Front Matter

Contributors

Preface

Introductory Comments

PART I: Ethics and Professionalism

1 Ethics, Professionalism, and the Field of Mental Health An Overview

Laura Weiss Roberts, M.D., M.A.

Max Kasun, B.A.

Gabriel Termuehlen, B.A.

2 Ethics in the Mental Health Professions

Laura Weiss Roberts, M.D., M.A.

Max Kasun, B.A.

Gabriel Termuehlen, B.A.

PART II: Questions and Annotated Answers

3 Core Concepts in Ethics and Professionalism

4 Ethics and Professionalism in Clinical Care

5 Ethics and Professionalism in Medical Research

6 Ethics and Professionalism in Interactions With Colleagues and Trainees

PART III: Self-Assessment and Further Study

7 Ethics and Professionalism Questions for Review

References

Subject Index

Q&A Index

Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law; Director, Center for Law, Ethics, and Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York

Clinical Professor of Psychiatry, Baylor College of Medicine, Houston, Texas

Roberts Ethics Lab, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Katharine Dexter McCormick and Stanley McCormick Memorial Professor, Stanford University; Chair, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Editor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Professor of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland; Professor of Psychiatry, George Washington University School of Medicine, Washington, D.C.

Every era of medicine has ethical challenges—some new, such as those we have experienced with the COVID-19 pandemic and effects of recent extreme weather events caused by climate change, and some not as new, such as those we face when determining how to uproot systemic barriers to equity in the workplace and in the provision of care, and how best to demonstrate respect for patients' cultural values, self-governance, and privacy. Psychiatrists, psychologists, therapists, and clinicians caring for people with mental health concerns encounter additional and specific ethical concerns, also both modern and ancient. Should a psychiatrist consider including artificial intelligence decision tools in her clinical practice, for example? How does one intervene with an exhausted, care-worn clinical colleague while maintaining appropriate boundaries? What are the best ways to support the autonomy of a patient who is living with a severe but intermittent disorder affecting mood and cognition? These are hard questions, and the answers are nuanced and dependent on multiple factors and context. For these reasons, mental health clinicians and trainees as well as practitioners in related health fields must understand the requirements of professionalism and cultivate a strong set of ethical decision-making skills.

This book is a second edition of an earlier text that sought to help clinicians and clinical trainees across the health professions to prepare for professional and ethical issues in their everyday work and education. We have structured the second edition to provide commentaries on the role of professionalism and ethics in clinical care, training, research, and leadership activities of mental health professionals. The first two chapters provide a brief overview of key elements of professionalism and ethics. These first chapters give essential guidelines, strategies, and best practices for mental health clinicians and trainees. Subsequent chapters proffer questions and answers based on terms, principles, and clinical, training, and research scenarios. The last chapter of the book provides dozens of questions that draw on content throughout the entire text.

We hope that this second edition will continue to be a resource of value to mental health professionals of different backgrounds and experiences at different points in their professional developmental paths. This new edition includes updated references, expanded and revised introductory material on ethics and professionalism in the field of mental health, new clinical vignettes, and dozens of new questions and answers, covering timely and timeless topics, including assisted suicide, euthanasia, social media, technology, burnout, professional well-being, and belonging. The expanded bank of questions for review in Chapter 7 is intended to help readers to assess their knowledge and areas for further study.

This book would not be possible without the generous contributions of those who worked on the first edition. We wish to thank Jinger G. Hoop, M.D.; Teresa T. Anderson, M.D., M.A.; Robert A. Bailey, M.D.; Jerald Belitz, Ph.D.; Philip J. Candilis, M.D.; Carlyle H. Chan, M.D.; John H. Coverdale, M.D., M.Ed., FRANZCP; Cynthia M. A. Geppert, M.D., Ph.D., M.P.H.; Thomas W. Heinrich, M.D.; Joseph B. Layde, M.D., J.D.; Jon A. Lehrmann, M.D.; Teresita McCarty, M.D.; Joshua C. Reiher, B.A.; Ryan Spellecy, Ph.D.; Carol I. Tsao, M.D., J.D.; Paul S. Appelbaum, M.D., Laura B. Dunn, M.D.; Glen O. Gabbard, M.D.; Thomas N. Wise, M.D.; and Ann Tennier, E.L.S. for their work on the first edition. For the second edition, we also thank Jane Paik Kim, Ph.D., for her introductory comment and Max Kasun, B.A., for his diligent and thoughtful efforts in providing background literature and editing assistance.

