Psychosomatics 47:520-526, November-December 2006
doi: 10.1176/appi.psy.47.6.520
© 2006 Academy of Psychosomatic Medicine
The Role of Psychosomatic-Medicine Psychiatrists in Bioethics: A Survey Study of Members of The Academy of Psychosomatic Medicine
James A. Bourgeois, O.D., M.D., F.A.P.M.,
Mary Ann Cohen, M.D., F.A.P.M., and
Cynthia M.A. Geppert, M.D., Ph.D.
Received September 6, 2005; revised January 3, 2006; accepted January 6, 2006. From the Univ. of California, Davis Medical Center, Sacramento CA. Send correspondence and reprint requests to James A. Bourgeois, O.D., M.D., F.A.P.M., Alan Stoudemire Professor of Psychosomatic Medicine, Univ. of California, Davis Medical Center, 2230 Stockton Blvd., Sacramento CA 95817. e-mail: james.bourgeois{at}ucdmc.ucdavis.edu
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ABSTRACT
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The Bioethics Subcommittee of The Academy of Psychosomatic Medicine developed a survey to assess the involvement of psychosomatic-medicine psychiatrists in bioethics and the extent of their participation on bioethics committees and in the teaching of bioethics. Of 599 Academy members surveyed, 122 (20.4%) responded. The majority of respondents reported that the management of bioethical dilemmas had a significant impact on their work in psychosomatic medicine. Many respondents were involved in teaching bioethics and in serving on ethics committees. The majority of respondents reported psychiatry-resident involvement on ethics committees. Bioethics work is an integral part of the fabric of psychosomatic medicine.
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INTRODUCTION
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Bioethics consultation, teaching bioethics, and bioethics committee leadership have been traditional areas of expertise for psychosomatic-medicine (PSM) or consultation–liaison (C–L) psychiatrists. The knowledge-base, training, and skill-set of PSM psychiatrists are particularly suited to addressing bioethical issues at the interface of psychiatry and other medical specialties. Four useful skill-sets for the PSM psychiatrist in the area of bioethics include 1) "a reasonable knowledge of medicine and comfort working in a medical setting and an understanding of the complex emotional issues evoked in such settings; 2) skill at conflict resolution; and 3) a knowledge-base in medical ethics and law."1 Three factors that strengthen the association between psychosomatic medicine and bioethics consultation include the ideas that 1) "psychiatrists have historically and currently been extensively involved in the clinical problems that constitute most ethics consultations; 2) there is a special nature to the psychiatric aspects of bioethics programs; and 3) many of the necessary skills of the bioethicist are similar to the C–L (or PSM) psychiatrist, who has been specifically trained in these areas."2 The overlapping skill-sets of the PSM psychiatrist and the bioethics consultant include empathic listening, weighing of complex and competing interests, and conflict-resolution and mediation.2 Other skills of psychiatrists, including group-process assessment, the mental status examination, and character assessment are helpful for bioethics-committee participation.3 Common clinical problems resulting in bioethics consultation include determination of decisional capacity, end-of-life decision-making (e.g., limitations of care), requests for "against medical advice" discharge, and Do-Not-Resuscitate orders.2,4
Bioethics committees are mandated in the United States by the Joint Commission for the Accreditation of Healthcare Organizations.5,6 In addition to their role in the consultation model, PSM psychiatrists are obvious choices for active participation in bioethics committee work and bioethics policy development. PSM psychiatrists are commonly assigned to duties as statutory members (often in leadership positions) on bioethics committees.2,3,6
Although there have been conceptual papers and case reports describing the involvement of PSM psychiatrists in bioethics work, especially in the general-hospital setting, the survey described in this article is, to our knowledge, the first quantitative and systematic examination of the role of PSM psychiatrists in practicing and teaching bioethics, bioethics committee membership, and bioethics consultation.3,7 Publication of these survey results is particularly timely because, in 2003, psychosomatic medicine was recognized as a psychiatric subspecialty,8,9 and the first board examination in the discipline was administered in 2005. PSM psychiatrists are often presented with consultations that have bioethical and psychiatric dimensions. They practice and teach bioethical principles on a routine basis. As a result, PSM psychiatrists have the potential to become recognized leaders in the field of bioethics education and consultation. For this goal to be realized, we need information about the bioethics training and qualifications of PSM psychiatrists, their respective functions and skills, and, most importantly, areas requiring further professional development.10 This survey presents the first data addressing these issues.
