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Hidden Ethical Dilemmas in Psychiatric Residency Training: The Psychiatry Resident as Dual Agent

Dr. Hoop is with the Department of Psychiatry and the MacLean Center for Clinical Ethics, University of Chicago, Chicago, Illinois. Address correspondence to Dr. Hoop, Department of Psychiatry, University of Chicago, MC 3077, 5841 S. Maryland Ave, Chicago, IL 60637; jhoop{at}yoda.bsd.uchicago.edu (E-mail).

ABSTRACT

In addition to learning about confidentiality, civil commitment, informed consent, and other ethical issues, psychiatry residents must deal with less visible ethical dilemmas that arise from the training process itself. Residents grapple with three inherent conflicting duties between their dual roles as physician and learner, as physician and supervisee, and as physician and employee of a training institution. These conflicts must be negotiated at a time of high stress, when residents are plagued with self-doubt, fear, fatigue, and other vulnerabilities that can lead good doctors to make ethically dubious decisions. While such conflicts and stressors are common to residency training in most specialties, they may be heightened in psychiatric residency. This paper proposes a model for understanding covert elements of ethical decision making during psychiatric residency and recommends strategies training programs can use to help residents navigate an ethical minefield.

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.

CONFLICTS BETWEEN ROLES AS PHYSICIAN AND LEARNER

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 resident performs a lumbar puncture for the first time, knowing that he is likely to cause the patient unnecessary discomfort and that more skillful hands are readily available.
  
• A resident recommends a second-line antidepressant for a patient, in large part because the resident needs to gain experience using that drug.
  
• A resident accepts a chronically suicidal patient for psychotherapy, even though the resident doubts both his own competence and the availability of his assigned supervisor.
  
• A resident asks a patient to be videotaped for a class or to be described in a case report, knowing that the patient's transference may make refusal difficult.
  

CONFLICTS BETWEEN ROLES AS PHYSICIAN AND SUPERVISEE

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 resident who disagrees with a supervisor's recommendation for electroconvulsive therapy falsely tells the supervisor that the patient refused the treatment.
  
• A resident working in the emergency room releases a patient on his supervisor's advice without protest, even though the resident's "gut feeling" is that the patient requires admission.
  
• A resident tells a psychotherapy supervisor only about the resident's interventions that suit the supervisor's theoretical bent.
  
• A resident agrees to a supervisor's suggestion to falsely document evaluation of a suicidal patient to reduce liability risks.
  

CONFLICTS BETWEEN ROLES AS PHYSICIAN AND EMPLOYEE

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:

Your first effort should be directed at getting the hospital to remedy the situation. That failing, you might feel compelled to resign. If you remain and do your best, you are behaving ethically. For us to declare otherwise might place an even greater burden upon our underfunded public institutions (9).

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:

• A resident agrees to discharge a hospitalized patient because the insurance coverage has run out, even though the resident believes the patient needs continued hospitalization.
  
• A resident works without complaint in a system that gives preferential treatment to wealthy patients or those with less-stigmatized diagnoses.
  
• A resident fails to disclose a medical error to a patient on the advice of the institution's risk-management office.
  
• A resident recommends a particular medication in part because the institution encourages the drug manufacturer to provide educational resources, free meals, and samples.
  

THE IMPACT OF RESIDENT STRESS AND VULNERABILITY

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.

RECOMMENDATIONS FOR RESIDENCY TRAINING PROGRAMS

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.

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TABLE 1. Helping Residents Manage Conflicting Ethical Duties

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.

CONCLUSION AND FUTURE DIRECTIONS FOR RESEARCH

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.

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FIGURE 1.  A Model for Ethical Decision Making During Residency Note: Factors that influence resident decision making include not just the resident's view of beneficence and patient autonomy but also the resident's duty to conform to supervisor preferences and institutional practices. In the ideal world, all four of these circles will overlap, and patient, resident, supervisor, and institution will agree on the best course of action. In practice, there will often be discord. Resident stress and personal vulnerabilities—such as fear, fatigue, self-doubt and immaturity—may tip the balance against acting in the patient's best interest. Training programs that offer support and education can minimize the impact of stress and personal vulnerability and directly help residents negotiate these multiple conflicts of interest.

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.

ACKNOWLEDGMENTS

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.

