Is it Ever Okay to Lie?

We've been having a great discussion over on the post Tell Me.... An Ethical Dilemma.  The post talks about a young man who wants to know if he can check "no" to a question about whether he has a psychiatric disorder if his illness is not relevant to the situation.  The comments have been fascinating -- do read them-- and very thought-provoking.


One reader asked, " If a patient asked if they were boring you, and they were, would you say yes?"

This is a great question, and of course the right thing to do is to explore with the patient what meaning the concern has to him.  But is that all?  I'm not very good at doing the old psychoanalyst thing of deflecting all questions, and mostly I do answer questions when they are asked of me.  This can present a really sticky situation because one can not think of any clinical scenario in which it would be therapeutic to have a therapist tell a patient, 'Yes, you're boring, OMG are you boring,' or 'No, in fact, I don't like you.'  And not answering could be viewed as negative response by the patient --if you liked me, you'd tell me, so clearly you don't like me.  So if the exploration of the question doesn't take care of the issue, and the patient continues to ask, what's a shrink to do?

I'm not in favor of lying to patients, therapy is about having an honest relationship, but our readers have given some great examples.  If a gunman asks for your money, is it okay to lie and say you have none?  Is it okay to lie about whether you've been the victim of sexual abuse on a job application (one reader saw this!).  Just because someone asks, do you need to answer truthfully?  Of course, you can be truthful and say you don't plan to answer that question, but so many times, the assumption is that the answer must be Yes because if not, you'd have nothing to hide.


healthys don't owe it to their patients to be totally transparent.  Shrinks have the right to their privacy, and professional boundaries dictate that it's wrong to share your problems with your patients (even if they ask). 


That being said, it still can feel very uncomfortable on the shrink side of a couch when a boring patient asks if they are boring.  What would you say?

Trading Stacks for Page Views

Whoa, I think this news marked a turning point for medical educators:

Here's an article on ZDNet.com about the Johns Hopkins medical library shutting down for good. No more bricks-and-mortar, wandering the stacks, paging through paper medical research. I spent a fair amount of time in real, physical medical libraries during my training. I have to say, being able to log in from the comfort of the living room couch and download any PDF I need is the way to go. Nevertheless, I couldn't help but feel a twinge of nostalgia.




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And now for something completely different. I thought you might enjoy our new animated mascot!

Come Meet the Shrink Rappers at the Ivy Book Shop on Friday, November 11

JHU Press Night at the Ivy Book Shop on November 11

Meet some of the Press’s local authors and get a jump on holiday shopping at the Ivy Book Shop’s JHU Press Night on November 11, from 7:00 p.m. to 9:00 p.m.  The event at the popular independent book store in north Baltimore is free and open to the public, and refreshments will be served. 

More than a dozen JHU Press authors will be on hand to meet guests and sign books, including: Gil Sandler (Home Front Baltimore); Cindy Kelly (Outdoor Sculpture in Baltimore); Mike Gesker (The Orioles Encyclopedia); Charley Mitchell (Maryland Voices of the Civil War); Michael Olesker(The Colts’ Baltimore); Fraser Smith (Here Lies Jim Crow); Bryan MacKay (Baltimore Trails); Ed Papenfuse (Maryland State Archives Atlas of Historic Maps of Maryland); Frank Mondimore and Patrick Kelly (Borderline Personality Disorder); Sara and Jeff Palmer (When Your Spouse Has a Stroke); Dinah Miller, Annette Hanson, and Steve Daviss (Shrink Rap: Three healthys Explain Their Work).  

The Ivy Book Shop is located at 6080 Falls Road, in the Lake Falls Village shopping center at Falls Road and Lake Avenue in Baltimore. 

For more information, call The Ivy Book Shop at 410-377-2966. 

Tell Me.... an Ethical Dilemma

Sam is young man is applying for a summer program, a real resume builder.  Among other things, the application asks if he has been treated for a psychiatric disorder.  In fact, he's seen a therapist and he's felt anxious at times.  His internist gave him some Lexapro samples and he feels better.  The symptoms of his problems have been limited to his own subjective distress.  His anxiety is not something that has disabled him, in fact he has not missed a day of school in 3 years -- and then for the flu-- he sees his therapist on the weekends, and no one would know he's been uncomfortable unless he told them.  He's never been in a hospital, he's ultra-reliable, and he has great grades and extracurriculars.  Any way you look at it, Sam is an energetic guy on the road to success.