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METHOD
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The Academy of Psychosomatic Medicine (APM) is developing a database of information and specialists in psychosomatic medicine who are also working in the area of bioethics. In order to establish this database, the Executive Council of the APM requested that the Bioethics Subcommittee develop a survey to determine the number of APM members involved in bioethics and the extent of that involvement. The goal of this effort was to determine the needs for bioethics training and to understand clinical, administrative, and research development needed in the newly recognized subspecialty of psychosomatic medicine.8,9 The specific goals and objectives of this survey are summarized in Table 1.
The subcommittee developed a survey (Figure 1), which includes responses, with free-text responses removed, in November 2004 and sent it with a letter of explanation on December 13, 2004 to 572 of the 742 members available by e-mail. The survey was not formally piloted before dissemination to APM members but was piloted by the chair and some of the members of the bioethics committee who reviewed and responded to the survey and assessed the length of time it took to complete. The survey was designed to be completed in less than 30 minutes. In order to maximize the number of responses, the same survey and letter were sent a second time on January 18, 2005. This second mailing was sent to 599 members available by e-mail.
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RESULTS
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Of the 599 APM members surveyed, 122 (20.4%) responded. We have no way of assessing the demographics of the non-responders and would be speculating if we were to try to do so without undertaking another survey of the non-responders. Also, we may have been able to collect more demographic data if we had sent a survey asking a single question about whether the APM member has addressed any bioethics issues during routine daily work as a PSM psychiatrist.
Most respondents (77%) reported moderate or frequent intense involvement in bioethical dilemmas; the same percentage believed that bioethical issues had a moderate, profound, or practice-changing impact on their work in PSM. About 90% had had training in bioethics (e.g., on-the-job training or experience and/or reading of the literature on bioethics or seminars/workshops) and, of those, only 20% had had more formal training (e.g., a course, series of courses, or an academic degree specific to bioethics). Nearly 75% of respondents felt that their bioethics training was adequate to prepare for their role in bioethics, whereas 25% felt that their training was inadequate. Table 2 provides a summary of the free-form text responses to Survey Question #3 (answer choice: 3e) about "special formal bioethics instruction since completing training." Degree of formal bioethics training varied widely among respondents, from 10% who had no bioethics training to nearly 20% who had specialized formal continuing education in bioethics since completion of training. These educational experiences also were quite diverse, ranging from earning advanced degrees in bioethics or completing fellowships at prestigious institutions to certificate programs or short courses in bioethics. It is encouraging that nearly half of respondents had some exposure to bioethics in medical school and residency but of some concern that only about 25% reported bioethics education as a part of their PSM fellowship.
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TABLE 2. Respondent Survey Results to Question 3, Answer Choice 3e, re: "Special Formal Ethics Training Since Completing (Specialty) Training"
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Frequent bioethical problems encountered included informed consent, decisional capacity, withdrawal of care or life support, and psychiatric commitment of medically ill patients (each of these issues was mentioned by approximately 20% of respondents), whereas issues involved with determination of brain death (3%) and management of impaired colleagues (11%) were less frequently reported. Decisional-capacity evaluations were done by psychosomatic faculty and trainees at the institutions of 75% of respondents.
Teaching ethics was an essential duty of more than half of the respondents. Fifty-three percent reported involvement in teaching bioethics to all hospital staff as well as medical students, residents, and fellows. Table 3 summarizes the categories of medical staff (other than medical students, psychiatry residents, or PSM fellows) who were taught bioethics by APM members (in response to Question #7; answer choice 7d, "Other") of the survey. Regarding their own continuing education in APM-sponsored ethics events, only 42% had attended an APM bioethics symposium, workshop, or roundtable breakfast in the last 3 years. The reasons given for non-attendance were the following: not enough publicity about the bioethics programs (37%), competing topics of more interest (28%), the "Breakfast Roundtable is too early for me" (17%), and a need for more intriguing topics (12%).
