Professionalism in Psychiatry

For those without recent experience in evaluating the so-called disruptive physician or teaching medical students and residents within a medical school environment, the timeliness of this book may not be readily apparent. More precisely defined unprofessional behavior with patients, colleagues, and health care staff is no longer tolerated as it was even a decade ago. The demand for a more rigorous definition and assessment of professionalism has been driven largely by accrediting organizations, such as the Accreditation Council for Graduate Medical Education and the Liaison Committee on Medical Education as well as state medical boards and professional societies. The public, of course, has demanded greater accountability from their physicians, and it is not possible to say with certainty what has been the precise effect of more women than men entering U.S. medical schools each year. Issues of patient and physician diversity have assumed more prominent positions in education and training with respect to current practices and also with respect to the increasing role they are likely to play in the future (1). Diversity issues, however, are not narrowly focused on gender but also include ethnocultural, sexual, age, and religious characteristics in the health setting. Ethical conflicts with the pharmaceutical and medical device industries as well as the practices of continuing medical education have affected many areas of academia and the daily treatment of patients. Psychiatry has received its fair share of exposure and criticism. Last, but not least, has been the growing influence of cyberspace and informatics on the doctor-patient relationship. Not only do many patients come to their initial visit knowing more about their psychiatrists than ever before, but the role of electronic communication with patients and the advent of telepsychiatry in all of its forms have significant ethical dimensions. (Is it ethical for the clinician to “google” a patient, to be on Facebook, or to blog?)

This new book by Glen Gabbard, Laura Roberts, and four coauthors is appealing because of its broad-based coverage of so many central issues of professionalism in psychiatry. The book comprises 10 chapters, with the initial one providing an overview of the evolution of professionalism in medicine and psychiatry. Chapter 2, reflecting Laura Roberts' enduring interest in medical ethics, discusses in a reader-friendly fashion the ethical constructs that define clinical practice and is a succinct review of the basic professional skills required for ethical psychiatric practice. Discussion of how to anticipate an ethically risky situation, which according to the authors may be more characteristic of psychiatry than of any other specialty, is especially relevant and persuasive. Psychiatry, they argue, appears to be held to higher standards compared with some other specialties because of the inherent vulnerability of our patients and the intense doctor-patient relationships that characterize psychiatric treatment. The third chapter, on professionalism in the clinical relationship, elucidates the effect of the therapeutic relationship on the patient and the treatment of boundary crossings and violations. It should be required reading for every psychiatric resident. This chapter, obviously written by Gabbard (chapter authors are not identified), also discusses the importance of the frame in psychotherapy, the primacy of confidentiality, self-disclosure, the language and clothing of the clinician, the receiving of gifts, and the inherent dangers of physical contact. The destructiveness of posttermination sexual contact is well explicated. Undoubtedly once again written by Gabbard and based on his previous articles, chapter 4 provides a balanced and vital discussion of professionalism and boundaries in cyberspace. Every clinician contemplating a Facebook page should read this chapter. Recommendations and guidelines are provided for every aspect of cyberspace. Chapter 6 provides a concise discussion of ethnocultural, sexual, gender, and race issues and is firmly anchored in clinical practice. This is not a chapter on culture-bound syndromes, cultural variation in the presentation of psychiatric disorders, or cultural approaches to special patient populations. All content of this chapter is devoted to the enhancement of the treatment relationship. The chapters on conflict of interest and interprofessional and intercollegial relationships are most informative. The discussion of diagnosis and treatment of the disruptive physician (another one of Gabbard's interests) is superb and includes specific recommendations about assessing fitness for duty. The penultimate and ultimate chapters of the book discuss training and educational issues, chiefly in terms of the power of the “hidden curriculum” (what teachers actually do and say as reflected in their behavior toward and about patients and colleagues and the potent effect it has on psychiatrists in training and their patients). The well-known intergenerational transmission of unprofessional behavior is detailed. Many educators are unaware of the traumatic deidealization of the student and resident when unprofessional behavior, such as verbal abuse, is practiced by their teachers and supervisors (2).

A popular photography magazine reviews camera equipment according to the following format: “What's hot, what's not, and who is this for?” First, this is the best “one-stop shopping” book published on professionalism in our field. It addresses nearly every substantive issue faced by the psychiatrist and resident. It is well written and integrates important points through the use of clinical vignettes. Unlike many books, this one utilizes tables and charts in an effective manner. Helpful key points are reviewed at the end of each chapter. Every topic is framed in terms of how attention to professionalism makes for better clinicians, who can therefore treat patients more empathically and thoughtfully. There are many scholarly books and chapters on diversity, for example, but the treatment of this topic in Professionalism in Psychiatry is always in the service of attending to building a more helpful treatment relationship. This book emphasizes prevention of ethical violations and professional misconduct and repeatedly speaks to the helpfulness of understanding countertransference. (Parenthetically, if there are arguments for retaining psychotherapy as a core clinical skill in psychiatry, this is undoubtedly one of them.) It strongly advocates lifelong learning and the use of consultation and supervision. Unfortunately, many residents do not avail themselves of consultation and supervision after graduation. Yes, medical student indebtedness may have some role in the reluctance to pay for supervision, but this is professionally shortsighted. It may cost nothing, except some time, to develop regular peer-group supervision after graduation. What's not “hot” about this book? There is little attention to the role of psychiatry in teaching ethics and professionalism to medical students. This is a significant issue because, after all, many of the effects of the hidden curriculum are first evident in medical school. I would have preferred much greater discussion on the destructiveness of physician sexual misconduct to the patient. The ubiquity of this problem in psychoanalytic institutes, hospitals, and the private practice of psychiatry is deplorable, and readers should understand that such behavior is “professional suicide” and career ending, and more critically, the damage to the patient is both dramatic and enduring. Boundary crossings and violations in supervisory relationships merit some explication as well.

Finally, who is this book for? This book should be required reading in every psychiatry residency program in this country and, for that matter, in other countries as well. Psychiatric hospital administrators, academic psychiatrists (remember the hidden curriculum), and nonacademic psychiatrists will also benefit from reading this book. Professionalism in Psychiatry addresses the fundamental ethical and professional topics required for program accreditation. Most importantly, however, attention to the issues in the book will enhance everyone's practice of psychiatry. The organizing principles of professional behavior defined as always being in the service of the patient and emphasis on the absolute need for vigilance about clinicians' motivation in the care of patients are reaffirming.