REFERENCES

1. Accreditation Council for Graduate Medical Education: ACGME Outcome Project: ACGME General Competencies Version 1.3 (9.28.99), 2000
2. Gartrell N, Herman J, Olarte S, Feldstein M, Localio R: Psychiatrist-patient sexual contact: results of a national survey, I: prevalence. Am J Psychiatry 1986; 143:1126–1131[Abstract/Free Full Text]
3. Gartrell N, Herman J, Olarte S, Localio R, Feldstein M: Psychiatric residents' sexual contact with educators and patients: results of a national survey. Am J Psychiatry 1988; 145:690–694[Abstract/Free Full Text]
4. Roberts L, McCarty T, Lyketsos C, Hardee J, Jacobson J, Walker R, Hough P, Gramelspacher G, Stidley C, Arambula M, Heebink D, Zornberg G, Siegler M: What and how psychiatry residents at ten training programs wish to learn about ethics. Acad Psychiatry 1996; 20:131–143[Abstract]
5. Rudin E, Edelson R, Servis M: Literature as an introduction to psychiatric ethics. Acad Psychiatry 1998; 22:41–46[Abstract/Free Full Text]
6. Schnapp W, Stone S, Van Norman J, Ruiz P: Teaching ethics in psychiatry. Acad Psychiatry 1996; 20:144–149[Abstract]
7. Roberts L, McCarty T, Roberts B, Morrison N, Belitz J, Berenson C, Siegler M: Clinical ethics teaching in psychiatric supervision. Acad Psychiatry 1996; 20:176–188[Abstract]
8. American Psychiatric Association: Ethics Primer of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 2001
9. American Psychiatric Association: Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2001
10. Group for the Advancement of Psychiatry: A Casebook in Psychiatric Ethics. New York, Brunner/Mazel, 1990
11. Beauchamp T: The philosophical basis of psychiatric ethics, in Psychiatric Ethics, third ed. Edited by Bloch S, Chodoff P, Green S. Oxford, UK, Oxford University Press, 1999
12. Vinicky J, Connors R, Leader R, Nash J: Patients as "subjects" or "objects" in residency education? J Clin Ethics 1991; 2:35–41[Medline]
13. Fry S: Is health-care delivery by partially trained professionals ever morally justified? J Clin Ethics 1991; 2:42–44[Medline]
14. Fann J, Hunt, D Schaad D: A sociological calendar of transitional stages during psychiatry residency training. Acad Psychiatry 2003; 27:31–38[Abstract/Free Full Text]
15. Butters J, Strope J: Legal standards of conduct for students and residents: Implications for health professions educators. Acad Med 1996; 71:583–590[Medline]
16. Collier V, McCue J, Markus A, Smith L: Stress in medical residency: status quo after a decade of reform? Ann Intern Med 2002; 136:384–390[Abstract/Free Full Text]
17. Green M: What (if anything) is wrong with residency overwork? Ann Intern Med 1995; 123:512–517[Abstract/Free Full Text]
18. Brent D: The residency as a developmental process. J Med Educ 1981; 56:417–422[Medline]
19. Kozlowska K, Nunn K, Cousens P: Adverse experiences in psychiatric training, part 2. Aust N Z J Psychiatry 1997; 31:641–652[Medline]
20. Pilkinton P, Etkin M: Encountering suicide: the experience of psychiatric residents. Acad Psychiatry 2003; 27:93–99[Abstract/Free Full Text]
21. Rao NR: Recent trends in psychiatry residency workforce with special reference to international medical graduates. Acad Psychiatry 2003; 27:269–276[Abstract/Free Full Text]
22. Cole-Kelly K: Cultures engaging cultures: international medical graduates training in the United States. Fam Med 1994; 26:618–624[Medline]
23. Igartua K: The impact of impaired supervisors on residents. Acad Psychiatry 2000; 24:188–194[Abstract/Free Full Text]
24. Hantoot M: Lying in psychotherapy supervision. Acad Psychiatry 2000; 24:179–187[Abstract/Free Full Text]
25. Whitman S: Teaching residents to use supervision effectively. Acad Psychiatry 2001; 25:143–147[Abstract/Free Full Text]
26. Whitman S, Ryan B, Rubenstein D: Psychotherapy supervisor training. Acad Psychiatry 2001; 25:156–161[Abstract/Free Full Text]
27. Egan E: Organizational ethics in residency training: moral conflict with supervising physicians. Camb Q 2003; 12:119–123
28. Council on Ethical and Judicial Affairs, American Medical Association: Disputes between medical supervisors and trainees. JAMA 1994: 272:1861–1865
29. Clarke D: Measuring the quality of supervision and the training experience in psychiatry. Aust N Z J Psychiatry 1999; 33:248–252[CrossRef][Medline]
30. Green M, Mitchell G, Stocking C, Cassel C, Seigler M: Do actions reported by physicians in training conflict with consensus guidelines on ethics? Arch Intern Med 1996; 156:298–304[Abstract]
31. Eron L: Effect of medical education on medical students' attitudes. J Med Educ 1955:30:559–566
32. Feudtner C, Christakis DA, Christakis NA: Do clinical clerks suffer ethical erosion? students' perceptions of their clinical environment and personal development. Acad Med 1994; 69:670–679[Medline]
33. Christakis DA, Feudtner C: Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993; 68:249–254[Medline]
34. Baldwin D, Daughtery S, Rowley B: Unethical and unprofessional conduct observed by residents during their first year of training. Acad Med 1998; 73:1195–1200[Medline]
35. Hafferty F, Franks R: The hidden curriculum, ethics teaching and the structure of medical education. Acad Med 1994; 69:861–871[Medline]
36. Hundert E: Lessons from an Optical Illusion: On Nature and Nurture, Knowledge and Values. Cambridge, Mass, Harvard University Press, 1995

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