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TABLE 3. Respondent Survey Results to Question 7, Answer Choice 7d, re: "If you teach bioethics, is it to ...?" (Other Than to Medical Students, Psychiatry Residents, and Psychosomatic Medicine Fellows)
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At least half of APM psychiatrists responding were members of bioethics committees at their facilities. Approximately 52% of respondents serve, or had served, on bioethics committees. These members provided a list of the facilities where they had served from less than 1 year to a maximum of 31 years, with nine respondents having served for 16 years or more (Table 4). The respondents’ roles on Bioethics Committees included leadership: 12.5%; membership: 31.9%; regular committee attendance: 21.3%; ethics consultations: 20.6%; and consulting: 13.8%. Fifty-seven percent of respondents reported resident involvement, and 43% reported medical student participation on bioethics committees. The bioethics committee meeting frequency was 11% as needed, 1.6% twice yearly, 20.6% quarterly, and 66.7% monthly.
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TABLE 4. Respondent Survey Results to Question 9 re: "How long have you served (on a bioethics committee)?" (Fewer than 122 responded to question.)
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Bioethics consultation was less common than membership on bioethics committees or teaching bioethics. Those on bioethics consultation services had served in various capacities, with 26.6% responding to bioethics consults, 18.3% on pager availability for bioethics questions, 17.4% on call for ethics questions, 25.7% for clarification of ethical versus psychiatric issues, and 11.9% for other roles.
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DISCUSSION
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The members of the Bioethics Subcommittee of the APM created and distributed to APM members a survey on member participation in bioethics-related clinical activity, bioethics committee participation, training in and teaching of bioethics, and involvement of trainees in bioethics committee activities. With two solicitations, there was an eventual response rate of 20%. Among respondents, nearly all were involved in clinical work where there were significant bioethical aspects. Although the vast majority had some training in bioethics, only a small percentage had had formal training. The types of bioethics training varied widely (Table 2). The survey data document that core medical-ethics dilemmas, such decisional-capacity evaluations, informed consent, withdrawal of care, and commitment of medically ill patients are commonly encountered.
Approximately half of respondents had had active involvement on bioethics committees, many with leadership roles and/or long tenure on these committees. Respondents involved in bioethics committees typically included in their duties response to requests for bioethics consults. Encouragingly, a majority of respondents reported involvement of residents in bioethically-related psychosomatic medicine cases, and nearly 50% involved medical students, as well.
Despite their active involvement in ethics committees, consultation, and teaching, 25% of respondents felt that the training was inadequate, whereas 75% felt it was adequate. This is a highly significant finding, which is also reflected in the finding that only 20% of the APM psychiatrists responding had formal training and that the type and extent of ethics education was highly variable. Although nearly half of the respondents had attended an APM-operated bioethics roundtable discussion in the last 3 years, there is clearly a need for a more comprehensive and structured approach to bioethics education and training for PSM psychiatrists. The question of what constitutes adequate training and preparation for performing bioethics consultation and for ethics committee leadership has increasingly been a topic of discussion in the bioethics literature.11–14
In a 2000 survey of bioethics committee chairs, Hoffmann15 found that less than one-third had a formally trained bioethicist in that position, and 62% reported no formal educational background in ethics, although 62% had a medical background. Sixty-seven percent of the committees had membership criteria, but only 11.4% required any training or apprenticeship, and only 8.8% required any education in bioethics. Eighty-six percent of committees offered some type of education to bioethics committee members, but 42% of this education was confined to providing readings in bioethics as the main means of education. These results are similar to those found in our own survey. This finding raises the question of whether PSM psychiatrists working in the field of bioethics have an adequately broad perspective on the field of bioethics, in general, beyond those cases where there is a psychiatric clinical aspect. This could be an area for future inquiry.
In an effort to standardize and improve the ethics qualifications of ethics committee members, The American Society for Health and Human Values Society Standards for Bioethics Consultation produced a position paper in 2000 titled "Health Care Ethics Consultation: Nature, Goals, and Competencies."16 This report identified basic and advanced knowledge and skills that ethics committee members and leaders should possess that could inform curriculum design and continuing-education efforts for psychosomatic residents, fellows, and attending clinicians.
Historically, formal bioethics training and experience have not always been a priority in general-psychiatry residency programs. The 1997 Report of the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation–Liaison Psychiatry recognized training in bioethics in C–L psychiatry to be an "advanced" topic, ".... above and beyond the level necessary for all general psychiatrists to master. The topic may be appropriately offered to general-psychiatry residents by ambitious C–L programs..."17 It may be timely to re-open this issue and to re-emphasize a formal bioethics curriculum for all psychiatry residents, not just those later specializing in PSM.18,19 The question of what format is most appropriate for bioethics training for general-psychiatry residents will need to be addressed.
