The development of core competencies for residency training has highlighted the need to assess residents' professionalism, one component of which is acting in adherence to ethical principles (+1). It is hoped that this effort will enhance the ethical behavior of psychiatric residents and practicing psychiatrists, which has been most extensively studied in the area of sexual boundary violations (+2, +3). The literature also supports calls for increased attention to ethics instruction. In a survey conducted by Roberts et al. of 181 psychiatry residents at 10 training programs in the United States, for example, 76.2% of residents reported they had "faced an ethical dilemma for which they felt unprepared during their medical training" (+4).

Recently, several strategies for improving ethics training in psychiatry have been proposed (+5—+7). While the process for teaching ethics may vary, most proposals recommend similar content, including boundary violations, confidentiality, commitment, forced treatment, informed consent, and reporting colleague impairment (+4, +8—+10). Such topics comprise the essential ethical issues in psychiatric practice, and residents must master them. In a sense, these are the "overt" ethical dilemmas of psychiatry. They also represent the big decisions in patient care and are situations in which attending physicians are apt to take a guiding role.

Another class of ethical problems is inherent in the training process itself. These "covert" dilemmas arise from the conflicting ethical duties that residents must balance between their dual roles as physician and learner, as physician and supervisee, and as physician and employee of a training institution. The tension among these roles is inescapable, and to a greater or lesser extent it influences many of the day-to-day decisions that residents make.

Conflicting loyalties (sometimes called "dual agency" or "double agency") can be ethically thorny for a fully trained physician. For a resident, these dilemmas must be negotiated at a time of high stress, when the personal weaknesses that lead good doctors to make ethically dubious decisions—among them fear, fatigue, self-doubt, and ignorance—may be most intense. The model of dual agency can be applied to residency training in most specialties, but for psychiatrists-in-training, the ethical conflicts may be heightened by the vulnerability of psychiatric patients, the prominent role of the psychiatric supervisor, and the unique stressors of psychiatric residency training.

The most ubiquitous ethical conflict among medical trainees arises from the dual roles of clinician and learner. Like all residents and medical students, psychiatrists-in-training provide treatment not just to benefit the patient, but also as a means of gaining clinical expertise. This can be conceptualized as competing ethical duties: the first of which is the duty to one's current patient and the ethical requirement that doctors generally must consider patients as ends in themselves and not as means to another aim (+11). The second duty is for residents to learn from current patients in order to adequately provide for future ones, and it stems from the benefit society receives by producing fully trained clinicians (+12).

These duties are at times incompatible, for example, when a resident's first psychotherapy patient is psychologically harmed by the resident's clumsy interventions. At least one clinical ethicist has questioned whether it is ever ethically justified to allow trainees to treat patients when fully trained clinicians are available (+13). Others have likened patients in training institutions to patients in research trials—describing them as educational "subjects" with the same vulnerabilities as research subjects (+12).

Medical trainees in every field cannot escape the need to fulfill these sometimes-conflicting roles of physician and learner. The vulnerability of psychiatric patients may make this ethical dilemma particularly morally troubling for psychiatric trainees. It is present to some degree in a wide variety of clinical situations:

A second ethical dilemma arises from residents' dual obligations to their patients and to their supervisors, who are generally held legally and ethically accountable for all patient-care decisions. First-year psychiatry residents tend to feel most dependent upon their supervisors (+14), but even senior residents owe them deference. However, as full-fledged medical doctors, all residents also have a fiduciary responsibility to their patients. On occasion, the courts have borne this out by finding residents legally responsible for patient-care mistakes (+15).

In the ideal residency program, all attending physicians are ethical and clinical exemplars, and the resident's idea of beneficence is in perfect alignment with the supervisor's. In the real world, residents and supervisors may disagree on what is best for the patient—often because of the resident's inexperience but sometimes because the supervisor is incompetent or frankly impaired.