Laura Weiss Roberts, M.D., M.A.

Gabriel Termuehlen, B.A.

Ethics can sometimes seem a bit ethereal. With its roots in philosophy and much talk of principles, virtues, and values, ethics may appear too distant from the everyday realities of clinical practice to warrant close attention by a busy mental health professional. There is, after all, so much other art and science to learn, so many skills that do not come naturally to the mind of a good person, as many imagine that ethical practice does. When it comes time to triage the hours of the day, it is understandable that time for serious ethical reflection often loses out.

But what an unfortunate result that is! Moreover, this outcome springs from a mistaken notion about the nature of ethics. Just as good people do not instinctively follow good diagnostic practices without the training required to do so, just as they cannot be expected to have an intuitive sense of interactions among medications without studying pharmacology, so good people are not necessarily able to avoid the pitfalls inherent in the ethical challenges ubiquitous in clinical work. Sound ethical practice, like good psychotherapy, requires a judicious mixture of theoretical knowledge, supervised learning, and reflective practice. And like most other aspects of the job of a clinician, learning ethics takes time and intellectual effort.

What is this body of knowledge that we call ethics? The dominant approach in mental health ethics today, which is reflected in this book, relies on a set of principles that embody actions representing moral goods. Such principles—autonomy, beneficence, justice, and fidelity among them—are part of the ordinary moral discourse of our professions and the broader society. In this view, ethical knowledge involves the ability to recognize the moral principles at play in a situation and, to the extent that different principles lead to varying courses of action, to reason through an approach to the situation that represents a justifiable prioritization of one principle or combination of principles over alternative formulations.

Consider just a sample of issues that have come across my desk recently from trainees and colleagues alike. How certain does a clinician have to be that child abuse has occurred at the hands of her patient to risk rupturing the therapeutic relationship by reporting her suspicions to the authorities? When is it appropriate, if ever, for a psychiatrist to conduct an internet search to learn more about a current or prospective patient? What information can a psychiatrist disclose to the police about a former patient, when that person is stalking the psychiatrist? How should a training program deal with a resident who has serious difficulties with supervisors and peers but whose treatment of patients seems unimpaired? To what parts of the psychiatric chart in an electronic health record should nonpsychiatric clinicians in a hospital or clinic have access to be able to provide the best care for patients? How far does a researcher have to go to protect a nonpatient participant who indicates that he is experiencing suicidal thoughts?

Far from an exhaustive list, this assortment of ethical conundrums reflects the slew of routine issues with which mental health clinicians, teachers, and researchers must cope. None would be worthy of discussion if they did not involve the opposition of principles that, taken on their own, would ordinarily point toward a clear path of action. Take the question of when to report suspected child abuse as an example. Standing alone, protecting the confidentiality of the clinical setting is ordinarily seen as a good in itself or reflective of other goods, such as fidelity to the patient’s interests and respect for the patient as a person. But here in opposition to those desiderata is the well-being of a helpless child, who the clinician has reason to suspect is being endangered. Every state has codified a resolution of this ethical tension, requiring clinicians to report child abuse to the proper authorities, yet that does not fully settle the matter. How certain must the clinician be that abuse is occurring? Most states use word formulas with phrases such as “reasonable probability.” Whatever such language conveys to the legal mind, it will often leave the clinician struggling to define when a probability is “reasonable” and to what extent the potential negative consequences of a report to the authorities—including the rupture of the dyadic bond on which treatment relies—can legitimately influence that conclusion. On which side are we to err, confidentiality or beneficent protection of the helpless? And on what basis can we defend our choice?

Didactic experiences of a classroom variety are in themselves unlikely to prepare clinicians to deal with challenges such as these. Whatever the benefits of extensive education in the history and theory of moral philosophy, most mental health professionals have neither the time nor the predilection for such training. Nor is it clear that even the best moral theoreticians would be well suited to confront the common dilemmas that clinicians must resolve. After all, ethical problems rarely come with clear labels attached or sort neatly into the categories beloved by authors of philosophical texts. No, this is a field in which pure theory takes one only so far.