The standards of the APM consultation report described above emphasize the inculcation of bioethics history, principles, theory, and terminology that are not routinely included in general psychiatric residency or even, necessarily, PSM fellowship training. These areas would constitute an advanced education in bioethical vocabulary, reasoning, and methodology. A useful framework for ethics training and a detailed annotated bibliography was produced by Preisman et al.10 One option for obtaining this higher-level bioethics training would be to embed a bioethics module into either the PG-4 year of general-psychiatry residency programs, perhaps as a component of a senior resident experience in PSM, and in PSM fellowship programs. A critical task of this preparation would be teaching trainees to distinguish among bioethical, psychiatric, and psychosocial consultations and to respond appropriately on the basis of these distinctions.20–22 Residents and fellows at such institutions could become bioethics committee members and consultants as part of the training experience, with appropriately supervised experience. The present survey could provide initial data for the APM education committee or training directors to develop an innovative and rigorous bioethics curriculum that could be offered to all bioethics committee members, including resident/fellow members; this would include both didactic and clinical experiences similar to those offered in established bioethics fellowship programs.
We need to consider early inclusion of bioethics experience in the context of PSM rotations for medical students, junior psychiatry residents, and senior psychiatry residents. Adequate bioethics training in medical schools and hospital residencies would be helpful to trainees both in clinical practice and in preparation for board examinations. The American Board of Psychiatry and Neurology, as well as other specialty boards, require candidates to have a bioethics knowledge-base. Bioethics questions constitute a significant percentage of questions in specialties including not only psychiatry and psychosomatic medicine but also internal medicine. PSM fellowships need to provide for adequate and well-supervised bioethics experiences. CME and other lifelong learning activities for practicing physicians would benefit from a robust inclusion of bioethics topics. Enhancement of bioethics training will be of major benefit to patients, their families, and their physicians.
Although our study has implications for bioethics education and training, it also has limitations. An important limitation is the 20% response rate. Such a response rate, while disappointing, is not unusual in survey-based research. This may mean that only the most interested and enthusiastic APM members in the area of bioethics were sufficiently motivated to complete the survey. This parallels the authors’ experience, where only a minority of APM members typically attends bioethics activities at the annual APM meeting. For the past several years, 40 members have attended the bioethics Breakfast Roundtable. Attendance at the bioethics symposia have varied from about 15 to 40. Usually, 300 to 400 (about 50% of APM membership) attend the annual APM meeting. This may imply that our results are not completely applicable to all APM members, who may have less involvement in bioethics activities.
Also, this study addressed the bioethical issues specific to psychosomatic medicine practice, the bioethics of hospital care. Because this is a clinical setting in which bioethical considerations are frequent aspects of PSM duties, it may not capture the full scope of bioethics activities among PSM psychiatrists practicing outside academic settings or not involved in APM. Study of these groups might disclose important differences in education, skills, and interests, and this study is an area meriting further research.
Another limitation of our study is that we surveyed only APM members, a pre-selected group for involvement in psychosomatic medicine in an academic model at tertiary-care medical centers. Thus, our cohort of respondents may be pre-selected for intense involvement in bioethics and didactics. It would be helpful to further disseminate our survey to broader groups; that is, all medical schools and/or non-academic hospitals, to see whether our respondents’ experience generalizes to other environments. As the subspecialty of psychosomatic medicine consolidates and finds its permanent place among subspecialists, mastery of the more nuanced aspects of clinical practice and systems interventions will become all the more important.
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CONCLUSIONS
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Our survey instrument provides initial data about the bioethics practice and bioethics training of APM members, and, by inference, of PSM psychiatrists. PSM psychiatrists are commonly involved in clinical cases with a significant bioethics component. Specific training in bioethics varied widely both in quantity and type of educational experience. The data presented in this survey may serve as a springboard for similar studies of the bioethics background, training, and experience of other psychiatrists and other medical professionals.
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Issues in Bioethics
Psychosomatics,
December 1, 2006;
47(6):
519 - 519.
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ABSTRACT
INTRODUCTION
