As a steadily increasing number of psychiatrists spend part of their professional lives working in managed care and other organized settings, APA's Board of Trustees has turned its attention to the need to develop ethics guidelines to clarify situations unique to these evolving systems of care. Issues of particular concern center on informed consent, confidentiality, and situations in which a psychiatrist's professional role conflicts with organizations' interests.

Developments and information that have an impact on how psychiatrists practice in organized settings are appearing very rapidly, pointed out Robert McDevitt, M.D. McDevitt, who is Area 4 trustee and chair of the ad hoc committee appointed by the Board to write these new guidelines, reported on the committee's recommendations at the Board's March meeting in Washington, D.C. After adding several wording clarifications, the Trustees gave the report their enthusiastic endorsement.

Several of the new guidelines focus on appropriateness of treatment and treatment options, emphasizing, for example, that psychiatrists will not withhold information that could influence a patient's ability to make informed treatment decisions, including treatment options the psychiatrist may not be able to provide within the particular organized setting.

They point out as well that whether treating or reviewing, a psychiatrist must use a treatment plan "based on clinical, scientific, or generally accepted standards of treatment." Psychiatrists are also to take steps to ensure that they do not limit "beneficial treatment. . .to minimum criteria of medical necessity."

The guidelines also address financial arrangements and emphasize that psychiatrists are obligated to inform patients about financial incentives or penalties that could limit the treatment they can provide those patients.

Finally, on the controversial question of conducting or participating in treatment reviews, psychiatrists would be enjoined from acting in a manner "likely to demean the dignity of the patient, [including] asking for highly personal material not necessary for the conduct of the review."

The Board asked the Ethics Committee to comment on the issue of whether the words "or guardian" should be inserted in the guidelines each time they refer to "the patient," as several Trustees suggested.

The recommendations next go to the Assembly for review at its May meeting in San Diego, after which the APA Ethics Committee will have to decide where in the existing ethics guidelines these new annotations will best fit.

McDevitt noted that the American Medical Association (AMA) has already developed ethics guidelines for physicians in organized settings, and while they helped to clarify several issues for the ad hoc committee, unlike APA, the AMA does not hold ethics hearings or impose sanctions on violators. As a result, a substantial portion of his committee's work was devoted to ways to structure the guidelines "to meet a standard that would allow them to become part of the existing APA ethics process," which does contain provisions for punishing members who violate APA's ethics code.

AMA Issues

Joseph T. English, M.D., chair of the APA Section Council on Psychiatry at the AMA and APA delegate to the AMA House of Delegates, reported on several issues of concern to psychiatry that have or will soon come before the AMA.

An AMA initiative drawing mixed reviews among psychiatrists to which he alerted the Board is a project known as AMAP--the American Medical Accreditation Program--in which the AMA plans to accredit physicians through a process designed and controlled by physicians. The AMA intends it to replace the current "hodgepodge" of physician-based and nonphysician-based organizations that accredit physicians, he explained, and hopes this accreditation will be a "national benchmark" accepted by hospitals and other medical organizations. Psychiatric News will report additional information on the AMAP plan as it becomes available.

English announced that APA has qualified for an additional delegate and alternate in the House of Delegates, and APA President Harold Eist, M.D., announced that Jerry Wiener, M.D., a former APA president, will be filling that role. Jeremy Lazarus, M.D., speaker-elect of the Assembly, has been named to serve as alternate delegate.

APA is in the process of drafting resolutions to be brought to the AMA, English also noted, that would put the AMA and state medical societies on record as "active supporters" of mental illness parity legislation and "active opponents" of any legislative efforts to extend prescribing privileges to psychologists.

The AMA is also concerned about and exploring ways to remedy the paltry amount of education regarding ethical concerns that physician groups provide their members, English said. APA, he pointed out, is often acknowledged as the organization "in the vanguard of recognizing the importance of ethics for both doctors and patients."

In addition, the APA Board asked English to take to the AMA the issue of lack of medical staff input when hospitals or medical schools replace their staff's health care insurance plan with a new one, which often turns out to cut back coverage and options. The issue was raised by Member-in-Training Trustee Helen Link Egger, M.D., who indicated that she is hearing widespread complaints about this practice.

Workforce Issues

Distressed that fiscal pressures and politically motivated proposals rather than the medical needs of the U.S. population are shaping debates about the number of specialist physicians whom the country's medical schools should train, the Board voted to support any legislation or regulation that will ensure that "an adequate number of psychiatrists" are trained. This action also states that APA will back legislative proposals designed to guarantee that services to meet the psychiatric needs of underserved communities are available to residents of those areas.

In addition, the Board endorsed a statement that addresses the controversies swirling around the issue of the future size of the psychiatric workforce. It emphasizes that "there is no justification for a shift in policies that might serve to destabilize the size of the psychiatrist workforce," especially in light of "substantial evidence of unmet clinical and research needs in specific populations and areas."

Cited in particular are children, the elderly, people in rural areas, the poor, those who have developmental as well as psychiatric disabilities, the chronically mentally ill, and members of racial and ethnic minorities.

Both of these workforce-related actions followed a recent call from the AMA and the Association of American Medical Colleges and other groups for a reduction in the size of residency programs and a shift in the way medical education is financed, including severe restrictions on using federal dollars to support the training of international medical graduates (Psychiatric News, March 21).

The Board also directed APA President Eist to write a letter to the president of the Greater New York Hospital Association that points out the disproportionate impact on psychiatric housestaff of a demonstration project to reduce the number of residents the region's hospitals will continue to train. The federal Health Care Financing Administration will pay the hospitals a subsidy for reducing the number of residents on staff.

On a budget matter concerning the cost of APA component meetings, the Trustees approved a $70 per person maximum on the cost of any meal purchased by APA or any of its councils, committees, or editorial boards, which is to include food, beverage, tax, and service charges. They also voted to delete a rule that has prohibited the Association from reimbursing members for the cost of alcoholic beverages at APA component functions.

(Psychiatric News, April 4, 1997)