How then to pursue the task? As clinicians, we recognize the importance of context in all aspects of our patients’ lives, and the ethical dilemmas they present are no exception. The ethics of mental health practice, training, and research are best learned from situations that resemble those we face in our work, unavoidably shaped as they are by the rich details of the contexts in which they occur. We are surely not unique in that respect. Just as students of law gain most from analyzing actual legal cases and students of business focus on travails of real corporations, so clinical situations help us think through issues in ways that transfer meaningfully to our subsequent work with patients. Within the rich contexts of real life, general principles are easier to appreciate and apply and are more likely to be imprinted for future use. And the complexity of the situations that we study belies any efforts at ethical reductionism. These are inescapably complicated and difficult challenges, presenting choices that often represent significant trade-offs regardless of the course chosen.

Ideally, we might each have a tutor in ethics to accomplish this task, someone with a broad knowledge of ethical theory and an equally wide experience in dealing with the ethical dilemmas of mental health practice, training, and research. When a problem arose, we would turn to this person for guidance, learning to identify the relevant facts, clarify the principles involved, and reason to a satisfying conclusion. Few of us, however, are so blessed. Instead, we must search for more prosaic alternatives to that wise mentor.

Therein lies the value of this book and its interactive, case-oriented approach to mental health ethics. The brief case descriptions that frame each ethical question echo the real-life complexities of clinical practice. The questions test the reader’s reasoning and sharpen his or her ability to engage in ethical thought. And the explanations following each question offer background information about relevant ethical concepts, related legal and clinical considerations, and suggestions for further reading. Taken as a whole, it is a most congenial and effective way for both trainees and more experienced mental health professionals to develop and polish their ethical skills.

Not even a text as useful as this one will confer on us all the knowledge and experience we need to feel confident in our ethical judgments. We must still dip into the literature of clinical ethics, consult with colleagues when tough cases come along, and inevitably make mistakes and, one hopes, learn from them. But this book is a decidedly useful vehicle to carry us down that road and to make us more accomplished professionals in the process.

Paul S. Appelbaum, M.D.

When the first edition of Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals appeared in 2008, Dr. Laura Roberts’ book was a highly regarded text sought out by both experienced clinicians and students from all mental health disciplines. It appeared at an auspicious time, when professionalism and ethics were gaining increasing importance in the day-to-day work of psychiatrists, psychologists, social workers, and other mental health professionals. The first edition reflected a quiet revolution that was occurring—in particular, it signaled the arrival of professionalism as deserving of a place alongside the other core competencies. Problem-based learning, didactic courses on ethical dilemmas, an emphasis on the doctor-patient relationship, and other innovations were appearing in the curricula of medical schools. Arnold and Stern (2006) have defined professionalism as follows: “Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical and legal understanding, on which is built the aspiration to, and wise application of, the principles of professionalism: excellence, humanism, accountability, and altruism” (p. 19).

As a result of this sea change, professionalism and ethics are now universally considered essential to those in the field of mental health. There is a broad understanding that gaining the patient’s confidence with respect, empathic listening, and compassion is the groundwork that must be laid to optimize the clinical encounter. There is an altruism inherent in this position—that is, practitioners must consider their own needs as secondary to those of the patient. As was true of the first edition, Dr. Roberts has provided wonderful clinical vignettes to help the reader actively think through options and their potential consequences in the clinical setting. Similarly, she takes the reader through the complexities involving conflicts of interest in research, the difficult tasks of assigning authorship, the need for disclosure, and other dilemmas that both students and experienced researchers will find of great value.

In this new, second edition, Dr. Roberts also presents new content that will be welcomed by both researchers and clinicians, not to mention educators. One of the most controversial and thorny aspects of ethics is assisted suicide and euthanasia. This area is complicated by religious views, the complexity of informed consent, and the concern that some who choose euthanasia may be clinically depressed. Another area that has presented new challenges for all practitioners emerges from the digital revolution. How does one navigate social media and the loss of anonymity, not to mention self-disclosure of all kinds? Another area that has recently been the subject of much discussion among ethicists is the increasing frequency with which clinicians may be “googling” their patients. Questions have arisen regarding the lack of concern for patient privacy, the voyeurism of the professional, and the absence of consent.

Another new area in this second edition is the unprecedented rise in problems of burnout and professional well-being. What are reasonable limits in an era of the electronic health record and increased expectations of physicians? The delicate task of reporting impaired colleagues is also addressed in this edition. In addition, neuroethics is also carefully considered. What about artificial intelligence and algorithms? What about the ethics of gene editing technology? Novel modes of prediction, evaluation, and treatment are addressed, and further information on ethical peer review is also taken up.

