood had little experience treating many of the problems and populations he was encountering in his new community health clinic job. His background with a mostly healthy, middle-class, English-speaking, American-born population included little of the diversity seen in his new clinic.
What Actions Should Dr. Feelgood Take?
Certain parts of the Boundaries of Competence Standards are particularly relevant to Dr. Feelgood’s situation. For example, Standard 2.01c says, Psychologists planning to provide services…involving populations, areas, techniques or technologies new to them undertake relevant education, training, supervised experience, consultation or study. Similarly, Standard 2.01e states, In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect client/patients…from harm. And Standard 2.01b states, Where…an understanding of factors associated with…race, ethnicity, culture, national origin…disability, language, or socioeconomic status is essential for effective implementation of their services…psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure…competence.
The essence of these standards is the importance of obtaining as much training, consultation, and guidance as reasonably possible to ensure basic competence in areas that are new to the psychologist. As noted previously, most MH providers will have to attend to this to one extent or another when beginning work in PC. It will probably be even more important for those working in community health centers, given the diversity of problems and populations encountered there.
After assessing his areas of knowledge and skill deficits, Dr. Feelgood took several steps to improve his competence. To improve his ability to work with persons of varying language, racial, ethnic, national origin, and cultural backgrounds, he attended workshops and conferences dealing with these issues. Because the majority of patients enrolled at his new clinic were Hispanic, he attended a conference on improving health care for Latinos and used continuing education money to attend a weeklong course in basic “medical” Spanish. He also attended a workshop on the use of interpreters, which included strategies for improving cultural sensitivity. To improve his understanding of the unique challenges facing persons with disabilities and lower socioeconomic status, he visited numerous social service organizations in the area of his clinic and occasionally attended events and trainings they sponsored. This not only improved his awareness of the challenges faced by these populations but also improved his ability to advocate for his patients.
To improve his general clinical competence in this new field of PCBH consultation, Dr. Feelgood found a mentor and made a plan for regular consultation visits. He found this person by contacting professionals who had written articles and books on this model of care. Though not in his local area, the professional mentor was available via phone and email for occasional consultation. Dr. Feelgood also contacted others employed in similar work in his local area. Most were not utilizing the PCBH model, but they were at least MH providers working in a PC setting and so were able to provide some helpful insight. He visited some of these persons and talked over the phone with others, eventually establishing a network of persons from whom he gained support. Dr. Feelgood also attended workshops on PCBH consultation at a couple of conferences and read some of the growing collection of books published on the model. He further focused on reading and continuing education on many of the new clinical problems he was encountering.
Beyond the specifics of this case example, questions do remain about what constitutes appropriate training and experience for competent practice in the PCBH model. Some large healthcare organizations address this issue by developing program manuals that detail specific credentialing procedures for BHCs. For example, the US Air Force developed the Primary Behavioral Health Care Services Practice Manual (Air Force Medical Operations Agency, 2014), which stipulates that preparation for being a BHC in Air Force settings must include direct clinical training in the core competencies, in addition to a review of the manual. They have organized a network of trainers with a standard training and evaluation protocol to help ensure uniformity and basic levels of competence. Dobmeyer (2013) also emphasizes the importance of BHCs completing specific clinical training prior to providing services in Air Force (and other) settings.
Of course, for most individuals and small organizations, there will be no specific standards to meet for BHC practice, other than those they place on themselves. National certification for BHC work has not yet been developed. For many new BHCs, training to achieve competence will need to be accomplished on the job, through consultation, continuing education, and other formal and informal learning opportunities. In Chapter 3 we discuss BHC training in more detail, and Appendix A (Chapter 16) lists various training resources. Whatever training the BHC completes, the use of the BHC Core Competency Tool (see Chapter 5) will help guide and measure progress and is one way to achieve standardization in this field.
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