Ethical and Practical Considerations for Managing MultipleRole Relationships

Ethical and Practical Considerations for Managing Multiple-Role Relationships in Family Medicine Education Randall Reitz Ph. D Paul Simmons MD St Mary’s FMR in Grand Jct, CO Tina Runyan Ph. D Stephanie Carter-Henry MD UMass Medical School, MA

Objectives • Participants will be able to describe ethical principles related to multiple -role relationships in family medicine residency settings. • Participants will be able to apply theoretical models in evaluating common ethical dilemmas and engage in a decision making process that minimizes negative outcomes for all parties involved. • Participants will be able to assist residents and faculty colleagues in building insight for resolving common ethical dilemmas unique to managing role conflicts.

Timeline : 00 - : 10 Introductions, Objectives, Burning Questions : 10 - : 20 Small group case study discussion : 20 - : 25 Report out on case studies : 25 - : 45 Ethical guidelines and theoretical models : 45 - : 55 Small group case study discussion : 55 - : 60 Report out on case studies : 60 - : 80 Building self-awareness and avoiding problems : 80 - : 90 Q/A and Wrap-up

CASE DISCUSSION – PGY 1/2 Fran is a married PGY 3 acting as Rachel’s senior resident just starting her PGY 1 year. Rachel is very bright and balancing residency with caring for her child as a single parent. During their PGY 3 and PGY 1 year Fran and Rachel regularly socialize with each other and co-residents. Fran and Rachel live in the same neighborhood and both have dogs. Whenever one of them travels the other person stops by their house to walk and feed the dogs. They are Facebook friends and have posted on each other’s wall. Fran graduated and joined faculty as Rachel begins her PGY 2 year. Rachel continues to excel in her PGY 2 year. Later in the year, Fran sees Rachel’s son as a patient and removes a wart off of his finger. As they both registered for the same conference, they carpool 200 miles to attend. While driving, Rachel describes difficulties with her ex-husband from being a single parent. Fran listens actively, provides encouragement, and suggests that she sounds like she could be struggling with depression. During the return trip, Fran shares that she has had frequent run-ins with the residency program director and Rachel shares her similar frustrations. Fran has a cousin who she thinks would be compatible with Rachel, so she invites them both over for dinner. Rachel and the cousin didn’t work out.

CASE DISCUSSION- 1 1. 2. 3. 4. What are the different roles that Fran plays in Rachel’s life? Are these activities and roles typical in your residency? Do you have any concerns with these roles? As Fran’s previous mentor and more senior faculty member, what advice would you give Fran, if any?

Ethical Guidelines and Other Recommendations

Clinical Role AAMFT AMHCA ACA NASW PSYCH AMA PSYCHIATRY Do not provide therapy to current trainees Should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee. Refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness, or risks exploitation or harm to the other person. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. Development of a sound working relationship between a doctor and his or her patient should take precedence over all other considerations.

Sexual Relationships AAMFT AMHCA ACA NASW PSYCH AMA PSYCHIATRY Do not engage in sexual intimacy with students or supervisees during the evaluative or training relationship. All forms of sexual behavior with supervisees, students and employees are unethical. Sexual or romantic interactions or relationships with current supervisees are prohibited. Do not engage in sexual activities or contact with supervisees, students, trainees, or other colleagues over whom they exercise professional authority. Do not engage in sexual relationships with students or supervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority. Sexual harassment is unethical. Sexual relationships between medical supervisors and their medical trainees, even when consensual, are not acceptable regardless of the degree of supervision in any given situation. The supervisory role should be eliminated if the parties involved wish to pursue their relationship. Sexual involvement between a faculty member or supervisor and a trainee or student, in those situations in which an abuse of power can occur, may be unethical because: a. Any treatment of a patient being supervised may be deleteriously affected. b. It may damage the trust relationship between teacher and student. c. Teachers are important professional role models for their trainees and affect their trainees’ future professional behavior.