Throughout the book there are questions that are raised for contemplation. This new edition of Professionalism and Ethics is a superb text for clinicians of all mental health disciplines. Trainees will find it essential for their education. It will answer questions while also raising consciousness about dilemmas that have no easy answer. I highly recommend it for the shelves of all clinicians who must ponder the complexities of the human psyche.

Glen O. Gabbard, M.D.

Clinical Professor of Psychiatry, Baylor College of Medicine, Author of Professionalism in Psychiatry

The field of psychiatry has evolved drastically since the last edition of Professionalism and Ethics. The BRAIN 2020 initiative has brought to the forefront the most innovative neurotechnologies, as well as machine learning and artificial intelligence, which offer great promise in realizing the goals of modern medicine. Additionally, the COVID-19 pandemic has dramatically elevated the need for and use of telehealth and digital psychiatry. No longer confined to in-person encounters, physicians can implement a myriad of digital tools, including telemedicine, smartphone applications, and wearable devices. Information technology has changed in parallel: protected health information is transferred at high volumes from patients to health providers and third-party for-profit entities, and to and from cloud servers in which machine learning and artificial intelligence algorithms are deployed. Such algorithms, enabled by increases in computing speed and power and breakthroughs in deep learning algorithm development, have the ability to improve accurate diagnoses, predict preventable health events, and make personalized treatment recommendations for individuals.

The potential for artificial intelligence applications, specifically machine learning, to prevent, predict, manage, and even cure disease sparks immense hope for the future of health care (Abràmoff et al. 2018; Esteva et al. 2017; Gulshan et al. 2019; McKinney et al. 2020; Yeung et al. 2018, 2019). And yet, we must consider the new ethical issues posed by algorithmic medicine and algorithmic psychiatry. Professionals must remain aware of the latest developments in the research landscape, including revisions to the common rule. New technological innovations will also require an understanding of data privacy and confidentiality. Professionals must consider the risks and benefits posed by data and information handling by multiple agents. Further on the horizon, and less evident at the moment, professionals will need to know how to interoperate with artificial intelligence systems, and, in particular, how to understand the origins of data and algorithms and how to follow protocols related to technology and information sharing.

Outside of medicine, algorithms are already playing a role in human decision-making in unprecedented ways, from human resources to criminal courts (Barocas and Selbst 2016). And, yet, little is known about how algorithms perform in comparison with human judgment in complex situations (Dressel and Farid 2018). Of greater concern, there is now wide recognition that algorithms may reflect, reproduce, and perpetuate bias, which has prompted an explosion of theoretical and empirical research in the field of machine learning reflecting concerns about fundamental issues of fairness, justice, and bias (Barocas and Selbst 2016; Bolukbasi et al. 2016; Buolamwini and Gebru 2018; Chouldechova 2016; Corbett-Davies et al. 2017; Dressel and Farid 2018; Flores et al. 2016; Garg et al. 2017; Jackson et al. 2019; Jiang and Nachum 2019; Nachum and Jiang 2019). These concerns foreshadow the ethically laden arguments that are certain to emerge as algorithms become increasingly common in health care. An understanding of how unconscious bias in humans can propagate through algorithmic systems will be acutely necessary in the medical professions. Psychiatrists and emergency medicine physicians will be the first adopters of machine learning systems, and thus remain at the forefront of this crucial ethical issue.

The new edition of Professionalism and Ethics introduces ethical concepts related to algorithmic medicine in an engaging and proactive way. Dr. Roberts and colleagues present questions and answers that will allow health professionals to navigate this new, important territory. New content speaking to professionalism and wellness is also featured. Such content is especially salient and timely, given mental health care needs and unprecedented work conditions due to a devastating combination of biological and social traumas seen in 2020, namely, the COVID-19 pandemic and racism, police brutality, and violence against Black and minority communities. This new material on wellness is timely and its importance cannot be understated.

Dr. Roberts and colleagues have compiled a collection of forward-thinking content portrayed in a challenging question-and-answer format that allows the reader to think in real time and respond—providing an opportunity for learning in and of itself, through the act of showing, before telling. Although the application of ethics in clinical care and medical research is best learned through tangible and concrete lived experiences, this book provides a critical opportunity and point of learning to prepare professionals for challenges in care and research. It also offers a concrete tool and reference that will enable many in the profession, on all stages of the career path, to work toward the goal of improving global mental health with the utmost care and respect.

Jane Paik Kim, Ph.D.

