Psychiatric Treatment of Medical Colleagues and Their Families: Potential Risks.
Constantino, E., & Spina, T. (2023). Psychiatric Treatment of Medical Colleagues and Their Families: Potential Risks. Journal of psychiatric practice, 29(6), 489–492. https://doi.org/10.1097/PRA.0000000000000745
We start the New Year 2023 with an important article, reflecting an important line of work here at PSYXIA. Treating the “V.I.P” comes with it’s own challenges and rewards. In November 2023 (late last year), the Journal Of Psychiatric Practice published a letter from the editor, Dr John Oldham, about his personal experience in treating VIPs.
“One man in his mid-20s was admitted to my inpatient unit because of out-of-control substance use and disruptive, sometimes violent, behaviour. His very powerful and influential family had “covered” for him repeatedly. Predictably, the family started pulling strings, insisting on special treatment. The patient’s mother intrusively demanded information about her son’s condition and the qualifications of the treatment team, although her son had explicitly denied permission for the team to communicate with the mother. The extent of the mother’s influence was illustrated by the fact that she contacted the chairman of the board of the hospital, who, in turn, requested that I and the medical director meet with the mother, at her convenience. The meeting was held in the medical director’s office, at her request, on Thanksgiving Day! We respectfully listened to her concerns but provided no information about her son’s care, per his instructions. Enraged, she stormed out of the meeting. One week later, her son signed himself out against medical advice and was lost to follow-up”.
We can’t help but feel compassion for the patient, as well as the mother, the clinicians and all those involved when things don’t go quite right. Indeed, though it is inevitable that mistakes occur and situations don’t pan out as we hope, there can be mixed feelings in psychiatry about treating VIP patients and their families. It comes with its own set of unique challenges and rewards.
In light of this, Eduardo Constantino and Thomas Spina go on to publish their article about treating medical colleagues and their families. Though this is only one type of VIP, the elements of this article can be generalised, and are important take home messages.
In analysis, we can say that the article is recent, and there is no conflict of interest to declare. It is from the USA, and therefore the content, language and practical applications are impacted by geography. There may be certain elements of Australian culture, for example, that differs from the views represented here. The journal itself is strong, with a reasonable impact factor (frequency articles are cited), as well as trustworthy and topical articles.
So, lets dive in! The article starts by providing some background, for example that VIP patients can unfortunately receive inferior care, that may deviate from standard practice. The patient cohort are more advanced in knowledge of diagnoses and medications, their other options, and their increased concern for confidentiality. There is also an innate fear of insurance and licensing. Indeed and unfortunately, there has been tragedy associated with this.
What immediately comes to mind is Dr Daksha Emson, a British-Indian psychiatrist and new mother who died by suicide. She was unfortunately not seen as a patient in the community mental health centres to protect her anonymity. This meant that she missed out on multidisciplinary care, and her notes were not communicated. For more information, please read the legacy article 20 years on from her death: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238666/
The article today provides three cases that exemplify risks, therefore providing guidance for clinicians. The first case is a 62yo GP Dr A with depression following divorce. In this situation, Dr A prematurely stopped a medication started by a psychiatrist, changed to an alternative, and found another GP to prescribe him Alprazolam – a potent and potentially dangerous hypnotic medication. Dr A questioned his therapist’s ‘experience’ and when challenged about his hypnotic use, expressed dissatisfaction with his psychiatrist. Dr A then called his friend, who was chairperson of the hospital, and complained about his psychiatrist again.
When reading this first passage, clinicians may experience a range of emotion. We may feel disgusted, rejected, angry or sorrow for Dr A, as well as compassion for the psychiatrist. Alternatively, they may feel Dr A’s plight was reasonable, and that he was exercising his clinical knowledge and patient rights. Personally, I feel hopelessness, and this unusual confirmation of my own imposter-syndrome, the negative voice in my head siding with Dr A and impacting my own confidence.
Case 2, meanwhile, is Ms B a young 21yo daughter of an anaesthetist. She bypasses the waiting list for an assessment of ADHD. During the assessment, Ms B discloses cocaine use, as well as a relationship with a person from a different culture. Ms B vehemently insisted that this should not be disclosed to her parents. Ms B’s mother was very upset about this, and withdrew treatment.
I read this case with a sense of hopelessness and compassion for Ms B. I feel that she finally opened up to someone, only to then realise that the control is still held by her powerful and influential parents. She would feels so isolated and dejected. That feeling would be contagious, and you’d be left wondering if she is indeed okay, and what ends up happening for her.
Case 3 is Mrs C, a 78yo lady with dementia in a nursing home. Her son is a senior psychiatrist in the hospital, as well as teacher and director. Her son instructs the junior psychiatrist and registrar to review his mother. Despite a treatment plan by the team, Mrs C’s son then changes her medications, and she was eventually discharged home, whilst remaining on Clonazepam – another potent benzodiazepine.
After reading this case, I feel further undermined in confidence as the senior doctor misuses his authority and power. Having worked in busy tertiary public hospitals, the situation feels all too real, particularly given some of the personality and behavioural traits shared by those in leadership positions. Negative feelings towards Mrs C’s doctor overtake the compassion towards Mrs C, though I feel worry about her long term health, remaining on Clonazepam.
In the discussion section of the article, the authors divide complexities into three groups – patient, clinician and institutional.
For patient factors, the patient (who is also a doctor) possesses greater knowledge and opinions, which opens scope for disagreement. The psychiatrist can feel threatened, and react. The article states however that doctors often overestimate their knowledge, especially as patients, especially in psychiatry. Boundaries can also often be blurred, with an expectation of special treatment. This expectation can arise to difficulty usually in doctors who embrace a more traditional, and asymmetrical doctor-patient relationship, as they struggle to adapt to being the “patient”.
Clinician factors are also complex and dynamic. Sometimes it can be pride, being able to look after VIP patients, and can be part of being ‘star-struck’. This can impact professionalism and objectivity. There can be role confusion and it can be harder to set limits and take leadership in the health journey. Doctors, myself included, often find it hard to confront other doctors, particularly those who they admire, or those in positions of power.
Lastly, there are institutional factors. For example, bypassing triage and referral protocol, or pulling strings from seniors and friends. In a public health system without a specialised doctor’s health focus, bypassing waiting lists could been seen as ethical violations of fairness and equity. After all, everyone pays tax!
The article concludes with some recommendations. This includes not treating patients or families that you have friendships or connections with. Similarly, there should be ground-rules, clear boundaries and expectations. Discussing power imbalances (which can be louder in psychiatry), confidentiality and standardisation is all important. Constant self-reflection and monitoring for boundary crossings and violations is also important.
It is inevitable that, with overworked and underpaid doctors in Australia, more will require psychiatric care. In the ACT, with some of the lowest wages and poorest culture dynamics, this is not surprising. Awareness of specific issues, and maintaining value driven, standardised and compassionate care is especially important in these situations.