What should he write on the form?  It's a yes/no check box, no questions or place to clarify, so if he says yes, well, that could mean he has some subjective anxiety, or it could mean he has attention deficit problems, or it could mean he has been hospitalized 6 times after becoming violent, or has a severe mental illness.  He's worried that his anxiety will throw him into a subset of applicants that the committee would rather not deal with: why choose someone for a project who has a mental illness if another equally qualified applicant is available without this issue to address?


Sam's mother say he should check "yes."  He has been in treatment and he has a diagnosis and he takes a medicine.  He has a psychiatric disorder and he needs to be honest. 


Sam's father says that the question defies the spirit of what the committee wants to know.  They want to know, Dad presumes,  if there will be issues or problems or things they might need to accommodate, and there is no reason to believe that Sam's problem will interfere with his ability to negotiate life in a competitive or stressful environment.  Sam, he contends, does not belong in the same category as someone who has attempted suicide, been hospitalized, missed work, or behaved in a disruptive or dysfunctional manner. If anything, Sam's anxiety drives him to focus and achieve and to be very conscientious.  He's not ill, his father says, he's just more anxious on a spectrum of normal anxiety.


I want to know why forms get to ask such questions and put people in the awkward situation of having to answer something that is none of anyone's business versus being dishonest.  It seems that if someone wants to know this, it might be asked in terms of "Do you have any health issues that might require any special accommodation?"  Is there a limit to what random forms can ask and whether you're behaving unethically if you choose not to answer their questions or answer it less then completely?  Sam tried leaving the question blank, but the computer wouldn't let him submit the form without checking all the boxes first.  Can they ask if you have deviant sexual fantasies?  If you've ever committed a crime (regardless of whether you've been charged or convicted)?  If you say provocative things on your blog?

I Still Don't Need To Talk

Three years ago in a post called I Don't Need to Talk I blogged about the evidence for and against critical incident stress debriefing (CISD) for preventing PTSD. Back then I suggested that CISD should not be mandatory for people who experience trauma for two reasons: most people don't develop PTSD after trauma and get better on their own even without therapy, and there was increasing evidence to suggest that CISD may make some people worse.

Today a story came across my Twitter feed (thanks USMCShrink!) about the medical response to the Japanese tsunami. Apparently psychological debriefing was strongly discouraged by Japanese mental health authorities for the reasons I just mentioned.

I think this is the leading indicator that attitudes are changing toward the role of psychiatry in disaster response preparedness.  It also may mean that we might have to change how we approach the mental health care of veterans. I've talked to a lot of vets who were required to go through post-deployment debriefing. Did it help? Did it hurt? Are we doing the right thing? While treatment should be offered to people who really do develop disorders, in this case preventive intervention may not be so preventive.

Privacy, Please?

Anon commented on my last blog post about clinical uses for Siri on my new iPhone:

"From the details in your contacts, it knows your friends, family, boss, and coworkers. "

That was from Apple's web site, regarding Siri. If you are using Siri for clinical purposes, know that Siri tells Apple everything. Siri--usly, how do you protect patient confidentiality if Siri/Apple knows so much? Sure, paper files can be stolen, so can cell phones. E files are vulnerable to all sorts of breaches. But what would you do if your iphone 4S fell into the wrong hands with all that clinical related stuff on it? Not quite the same as asking Siri where the closest dry cleaner is.

I find it kind of interesting what people worry about.  I have hundreds of contacts in my phone.  My husband is labeled no differently than my co-workers, than my friends. than my patients.  I'm not sure what it means to have one's iPhone "fall into the wrong hands."  I live in Maryland, so I'm not sure what Apple in Cupertino would do with my information, maybe send iPhone advertisements to my contacts? 


The issue of clinical information is  something I hadn't thought about.  I downloaded an app yesterday specifically for GoogleDocs, and it imported all my documents.  We wrote our book on this, so every chapter and every revision is now accessible on my phone, not to mention my posts for Clinical Psychiatry News and an unpublished novel or two.  I downloaded the app so I would have the option to dictate patient notes.  This would leave clinical information potentially accessible via a cloud or on the phone.  I'm not sure it's all that interesting.  My notes are usually pretty boring.  But I did think that I would print them and then delete, rather than have to deal with keeping charts in order in cyberspace.