Professionalism has now been identified as one of the six core competencies for residency education, and it has been defined as consisting of three domains: commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations (Andrews and Burruss 2004). Bioethics overlaps with professional responsibility and may be considered the theoretical framework for professional behavior. The foundations of moral reasoning in patient care include respect for autonomy, nonmaleficence, beneficence, and justice (Beauchamp 1999). Only through ongoing and reinforcing discussions will trainees fully understand and incorporate the essential values and behaviors inherent in this concept of professionalism. Such teaching typically begins with a top-down outline of the basic principles of moral reasoning. This must be accompanied by a bottom-up analysis of specific cases. Volumes such as this one should therefore be introduced during the clinical clerkship and then utilized at all levels of postgraduate training.

A major training goal for nascent physicians is to understand the very clear historical and current professionally legislated contract within the physician-patient relationship. The word patient is used advisedly in this context. Slavney and McHugh (1987) discussed the issue of our mental health colleagues (as well as some psychiatrists) utilizing the term client in lieu of patient. Labeling individuals as clients suggests superficial understanding of psychiatric disorders and also connotes the notion of caveat emptor (“let the buyer beware”). This is a distortion of the medical professional relationship, and it does not reduce our fundamental fiduciary responsibility to those we treat. The ideal of primum nocere (“first do no harm”) highlights the difference between the concepts of clients and patients and suggests professionals’ true covenant with patients. This covenant has roots in the Hippocratic oath, which includes a code of duties to patients and obligations to teachers and colleagues (Andrews and Burruss 2004). This responsibility does not limit patient autonomy but is the foundation that governs physicians’ behaviors and treatment approaches.

Chapter 4 of this book, “Ethics and Professionalism in Clinical Care,” may be the most compelling for students who are currently immersed in clinical care. One of the more confusing moral issues for psychiatric trainees is the inequity in psychiatric care due to financial and systemic barriers. This is often an issue in our current health care system, which lacks universal access and in which managing care is often more focused on financial considerations rather than on clinically relevant evidence. Use of datasets that give quantitative guidelines for length of stay are often inaccurate and can lead to limited hospital lengths of stay or inadequate outpatient management. Alternatively, unlimited fee for service may foster financial incentives for the practitioner (Hellinger 1996). Another problematic issue arises from the competing theoretical models that psychiatry employs, which complicates trainees’ ability to understand what is the best care: although the disease perspective is currently predominant, as demonstrated by advances in biological psychiatry and the importance of DSM iterations in diagnostic classification, the life-story methodology is often what attracts students to psychiatry (Slavney and McHugh 1985). However, biological and developmental explanations for a patient’s problems need not be contradictory and can complement each other. Nevertheless, students can become confused when their teachers hold strong views of what constitutes the best approach. The solution is for all students to have a firm grounding in the different perspectives of psychiatry, including the strengths and weaknesses of each. Two outstanding volumes that cover these issues should be required reading for all residents: Ghaemi’s The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness (Ghaemi 2003) and McHugh and Slavney’s The Perspectives of Psychiatry (McHugh and Slavney 1998).

The role of psychotherapy in healing is fascinating, but unless practitioners understand transference and countertransference, dangers can arise and ethical boundary violations can occur. Thus, those teaching psychodynamic issues must focus on both the patient’s and the trainee’s reactions (Coburn 1997; Smith 1984; Springmann 1989). This seems to be common sense, but with the current emphasis on short-term treatments and medically oriented management, these essential elements can be minimized in curricula. One problem with the use of psychotherapy is that we have not really defined the optimal dosing of these interventions. For example, should an individual who is “medication managing” a patient see that patient every 6 months or on a more frequent basis? The answer should depend on the patient’s clinical status and on the other treatment options available, but some practitioners tend to underutilize careful follow-ups in this age of managed care. A second problem occurs when individuals tend to see patients on a very frequent basis but are not fully trained to manage the transference and countertransference phenomena that arise in such intense psychotherapy relationships. Such therapeutic situations can develop into extremely dependent transferential relationships with untoward results (McHugh 1994).