In psychiatry, assessing supervisor competence can be difficult, especially for junior residents, due to the wide range of acceptable treatments and the latitude with which competent psychiatrists diagnose patients. Residents may be left wondering where a supervisor's idiosyncrasies end and true incompetence begins. In such circumstances, residents must somehow balance the duty to the patient against the responsibility to a supervisor who advises a dubious course of action. Clinical situations in which a psychiatry resident's ethical behavior is influenced by the conflict between duty to supervisors and duty to patients include:

A third dilemma arises from psychiatry residents' roles as employees. This can lead to a conflict between residents' duty to patients and their need to follow the rules of the institution for which they work, which may adversely affect patient care. This conflict is not unique to residents, as fully trained psychiatrists also face this problem, particularly when working for managed care companies or in the public sector.

The American Psychiatric Association Ethics Committee has addressed this issue in terms of the ethical obligations of a fully trained psychiatrist who works at a public hospital and is forced to care for more patients than he can competently handle. The Committee recommends that:

Such a situation can be especially difficult during residency because psychiatrists-in-training are both less empowered to lobby for institutional changes and less free to move on. Circumstances in which residents' ethical behavior is influenced by their conflicting roles as physicians and employees include:

Maintaining a focus on duty to one's patients is possible despite these conflicting obligations, but it can be made more difficult by the very circumstances of training. Residency training in any field is a time of high stress, when residents suffer sleep deprivation, work long hours that cause separation from loved ones, feel inadequate and at times helpless, and suffer increased incidence of depression (+16—+18).

Psychiatry residents generally work fewer hours than those in some other specialties, but they suffer unique stressors. Some 90% report having been assaulted or threatened by patients, and an estimated 61% encounter suicide during residency training (+20). International medical graduates make up a relatively high percentage of the residents in United States psychiatric residency training programs (+21), and for them the stress of residency may be increased by separation from family and country of origin, discrimination, and limited career options (+22).

When a difficult choice must be made between competing ethical obligations, personal vulnerabilities may tip the balance toward the option that is most closely aligned with self-interest. For example, an exhausted resident on call may choose not to argue with a supervisor who wants to discharge an emergency-room patient the resident believes needs admission. The resident may rationalize the choice as appropriately deferring to a superior, yet the resident's fatigue and fear of confronting the supervisor may have been the unacknowledged deciding factors. Similarly, a resident under pressure to demonstrate competence in a specific psychotherapeutic modality may ignore indications that a patient is not suited to the assigned therapy, and a resident who had difficulty gaining acceptance into a residency training program may believe his position is too tenuous to risk speaking up about institutional policies that adversely impact patient care.

Training programs can do much to help residents manage the ethical dilemmas inherent in their position (+Table 1). The first task is making covert ethical dilemmas overt. During the first year of residency, trainees should be educated about the stresses of residency training and the multiple conflicting loyalties that must be managed. Training directors should clearly explain that duty to the patient is preeminent and that it is the responsibility of the training program to ensure residents are exposed to enough patients of sufficient variety to enable educational goals to be met while respecting patient needs and preferences.

Second, training programs should aggressively address problems in the supervisor/supervisee relationship. Kozlowska et al. conducted a survey of 233 psychiatric trainees in New South Wales and found that 58% of trainees experienced "educational neglect" by supervisors. Respondent comments included such statements as: "minimal time grudgingly given when harried by me" and "no supervision for 6 months despite requests" (+19). In Igartua's survey of 229 Canadian psychiatry residents, 7% reported having worked with an impaired supervisor. The resident's most common response was to become "prematurely independent" and work without supervision (+23).

Furthermore, Hantoot's case series of residents who admitted to lying to their psychotherapy supervisors points to a disturbing breakdown of trust, stemming largely from the residents' fear of criticism (+24). One resident described "editing everything" told to a supervisor over two years, while another admitted writing "creative process notes … molded to the taste of the supervisor" (+24).

Program directors must encourage residents to report supervisors who are impaired, incompetent, or under-involved. The residents' corresponding duty to supervisors should be articulated in terms of an ethical obligation to tell the truth and to openly voice disagreements when patient care is at stake. Several model programs for improving the supervisory relationship and handling disputes have been proposed in the literature (+14, +23, +25—+29). For example, Whitman proposes a 90-minute interactive educational program that describes characteristics of good supervisors and supervisees, helps residents define their expectations and address problems in the supervisory relationship, and educates residents about parallel process and boundary issues (+25).