Personal Role AAMFT AMHCA ACA NASW PSYCH Make every effort to avoid conditions and multiple relationships that could impair professional objectivity increase the risk of exploitation. When a dual/multiple relationship cannot be avoided, take appropriate precautions to make sure that detrimental effects are minimized. Engage in open discussions with supervisees when considering entering into relationships outside clinical and/or administrative supervisory roles. Document the rationale, potential benefits or drawbacks, and anticipated consequences for the supervisee. Clarify the specific nature and limitations of the additional role(s). Should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee. Refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness, or risks exploitation or harm to the other person. Nothing specific in AMA Code

Business Role AAMFT AMHCA ACA NASW PSYCH Make every effort to avoid conditions and multiple relationships that could impair professional objectivity increase the risk of exploitation. Make every effort to avoid dual/multiple relationships that could bias their judgment or increase the risk of personal or financial exploitation. Do not engage in any form of nonprofessional interaction that may compromise the supervisory relationship. Should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee. Refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness, or risks exploitation or harm to the other person. Nothing specific in AMA Code

Evaluative Role AAMFT AMHCA ACA PSYCH AMA Do not disclose supervisee confidences Disclosures are permitted only to other professional colleagues, administrators, or employers who share responsibility for training of the supervisee. Make every effort to avoid dual/multiple relationships that could bias their judgment. If supervisors must assume other professional roles (e. g. , clinical and administrative supervisor, instructor) with supervisees, they work to minimize potential conflicts and explain to supervisees the expectations and responsibilities associated with each role. When psychologists serve in more than one role they clarify role expectations and the extent of confidentiality at the outset and thereafter as changes occur. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. Nothing specific in NASW or Psychiatry

Patient Care AAMFT AMHCA AMA Take reasonable measures to ensure that services provided by supervisees are professional. The primary obligation of supervisors is to monitor services provided by supervisees to ensure client welfare. Counselors who are members of interdisciplinary teams clarify professional and ethical obligations of the team as a whole and of its individual members. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. Nothing specific in NASW, Psychology or Psychiatry

Synthesis • The AMA code is vague and places a lot of autonomy and • • • authority in the physician to assess potential ethical conflicts Behavioral health providers from various disciplines in primary care see their colleagues make decisions that are completely within bounds for the AMA, but confront commonly accepted practice in our disciplines Most codes are highly specific about dual relationships with trainees but assume the trainee is of the same discipline With collaborative care and collaborative training current ethical guidelines fall short as a guide because they do not take into account interprofessional models of healthcare or health education and training.

Mentor / Aloof Gatekeeper Friend Colleague Teacher Intimate Relation Personal Role Curbside Deflector / Gatekeeper Consultant Referrer Evaluator Personal Clinician Clinical Role Faculty Roles Un-involved Helping Gatekeeper Hand Coworker Gatekeeper Faculty Roles Other Roles Maintaining Roles and Relationships in Graduate Health Education Reitz, Simmons, Runyan, Hodgson (2012) Fiscal Partner Service or Fiscal Role

Case Discussion – PGY 3 Given their shared interests and comfort with each other, Fran is assigned to be Rachel’s faculty advisor. Rachel visits to Fran’s office increase in frequency as her depression deepens. She prescribes her sertraline. Rachel worries that her struggles will affect her future employment and requests that Fran not disclose her issues to other faculty members. Fran honors this request initially, but then becomes more concerned when other faculty members report that Rachel’s patient care and other duties have been sagging. The others chalk it up to senioritis.

Case Discussion - 2 1. 2. 3. Have you encountered similar situations in your residency? Do you have any concerns with these roles? As Fran’s previous mentor and more senior faculty member, what advice would you give Fran, if any?

Managing Multiple Roles

Emotional Intelligence Academic Medicine, Vol. 86, No. 12 / December 2011

The Problem of Human Frailty • The Hippocratic Oath assumes that human vulnerability is to be expected. • Maintaining physical and emotional boundaries is a developmental achievement. • Many of us, especially those with professional training, have not developed these skills during our development. • Boundary maintenance requires abstract conceptual thought: reflection, self-observation and situational awareness.

