Saturday, July 15, 2006

Ethics, Shmethics

Someone asked me an interesting question last night. He asked, "So, do you think it's appropriate to work in an environment that you think is so inadequate that you can't give even minimally adequate care?"

It wasn't the first time that someone suggested to me that correctional work was unethical. Many years ago when I first started working in prison a colleague of mine said to me, "Surely, you're not working there." He was implying that to work inside a correctional facility was equivalent to participating in punishment. Fortunately, times have changed.

In 1988 the American Psychiatric Association published a position statement on psychiatric services in jails and prisons, and this is what it said:

"Psychiatrists should take a leadership role administratively as well as clinically...the APA calls on its members to participate in the care and treatment of the mentally ill in jails and prisons, for without an increased commitment and involvement of its membership in providing services to the mentally ill in jails and prisons, position statements such as this will be meaningless. The breadth and depth of these problems demand much more."
Correctional experience is now mandatory in some situations. In the 1990's forensic psychiatry was recognized as an official medical subspecialty. The American Council for Graduate Medical Education (ACGME), the organization which accredits forensic psychiatry training programs, requires that all forensic psychiatry fellows have a minimum of six months experience working with inmates in a correctional facility. Child psychiatry fellowships also require forensic experience, which in some programs may involve work in juvenile correctional facilities.

Correctional psychiatry bears similarities to the newly developed field of disaster psychiatry. Disaster psychiatry developed as a result of the September 11th terrorist attack and other subsequent tragedies. It is based on the idea that when the health care need is urgent you treat the patient where you find them. The correctional environment may not be optimal or ideal, but it is no worse than caring for victims at the scene of a car accident or treating wounded soldiers on the battlefield. Or, for that matter, treating hurricane victims. In the latest issue of BrainWise, the newsletter put out by the Johns Hopkins Department of Psychiatry, Dr. Michael Kaminsky vividly described his experience providing mental health care in central Louisiana following Katrina:
"In one way, Katrina was paradise. No billing, no medical forms. We became super efficient. We just did what was needed. And we loved it."
They treated 45 patients in two days, many of them suffering from complicated major mental illnesses. And talk about an inadequate work environment---their clinic was an elementary school cafeteria with sheets draped over the windows for privacy. Surely this was not an environment that was adequate for providing mental health care. Surely, he didn't work there.

But fortunately, he did. Ethics, shmethics.

16 comments:

Murky Thoughts said...

Good that he was there, but note we feel so good we'll give people medals for murder and mayhem they commit as soldiers during a crucial mission or battle. We also pay people well for picking up garbage and handling nuclear waste. These are dirty jobs that somebody's got to do. Doesn't mean they won't legitimately strike some people as unseemly--and others legitimately as heroic.

ClinkShrink said...

I'm not sure I'd agree with the analogy between picking up garbage and treating patients in the correctional system; at least, that's not how I see them. If I did see it that way, it would be time to retire.

Dr. A said...

I agree with Kaminsky, if there were no paperwork and no worry of lawyers breathing down your throat - can you imagine the medical care that could be delivered?

As far as there is concerned, that's in the eye of the beholder. Some think it's prisons/jails, some inner city American, some rural America, and some the university setting *grin* - Surely you're not working at the university *LOL*

ClinkShrink said...

Dr. A,

So true; there is an environment and patient population for everyone. My personal 'surely not there' place would be an eating disorders unit. I have friends who specialize in this and I've told them I'm glad they are able to do this. They say the same thing about me and my prisoners.

NeoNurseChic said...
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annegb said...

Don't forget that "those people" were somebody's neighbor and will be again. I would prefer that my neighbor, the sex offender, had some counseling in prison.

Murky Thoughts said...

I guess I should have been clearer with my metaphor. The "garbage" is not the patients but the level of care relative to the private-practice standard--or to the higher frequency of mistakes/complications. I assume one of those things must be worse under crisis conditions. I don't think the personality of a perfectionist craftsperson would enjoy or succeed at it. But somebody cool, quick and who prefers not mull things over too much would like the exercise. Would you rather talk jumpers off ledges or over more time in an office guide them toward vital life lessons and/or personal insights? They're different kinds of highs, I suppose.

ClinkShrink said...

Thank you for the clarification. To keep the metaphor within the field, one could make a comparison between, say, a geriatrician versus a trauma surgeon. Different environment, different patient volume and acuity, different temperament requirements. But there's a place and a need for them all. A trauma surgeon would not be giving a lower level of care, but a level of care that is suitable for both the patient need and the environmental demand. I would not want a geriatrician's level of care at a car accident. It's not a bad approach to care, just not suitable for the situation.

To bring the hypothetical back into the correctional realm, the average correctional patient would not necessarily be appropriate for the average private practitioner's longterm insight-oriented practice (even assuming therapists would want to treat them!). Their ego strengths aren't wonderful, they have cognitive limitations and frustration tolerance issues that would bar participation in some types of therapy. I'm sure my co-bloggers could speak to that issue better than I can, but that's my experience.

Dinah said...

If they'll show up and pay for their care, I'm happy to treat your criminals in my private practice. If not, they can and do, come to the clinic. The challenge with your population, isn't the issue of insight, it's the issue of whether they'd rather come and get care or if they wouldn't prefer to be off committing crimes. You have them as a captive audience.

Dinah said...

take all those commas out of my last comment

Roy said...

"So, do you think it's appropriate to work in an environment that you think is so inadequate that you can't give even minimally adequate care?"

I think that is why one finds so many mental health practitioners practicing outside of managed care. It becomes so difficult to practice in a manner that expects, say, a psychiatrist to see 4-5 patients each hour, while adequately being able to find out what stressors are in each patient's life, how she is coping with these stressors, changes in symptoms, and assess medication effects and side effects -- oh, and also have time to document all these things, then review the next chart so that you are prepared to do it again.

Unfortunately, there are many consumers who cannot afford (financially) to venture outside their insurance network, leaving a continuing supply/demand imbalance. The pendulum is starting to swing in the other direction, but it may take the entire US health care system to implode beforfe meaningful change occurs. Until then, folks will need help. And others will provide it the best way they can while trying to maintain their professionial standards.

On the Same Page said...

I would note that I work in the prison and the university. So, I can offer the following advice as minimally adequate care, of sorts.

ClinkShrink said...

Personally, I prefer the special management meal AKA prison loaf.

NeoNurseChic said...
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Sarebear said...

That issues is mental health parity, Carrie. I found a link through this blog that compares the states mental health parity laws.

I briefly mentioned this in my recent conversation over the radio w/my state governer, in part because I had seen the info I found here through this link. So you guys on this blog caused this issue to be mentioned to the Utah State Governor. 8^D

Dinah said...
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