Increasingly, the delivery of health care is moving toward an integrated model, with psychologists practicing within medical clinics as part of multidisciplinary teams that holistically look at patient issues and work together to provide innovative treatments.
However, psychologists in hospital settings face unique ethical challenges, such as obtaining informed consent in a fast-paced environment, maintaining confidentiality with multidisciplinary teams and providing specialty training supervision.
Obtaining informed consent and discussing confidentiality take on particular challenges in the hospital setting. Patients are often referred from a medical practice and not actively seeking the services of a psychologist. They may not be particularly interested or motivated to seek mental health treatment and may see the referral as a barrier to overcome or have a negative connotation attached to the referral such as, “The doctor thinks it’s all in my head.”
It is crucial for psychologists to clarify the nature of the referral, the role of the psychologist and the purpose of the visit. Providing this information in writing and verbally with the patient helps build trust through transparency. Despite the fast-paced setting, psychologists need to be particularly mindful not to gloss over these issues in the interest of being “efficient.”
One important piece of informed consent is making sure the patient is clear about how records will be kept in the medical environment and who has access to these records and patient information. With the rise of electronic health records (EHR), notes are more accessible and searchable. The benefits of the EHR are numerous, easing care coordination and communication across disciplines. However, the ease of the EHR comes with misgivings on the parts of both patients and providers as to who will be accessing the records.
All EHR should include an audit system where a record of who has accessed the file can be reviewed. Many psychologists in hospital systems moving to EHR have strong concerns about patient privacy and confidentiality.
American Psychological Association (APA) Ethical Standards 4.01 and 4.02 discuss the psychologist’s obligation to protect confidential information and discuss limits of confidentiality.
For most health psychologists, it will be essential for their notes to be accessible to the medical team to be able to work in a truly integrated manner. Health psychologists should take care to write their notes as if the patient were reading the chart, using behavioral terms and quotes when possible and avoiding subjective or judgmental comments. Interestingly, many hospital systems are moving toward making patient notes, diagnoses and test results fully accessible to the patient online.
Further concerns about confidentiality arise when working as part of a multidisciplinary team. It is essential for health psychologists to explain the role of the psychologist as a member of the team and be clear that the team will discuss the results of the psychological evaluation. Some patients may still see the role of the psychologist like that of a lawyer or clergy and assume that “confidential” means that information is not recorded or shared.
Educating the patient about the role of the health psychologist is a critical piece of informed consent. In addition, the psychologist has the responsibility to keep the discussion with the multidisciplinary team relevant to the question at hand. Standard 4.04 notes that psychologists should include “only information germane to the purpose for which the communication is made.” Protecting the client’s confidential information is part of adhering to APA ethical principles, such as Respect for People’s Rights and Dignity (2010).
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Psychologists performing evaluations as a part of a medical team may be asked to give input on the potential psychological harm or benefit of a procedure and help the team weigh these with medical risks and benefits of a procedure. Ethical considerations include nonmaleficence, beneficence and the responsible use of power.
The psychologist acts as a consultant to the team, providing expertise from the literature as well as evaluation of the current mental state of the patient. This input, along with other team members, is used to help make a team decision for treatment that maximizes patient benefit and minimizes patient risk.
Again, it is important that the patient understands that the psychologist will be in communication with the team regarding these issues. In fact, psychologists performing evaluations in medical settings will often be helping the patients themselves weigh risks and benefits of procedures which can be important to share the patient’s own assessment with the multidisciplinary team.
Often, seeing patients in a hospital setting makes it more likely to see patients from diverse socioeconomic statuses and diverse cultural backgrounds. Assessing health care literacy is part of cultural competence.
Another common area of ethical issues in a hospital setting includes supervising trainees in health psychology specialties. Supervisors’ responsibilities include: a) supervisor competency in the areas of a supervisees’ training b) understanding the patient and the care that the student is providing c) ensuring the standard and quality of practice, which includes protecting the public d) overseeing all aspects of client services and e) mentoring the supervisee.
It is important to note that patient care is never sacrificed based on a student’s competency. The supervisor should always be closely involved in patient care if a student is not competent to handle a critical case.
It is essential that the supervisor is competent in both clinical practice and supervision, as past supervision experience does not necessarily guarantee supervisor competence. It is necessary that the individual consistently maintains knowledge through continuing education, relevant readings and consultation. Supervisor competencies relate to the constructs of knowledge, skills, attitudes and values.
It is important to be clear with patients during the consent process both the role of the supervisor and the supervisee in the treatment process. Addition-ally, consent discussion is often needed as well for other third parties present, such as family or support persons.
When working within a hospital setting, ethical issues are not uncommon. Almost every decision made can have ethical implications. These implications can affect patients, providers and health care systems. Ethical values direct daily practice by way of ethical principles and professional codes of conduct. Ethics by definition are a system of moral principles and values which include good, proper, honest and decent conduct. The APA Ethical Principles of Psychologists and Code of Conduct describes a body of rules, principles and standards which govern the conduct of our profession in clinical practice, research and publication.
The Ethics Code was developed to establish integrity in the profession of psychology. Health psychologists follow the APA Ethics Code as a set of aspirational principles and behaviors that are applied in diverse contexts. The Ethics Code is not a formula for solving ethical challenges, but a broad set of rules of conduct that are interpreted and applied in everyday practice. Health psychologists agree to have a commitment to these standards, but this commitment is just the first step to the decision making process.
Knapp and VandeCreek offer a five step model for ethical decision making that includes 1) identifying the problem 2) developing alternatives 3) evaluating options 4) action and 5) evaluation.
As a health psychologist, it is important to have a good network of colleagues to consult with regarding diversity and ethically challenging cases. Psychologists should refer to the APA guidelines, along with state rules and regulations and the state board of psychology. APA, APA Practice Organization and state psychological associations often offer informal consultation on ethical issues and are great resources. Additionally, health psychologists may consider board certification through ABPP as an additional level of credentialing of ethical foundation.
References available from authors
Kathleen Ashton, Ph.D., is a psychologist in the Bariatric and Metabolic Institute. Ashton’s clinical and research interests include bariatric surgery evaluation and treatment, binge eating disorder treatment, and behavioral weight management. She may be reached by email at: ASHTONK@ccf.org. Amy Sullivan, Psy.D., is staff clinical psychologist and director of behavioral medicine at the Mellen Center for MS Treatment and Research at the Cleveland Clinic. Her clinical interests are in individual, family and group work with patients and family members affected by Multiple Sclerosis. Her email is firstname.lastname@example.org.