What is a Professional Boundary? Peer definitions: • “Standard of care” • Professional associations / ethics • Organizational bylaws, codes of conduct • Legal / regulatory statutes • Fiduciary character of faculty-resident or doctor-patient relationship The “expectable” behaviors for a specialty and setting • Example: Touching a female patient’s breast: • Radiologist? • Psychiatrist? • Gynecologist? • Family physician? If her complaint is a sore throat?

What is the Nature of the Faculty/Resident Relationship? • Lack of reciprocity • Power differential (evaluation, • • knowledge, skills) Contract Clear beginnings and endings Clear task orientation Trust / Fiduciary responsibility

The Primary Role Frame Think of it as the “sterile field” of your professional interactions. There is some permeability, but we must get back into the frame if we step out.

The Boundary Spectrum Boundary Drift Internal Psychological Process: • Private thoughts, fantasies, reveries • Danger is not staying attentive and curious about this information Boundary Crossings Engaging in behaviors with resident outside the scope of one’s role -definition: • Intentionally interacting outside teaching context • Ubiquitous and harmless in isolation: reciprocating a hug, sharing minor personal information in passing Boundary Transgressions Violations Sharing personal information such as desires or conflicts, intentional social contact with resident, intentional dual relationship, initiating physical contact, giving a gift Sexual contact, financial exploitation, remaining in an intimate relationship with a current resident or with a former resident in violation of ethical guidelines.

Symptoms of Potentially “Dangerous” Interactions • Emotional over-stimulation (e. g. strong attraction or repulsion) • Unusual requests for action: “I normally don’t do this, but…” • Assigning “special” status • Disclosing role-discordant personal information: not always • • • wrong, but notice when you do it and ask yourself why Intense feeling of strong emotional conviction: “it just is, ” little desire to reflect about your actions Reluctance to share interpersonal interaction with colleagues or friends (i. e. , shame, defensiveness, secrecy) Others question the interaction

The Road to Hell. . . Most boundary problems begin with good intentions. • Giving, caring, flattery, being funny, desire to help or please. . . In all our relationships, we reenact scripts from the past Boundary transgressions originate in largely unconscious reenactment of interpersonal schemata that cause: • Loss of present-time orientation • Loss of role context • Invocation of emotional vulnerabilities and needs • Completely normal and valid in other contexts!

How To Stay Within the Primary Frame and Out of Trouble • Accept that all of us are vulnerable 2 and have potential for professional violations r (V x S) • Understand the= dynamics of the “slippery slope” and -----V p learn to identify boundary problem warning signs A of the “Primary Frame” to govern • Internalize the concept • • one’s practice Adapted Realize that authorities from your boss(es) to the State Acumen Institute (2010) Medical Board have very real, legitimate expectations for your “personal” conduct and consequences for violation. Mindfulness…

Learning Mindfulness • Mindfulness is the ability to reflect on your own state of mind and • • emotions in the present moment. Become a curious observer of your own behavior and thoughts: Why do I do that? Why do I think that? Take your own “emotional temperature” often. Learn your own signs of distress and vulnerabilities (loneliness, sleep deprivation, feeling wronged or unappreciated, feeling desired…) Maintain a robust social support network, friends outside of medicine, and professional mentors inside medicine who can give feedback.

Learning Mindfulness What am I doing here, right now?

Learning Mindfulness "That which is not brought to consciousness appears in our lives as fate. " - Carl Jung

The Enlightened Professional • Personal myth and objective expectations in healthy tension • Objective self-awareness • Thoughtful about idealized influence and counter-transference • Individualized consideration of others and context. • Can exhibit one's knowledge and skill within the context of ethical, and emotionally neutral, conduct with others

Ethical and Practical Considerations for Managing Multiple-Role Relationships in Family Medicine Education Randall Reitz Ph. D Paul Simmons MD St Mary’s FMR in Grand Jct, CO Tina Runyan Ph. D Stephanie Carter-Henry MD UMass Medical School, MA