It is also problematic when physicians use unorthodox tests and biological treatments. (This does not refer to the common use of rational polypharmacy or off-label indications of psychotropics that have a reasonable evidence basis.) Students often see patients managed in a nonsystematic manner, with both biological and psychological interventions that make no clinical sense and do not help patients. Trainees must learn how to respond to such situations, which may result in an uncomfortable confrontation with a colleague. Similarly, when practitioners learn of individuals treated unsuccessfully for weeks to months by therapists who fail to recommend biological interventions with proven efficacy, privately complaining about the therapist is not as helpful as finding methods to educate the person or intervening in other ways. Emerging new technologies also pose ethical challenges that can be helpful adjunctive elements to care or harm when used (Torous and Roberts 2017). There are no easy answers for these and many other situations psychiatrists face, and they pose special challenges that should be considered in training (Talbott and Mallott 2006).

Psychiatrists who practice within hospital settings are easily scrutinized by peers for significant aberrations from accepted practice. Such aberrations or sentinel events as defined by the Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) mandate investigation into the quality and competence of the practitioner. The office-based practitioner, on the other hand, is quite independent from such attention—a fact that requires ongoing discussion during training, not just a single lecture about ethics. The isolation of full-time office-based practice should be mitigated with peer supervision groups, clinical faculty appointments, or work in community mental health settings or hospitals. Ethics curricula in psychiatric residencies may ignore “hidden” issues that are not considered but potentially arise when the trainee enters clinical practice (Gupta et al. 2016).

In the past, the practice of medicine was a more personally autonomous enterprise, regulated only by other members of the profession (Freidson 1970). Such self-determination among mental health practitioners has begun eroding, as external forces have begun to shape decisions about therapeutic options as well as professional sanctions (McHugh 1996). In Chapter 4 of this volume, “Ethics and Professionalism in Clinical Care,” a vignette concerning the management of a suicidal patient whose insurer demands an early discharge cuts to the core of a dilemma facing contemporary hospital psychiatrists and should spark discussion in any hospital-based curriculum. The need to provide acute crisis management and stabilization has become the operant mode for the general hospital psychiatric program. Treatment is often limited to symptomatic change, rapidly followed by discharge. Sadly, it is all too easy to continue documentation that a patient is verbalizing self-harm when, in fact, the patient needs a few more days of stabilization but is not actively suicidal. Although one strategy is to phone the insurance reviewer and explain the need for continuing hospitalization, such feedback often falls on deaf ears and leads to further conflict. Furthermore, an increasing number of hospitals pressure physicians and psychiatric programs to reduce length of stay in an era of declining hospital benefits and increased indigent care. This points out the reality that psychiatric ethics is complex and often beset by a form of moral relativism. What is best for the patient is often not fully possible, and there are no easy answers (Beauchamp 1999).

As demonstrated by Chapter 5, “Ethics and Professionalism in Medical Research,” medical research also raises many ethical questions. For example, is it ever ethical to use placebo arms in clinical trials of patients with significant psychiatric disorders? Institutional review boards struggle with such questions daily. Managing relationships with pharmaceutical companies is another challenge, particularly in academic settings (Schneider et al. 2006; Wofford and Ohl 2005), and is touched on in Chapter 6, “Ethics and Professionalism in Interactions With Colleagues and Trainees.” The goal of the pharmaceutical company is to sell its products, and residents and faculty should remember that there is quite literally “no free lunch” (www.no-free-lunch.org). It may be easy to exclude pharmaceutical representatives from the training site, but residents will often see them at conferences and after work at industry-sponsored dinners. Shielding trainees from industry relationships entirely will not serve them well when they enter independent practice. One reasonable approach is to educate residents about the problems with industry-sponsored studies that often employ questionable statistics, dosing strategies, and patient selection to make a product seem better than alternatives. This kind of education will allow trainees to better assess the data they receive from industry programs and representatives.

A final topic to initiate early in training is how the resident can engage in lifelong learning, an essential aspect of professionalism. Although one of the core competencies is medical knowledge obtained and mastered during training, lifelong learning is essential given the rapidly changing advances in medical and psychiatric knowledge. It is increasingly easy to obtain and retrieve current medical knowledge through electronic journals and textbooks that allow the practitioner to have a sophisticated medical library on his or her desktop. Such resources are very often inexpensive, and it is not clear why all clinicians do not use them. The psychiatric trainee should easily incorporate knowledge acquisition as an essential part of professional practice if it is emphasized throughout their training.

In closing, this book offers a wonderful methodology for the beginning of training individuals in the basic construct of professionalism as a core competency in medicine, as well as for instilling the need for ongoing consideration of ethical behaviors and principles in the daily practice of psychiatry.

Thomas N. Wise, M.D., FACP

Professor of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland; Professor of Psychiatry, George Washington University School of Medicine, Washington, D.C.