Academic Psychiatry

, Volume 28, Issue 3, pp 183–189

Hidden Ethical Dilemmas in Psychiatric Residency Training: The Psychiatry Resident as Dual Agent

Special Feature Article Special Feature

Abstract

In addition to learning about confidentiality, civil commitment, informed consent, and other ethical issues, psychiatry residents must deal with less visible ethical dilemmas that arise from the training process itself. Residents grapple with three inherent conflicting duties between their dual roles as physician and learner, as physician and supervisee, and as physician and employee of a training institution. These conflicts must be negotiated at a time of high stress, when residents are plagued with self-doubt, fear, fatigue, and other vulnerabilities that can lead good doctors to make ethically dubious decisions. While such conflicts and stressors are common to residency training in most specialties, they may be heightened in psychiatric residency. This paper proposes a model for understanding covert elements of ethical decision making during psychiatric residency and recommends strategies training programs can use to help residents navigate an ethical minefield.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Accreditation Council for Graduate Medical Education: ACGME Outcome Project: ACGME General Competencies Version 1.3 (9.28.99), 2000Google Scholar
  2. 2.
    Gartrell N, Herman J, Olarte S, Feldstein M, Localio R: Psychiatrist-patient sexual contact: results of a national survey, I: prevalence. Am J Psychiatry 1986; 143: 1126–1131PubMedGoogle Scholar
  3. 3.
    Gartrell N, Herman J, Olarte S, Localio R, Feldstein M: Psychiatric residents’ sexual contact with educators and patients: results of a national survey. Am J Psychiatry 1988; 145: 690–694PubMedGoogle Scholar
  4. 4.
    Roberts L, McCarty T, Lyketsos C, Hardee J, Jacobson J, Walker R, Hough P, Gramelspacher G, Stidley C, Arambula M, Heebink D, Zornberg G, Siegler M: What and how psychiatry residents at ten training programs wish to learn about ethics. Acad Psychiatry 1996; 20: 131–143Google Scholar
  5. 5.
    Rudin E, Edelson R, Servis M: Literature as an introduction to psychiatric ethics. Acad Psychiatry 1998; 22: 41–46Google Scholar
  6. 6.
    Schnapp W, Stone S, Van Norman J, Ruiz P: Teaching ethics in psychiatry. Acad Psychiatry 1996; 20: 144–149Google Scholar
  7. 7.
    Roberts L, McCarty T, Roberts B, Morrison N, Belitz J, Berenson C, Siegler M: Clinical ethics teaching in psychiatric supervision. Acad Psychiatry 1996; 20: 176–188Google Scholar
  8. 8.
    American Psychiatric Association: Ethics Primer of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 2001Google Scholar
  9. 9.
    American Psychiatric Association: Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2001Google Scholar
  10. 10.
    Group for the Advancement of Psychiatry: A Casebook in Psychiatric Ethics. New York, Brunner/Mazel, 1990Google Scholar
  11. 11.
    Beauchamp T: The philosophical basis of psychiatric ethics, in Psychiatric Ethics, third ed. Edited by Bloch S, Chodoff P, Green S. Oxford, UK, Oxford University Press, 1999Google Scholar
  12. 12.
    Vinicky J, Connors R, Leader R, Nash J: Patients as “subjects” or “objects” in residency education? J Clin Ethics 1991; 2: 35–41PubMedGoogle Scholar
  13. 13.
    Fry S: Is health-care delivery by partially trained professionals ever morally justified? J Clin Ethics 1991; 2: 42–44PubMedGoogle Scholar
  14. 14.
    Fann J, Hunt, D Schaad D: A sociological calendar of transitional stages during psychiatry residency training. Acad Psychiatry 2003; 27: 31–38PubMedCrossRefGoogle Scholar
  15. 15.
    Butters J, Strope J: Legal standards of conduct for students and residents: Implications for health professions educators. Acad Med 1996; 71: 583–590PubMedCrossRefGoogle Scholar