Third, educators should recognize that a key to managing conflicts over residents' dual roles as physician and learner is ensuring that patients are freely consenting participants in the educational process. Without encouragement from supervisors and program directors, residents may be reluctant to explicitly inform patients of their level of experience. For example, Green et al. asked 397 internal medicine residents: "When performing a procedure in which you have had very little or no experience, have you ever intentionally chosen not to inform the competent patient of your inexperience?" Over 60 percent of the respondents answered "Yes" (+30). No similar surveys of psychiatry residents exist, but it seems unlikely that a significant percentage of psychiatrists-in-training disclose their inexperience, for example, to their first psychotherapy patients. Supervisors should address this matter as ethical issues of truth-telling, informed consent, and respect for persons. Supervisors can also help residents find thoughtful ways to explain to patients the implications of being treated in a training institution and by a resident under supervision.

Fourth, training directors and supervisors should take the lead in challenging institutional practices that harm patient care. In this way, they can model ethical behavior and assist residents who also wish to improve the system in which they work.

Finally, programs should continue to do what they can to minimize the inevitable stresses of being a psychiatric resident. Adherence to work-hours guidelines is an important first step. Other supportive strategies include offering residents personal mentoring and opportunities to participate in individual psychotherapy and process groups.

None of these suggestions should take the place of formal ethics curricula covering decisional capacity, confidentiality, commitment, and the like. As a complement to these topics, however, they may help residents recognize the ethical complexity of the myriad decisions they make on a daily basis. Because these issues are so personally relevant, ethical learning can be enhanced.

This paper has proposed a model for understanding ethical decision making among psychiatry residents based on multiple conflicting ethical duties and personal vulnerabilities (+Figure 1). Many of the clinical decisions a resident makes are influenced by these factors, though the complexity of the ethical issues may not be self-evident.

The notion of hidden ethical dilemmas in residency training owes a debt to research on the moral development of medical students. Since Leonard Eron's 1955 report on students in the first and last years of medical school (+31), surveys have consistently shown that the process of undergraduate medical training is a time of increasing demoralization, in both senses of the word, as trainees become more cynical and less ethical in their dealings with patients. Christakis and Feudtner's survey of 1,853 third-year medical students found that many students compromise their moral beliefs in order to please their superiors in the medical team. Forty percent of those surveyed reported having done something that the clerk thought "was wrong or improper for fear of a poor evaluation." The same percentage acted wrongly or improperly "to fit in with the team." By the end of the 1-year clerkship, most no longer questioned the ethics of such behaviors as falsifying records in order to work more quickly (+32). These and other studies have led to the concept of a "hidden" or "informal" curriculum through which medical students learn acceptable, but not necessarily ethical, professional behavior (+32—+36).

In psychiatric training, the idea of a hidden ethics curriculum has received scant attention, perhaps because the manifest ethics curriculum itself seems inadequate. Nonetheless, numerous questions can be raised about ethical dilemmas inherent in the training process: How often do psychiatry residents act contrary to established ethical guidelines? By what rationale do they make such choices? Do psychiatry residents perceive their conflicting loyalties as ethical dilemmas, and how do they resolve them? How satisfied are psychiatry residents with their ability to fulfill their duty to patients? How many are fully aware of their duty to supervisors? Do psychiatry residents perceive themselves as having an ethical duty to challenge institutional policies that adversely impact patient care? How does ethical behavior change during the course of residency training?

Finally, this paper has proposed strategies that training programs can use to educate residents about their ethical obligations and help them balance their conflicting duties. One hopes that residents who are taught to scrutinize their decisions in this way will continue to do so once they enter psychiatric practice. This, too, is an area that merits further study.

The author thanks Stephen Dinwiddie, M.D. for assistance with the conceptualization of this article and Thomas A.M. Kramer, M.D., Michelle Pent, M.D., Valerie Davis Raskin, M.D., Lainie Friedman Ross, M.D., Ph.D., and three anonymous reviewers for their helpful comments and suggestions.