Rebecca W. Brendel

Medical professionalism in the age of online social networking

The rapid emergence and exploding usage of online social networking forums, which are frequented by millions, present clinicians with new ethical and professional challenges. Particularly among a younger generation of physicians and patients, the use of online social networking forums has become widespread. In this article, we discuss ethical challenges facing the patient–doctor relationship as a result of the growing use of online social networking forums. We draw upon one heavily used and highly trafficked forum, Facebook, to illustrate the elements of these online environments and the ethical challenges peculiar to their novel form of exchange. Finally, we present guidelines for clinicians to negotiate responsibly and professionally their possible uses of these social forums.

Abuse and Neglect

The Child: • Shows sudden changes in behavior or school performance • Has not received help for physical or medical problems brought to the parents’ attention • Has learning problems (or difficulty concentrating) that cannot be attributed to specific physical or psychological causes • Is always watchful, as though preparing for something bad to happen • Lacks adult supervision • Is overly compliant, passive, or withdrawn • Comes to school or other activities early, stays late, and does not want to go home (if abuse/neglect at home)

A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans.

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.

An approach to selected legal issues: confidentiality, mandatory reporting, abuse and neglect, informed consent, capacity decisions, boundary issues, and malpractice claims.

Medical practice occurs within a legal and regulatory context. This article covers several of the legal issues that frequently arise in the general medical setting. While this article provides an overview of approaches to informed consent, boundary issues, and malpractice claims, it is critical for clinicians to be familiar with the specific requirements and standards in the jurisdictions in which they practice. As a general rule, it is most important that physicians recognize that the best way to avoid legal problems is to be aware of legal requirements in the jurisdictions in which they practice, but to think clinically and not legally in the provision of consistent and sound clinical care to their patients.

Documentation of Decision-Making Capacity, Informed Consent, and Health Care Proxies: A Study of Surrogate Consent

BACKGROUND Patients in the general hospital are routinely asked to make decisions about their medical care. However, some of them are unable to express a choice, understand the information provided, weigh the options, or make a decision for themselves; when this occurs, the task of making an appropriate medical decision is left to another-a substitute decision-maker (SDM). OBJECTIVE We sought to understand the practice patterns surrounding surrogate consent. We hypothesized that SDMs would be used frequently for patients with an altered mental status (AMS) but that there would be insufficient documentation of health care proxies (HCP) and of clinician assessment of a patients decision-making capacity. METHODS A retrospective chart review was conducted on inpatients who underwent a lumbar puncture. The review assessed whether patients had a HCP in the record, if the patients mental status was evaluated prior to obtaining informed consent, if the patients capacity was addressed in this assessment, and whether a SDM was asked to provide the informed consent. RESULTS Consistent with our hypotheses, we found that the majority of patients did not have documentation of a HCP in the record. We found that the mental status of all patients was assessed prior to the procedure, but that documentation regarding assessment of decision-making capacity was lacking. CONCLUSIONS Our pilot investigation suggests that there is need for improvement in our evaluation and documentation of altered mental status and a patients ability to make informed decisions. To this end, several quality-improvement suggestions are discussed.

HIPAA for Psychiatrists

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established federal regulations governing the management of health care information.1 Although the first phase of HIPAA regulations went into effect in April of 2003, there is little written in the psychiatric literature about the practical implications of HIPAA for psychiatric practice. This column outlines the main provisions of HIPAA relevant to psychiatric practice: applicability, compliance, protected health information and its disclosure, patient access to records, and protections for psychotherapy notes. Although HIPAA is often considered privacy legislation, we also discuss how HIPAA actually reduces protection for psychiatric records. This column concludes with a practical framework for the management of clinical information in light of HIPAA regulations.

An approach to the patient in crisis: assessments of the risk of suicide and violence

Suicide is one of the leading causes of death in the United States and is defined as intentional self-harm with the intent of causing death. Various mental disorders may be a cause for increased violence. This article outlines the elements of the risk assessment (for harm to self and/or others) in patients in crisis and addresses which contributing factors may be modifiable. This article also proposes a practical framework for the management of risk regarding suicide and violence.

Beyond Emergencies: The Use of Physical Restraints in Medical and Psychiatric Settings

&NA; Physical restraints, such as locked‐door seclusion and two‐ or four‐point leather restraints, are frequently used in both the medical and psychiatric settings. Efforts are currently under way to reduce the use of physical restraints in psychiatric settings; various institutional, state, and federal policies are place. However, using these same restraints in the context of providing medical care for psychiatric patients is more complicated, as it is uncertain which principles and regulations apply in a particular setting. For example, is the restraint governed by the policies that regulate the psychiatric application of restraints, by those that regulate the medical application of restraints, or by both? This article reviews the principles and regulations governing the use of restraints on psychiatric patients, with specific attention to the use of restraints in providing medical treatment to that patient population. Also addressed are general principles of risk management to help avoid negative outcomes and to reduce the risk of litigation for unauthorized or unlawful restraint. A case example is used to illustrate these concepts.

Legal Concerns in Psychosomatic Medicine

In the practice of psychosomatic medicine, psychiatrists frequently encounter issues of legal concern. This article provides an overview of legal topics frequently encountered by the psychiatric consultant. One such area, discussed first in this article, is confidentiality and the management of private patient information. A second common interface between law and psychiatry is in the area of medical decision making. The psychiatric consultant is often asked to evaluate a patients ability to accept or refuse treatment, and then make a determination of capacity. When the patient cannot give informed consent, an alternate decision maker must be found. Finally, malpractice liability is often a concern for the psychiatric consultant. Overall, psychiatrists should approach the care of patients foremost from a clinical perspective, while understanding the applicable laws and regulations of the jurisdictions in which they practice. In addition, clinicians should be aware of the legal and risk management resources available to them should a complex situation arise.

Strategies for the Prescription of Psychotropic Drugs with Black Box Warnings

BACKGROUND The Black Box Warning (BBW) is the Food and Drug Administrations highest level of drug warning. It signifies that a medication has serious (or potentially life-threatening) side effects and is prominently displayed on a medications package insert. It literally consists of the medication warning and is surrounded by a bold black border. OBJECTIVE This article aims to review data related to BBWs on psychotropic medications currently used in clinical practice, with special attention to clinical situations and questions relevant to consultation-liaison psychiatrists. RESULTS We review 3 clinical advisories or BBWs for psychotropic medications (i.e., antidepressant medication and suicidality in the pediatric population, stimulant medication and sudden death in the pediatric population, and antipsychotic medication and increased mortality in the elderly) and discuss the effect they have had on prescribing practices. We provide a table of current BBWs relevant to psychotropic medications. CONCLUSIONS BBWs can have unintended and far-reaching consequences, albeit with a limited ability to target specific populations and practice patterns. Although it is critical for clinicians to be aware of these serious potential side effects and to inform patients about these warnings, medications with boxed warnings remain Food and Drug Administration-approved and may have critically important therapeutic roles.