  16. 16.
    Collier V, McCue J, Markus A, Smith L: Stress in medical residency: status quo after a decade of reform? Ann Intern Med 2002; 136: 384–390PubMedCrossRefGoogle Scholar
  17. 17.
    Green M: What (if anything) is wrong with residency overwork? Ann Intern Med 1995; 123: 512–517PubMedCrossRefGoogle Scholar
  18. 18.
    Brent D: The residency as a developmental process. J Med Educ 1981; 56: 417–422PubMedGoogle Scholar
  19. 19.
    Kozlowska K, Nunn K, Cousens P: Adverse experiences in psychiatric training, part 2. Aust N Z J Psychiatry 1997; 31: 641–652PubMedCrossRefGoogle Scholar
  20. 20.
    Pilkinton P, Etkin M: Encountering suicide: the experience of psychiatric residents. Acad Psychiatry 2003; 27: 93–99PubMedCrossRefGoogle Scholar
  21. 21.
    Rao NR: Recent trends in psychiatry residency workforce with special reference to international medical graduates. Acad Psychiatry 2003; 27: 269–276PubMedCrossRefGoogle Scholar
  22. 22.
    Cole-Kelly K: Cultures engaging cultures: international medical graduates training in the United States. Fam Med 1994; 26: 618–624PubMedGoogle Scholar
  23. 23.
    Igartua K: The impact of impaired supervisors on residents. Acad Psychiatry 2000; 24: 188–194CrossRefGoogle Scholar
  24. 24.
    Hantoot M: Lying in psychotherapy supervision. Acad Psychiatry 2000; 24: 179–187CrossRefGoogle Scholar
  25. 25.
    Whitman S: Teaching residents to use supervision effectively. Acad Psychiatry 2001; 25: 143–147CrossRefGoogle Scholar
  26. 26.
    Whitman S, Ryan B, Rubenstein D: Psychotherapy supervisor training. Acad Psychiatry 2001; 25: 156–161CrossRefGoogle Scholar
  27. 27.
    Egan E: Organizational ethics in residency training: moral conflict with supervising physicians. Camb Q 2003; 12: 119–123Google Scholar
  28. 28.
    Council on Ethical and Judicial Affairs, American Medical Association: Disputes between medical supervisors and trainees. JAMA 1994: 272: 1861–1865CrossRefGoogle Scholar
  29. 29.
    Clarke D: Measuring the quality of supervision and the training experience in psychiatry. Aust N Z J Psychiatry 1999; 33: 248–252PubMedCrossRefGoogle Scholar
  30. 30.
    Green M, Mitchell G, Stocking C, Cassel C, Seigler M: Do actions reported by physicians in training conflict with consensus guidelines on ethics? Arch Intern Med 1996; 156: 298–304PubMedCrossRefGoogle Scholar
  31. 31.
    Eron L: Effect of medical education on medical students’ attitudes. J Med Educ 1955: 30: 559–566PubMedGoogle Scholar
  32. 32.
    Feudtner C, Christakis DA, Christakis NA: Do clinical clerks suffer ethical erosion? students’ perceptions of their clinical environment and personal development. Acad Med 1994; 69: 670–679PubMedCrossRefGoogle Scholar
  33. 33.
    Christakis DA, Feudtner C: Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993; 68: 249–254PubMedCrossRefGoogle Scholar
  34. 34.
    Baldwin D, Daughtery S, Rowley B: Unethical and unprofessional conduct observed by residents during their first year of training. Acad Med 1998; 73: 1195–1200PubMedCrossRefGoogle Scholar
  35. 35.
    Hafferty F, Franks R: The hidden curriculum, ethics teaching and the structure of medical education. Acad Med 1994; 69: 861–871PubMedCrossRefGoogle Scholar
  36. 36.
    Hundert E: Lessons from an Optical Illusion: On Nature and Nurture, Knowledge and Values. Cambridge, Mass, Harvard University Press, 1995Google Scholar

Copyright information

© Academic Psychiatry 2004

Authors and Affiliations

  1. 1.Department of Psychiatry and the MacLean Center for Clinical EthicsUniversity of ChicagoChicagoUSA
  2. 2.Department of PsychiatryUniversity of ChicagoChicagoUSA

Personalised recommendations