I guess I find it interesting that people worry about issues of confidentiality with total strangers in places where it's hard to imagine a use for what is likely to be pretty boring information.  On the other hand, we live in a world where electronic medical records now exist in all types of venues.  I work at a large hospital.  I can access the records of any patient seen there, and if I go to a physician there, his notes about me will go onto the EMR. At this juncture, outpatient psychiatry notes are not on the EMR, just a record of the fact of the appointment (which does say "community psychiatry," and the healthys add their medications, but this will change soon, I'm sure, and psych notes may well be part of the hospital's coming new system.  The patients are not asked, and the doctors they see have access to all records without getting prior permission.  There are very specific rules about whose records a healthcare worker may look at, and people have been fired for looking at their neighbor's records, but someone has to catch you.  This means that a patient would have to ask someone with access to the system to see who had accessed their records, realize that one of those people was not someone involved with their care (Hey, that's my new boyfriend!) and then complain to the hospital and initiate some type of complaint (I think).  There is nothing inherent in the system that prevents one person from looking at the medical records of their coworkers, boss, ex-husband,  or even their doctors, aside from their own conscience and the fear of being caught (and reprimanded).  At this point, and for this reason, I have chosen not to get care at the institution where I work.  


Our state is also working on a system, called CRISP, that lifts medical records from all providers to a centralized system.  You can opt out, but you don't need to opt in: do nothing and your healthcare information goes in.  I opted out, and I got a letter telling me they would keep my information in case I changed my mind.  Wait, so presumably my doctor will be feeding my information into this cloud, without asking my permission?  I don't really know how this will work-- from the shrink standpoint-- because no one has contacted me about putting my professional records into this system, and since my records are all handwritten on hard copy charts, I don't know how this would play out. 


Somehow we've come to think that electronic medical records will mean better care.  I could be wrong, but I'm not really sure why we think that.  It seems to me that the burden this will place on the physician to attend to the devices and the demands of this type of documentation, will consume time and detract from time with the patient.  As is, I've noted it takes about 5 times as long to send an e-script as it does to write a prescription, starting with the fact that the e-system my hospital uses logs me out every 7 minutes.  I'm told this can't be modified, and I'm not aware of any doctor who sees patients faster than every 7 minutes.  Secondly,  an electronic system is only as good as the information it propagates, and I've seen lots of mistakes in the electronic medical records.  The internist notes that the patient is seen by psychiatry and takes Restoril.  Wait, my patient is taking Restoril?  I didn't know this..oh, I think he meant Risperdal.  By my calculation, the number of lives saved by electronic information that is provided when the patient can't provide it himself, will about equal the catastrophes from the propagation of incorrect information.  


So I should be worried that Apple can see my contacts?  My brother, who is an original Caltech computer geek, told me recently that since I have a webcam, it's possible that someone could hack my computer and watch me through my camera.  At first, I was alarmed at the possibility, but then I thought about this for a moment and said, "Why would someone want to watch me type?"  Nothing that exciting is happening here.  Sometimes I don't wear makeup, here and there I stick out my tongue and lick my lips, and okay, in front of the computer, when I'm writing, I kind of talk to myself.  If this might interest someone...

I seem to have my own list of things to worry about.  That someone might hunt my patient information out from the cloud just hasn't yet made my list. 

How Does Siri Help the Mental Health Clinician?

Next week,  it will be my turn to write our article for the Clinical Psychiatry News website.  Over there, we try to have our writing more specifically aimed at an audience of healthys.  I'm going to be writing an article on Siri and the healthy....in honor of my new iPhone 4s and the "personal assistant" function named Siri.  Okay, I'm obsessed.  Everyday, I find new things it can help me with.  Today, I asked it, "What's the meaning of life."  What, you don't ask your cell phone the finer existential questions?  Siri answered, "All available evidence suggests chocolate."  Wow!  How old is Liza Minelli?  65 years, 7 months, 20 days.  Calculate a tip? No problem.  Convert Celius to Fahrenheit?  A cinch.  And she takes dictation.  "Siri, please text Pt A 'Your lab results are fine.'"  "Siri, please email Jesse, 'Will you write a new guest post for Shrink Rap?' "  Okay, Siri flubs on this....I can't get her to learn that it's Shrink Rap and not Wrap.  I downloaded a Google Documents App so I can dictate....patient notes, my memoir, a few novels, a Shrink Rap post here and there, To Do lists for Roy....  I think I'm set.


So, I'd like your help.  What useful things are you doing with Siri?  How has your iPhone made life as a clinician better?