There were some discussions about my article on the standard of care and to respond to some
questions I posted this followup explanation that provides my take on why psychologists so frequently turn on each other:
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By way of background, someone on an email discussion group posed a question/statement that it is often difficult to ascertain the standard of care and remarked that the question of “what to do” is often murky, at best.  As an example, he remarked that he often wonders about whether he is required to have a segment of his voicemail message suggesting to callers that “if there is an emergency, please hang up and dial 911.”  He wondered what was the standard of care surrounding such messages.  In other words, is it a standard of care for psychologists that we are required to have those disclaimers on our voicemail messages?

In response, someone posted that some people do, whereas some people don’t, and bemoaned his own observation that it would be fairly easy to find a psychologist expert who would say that it would be a violation of the standard of care to not have such an outgoing greeting.  He said that he felt that psychologists were much more likely to turn on one another for alleged ethics violations than are physicians, and (rhetorically) asked why.

My response follows:
I think this is due to a number of reasons, but I’ve always suspected that two of them are primary:

1.) Psychologists use ethics as a means of regulating the profession.  Other healthcare professions, such as medicine, use data-driven science to answer questions about practice competency.  This basically means that (when it comes to questions of discipline), as a profession, we’ve decided to eschew questions about what works, and have instead decided to go with the metric of “what’s ethical.”  I think this is kind of backward, but it’s what our profession has chosen.  Not that I think ethics are bad, but I think questions of professional discipline should be determined according to the data that backs up our services, as well as professional misconduct.
Because our profession relies almost solely on ethics, that means that if you do “past lives therapy” with a patient and tell her that she’s probably depressed because she was Joan of Arc in a past life, proceed to do therapy based upon that assumption, and end up telling a colleague about your patient, you can be disciplined for the violation of confidentiality but probably not for telling your patient that she needs treatment because she used to be Joan of Arc.  In my opinion, that’s bananas.  I think the violation of confidentiality is (by far) the lesser of the two offenses, if it is even one at all.
I think that by relying solely on ethics, which are often inherently subjective, we’ve created a system where we constantly strive to be the “most ethical,” rather than to provide the most effective treatment.  I don’t think it’s an accident that the most respected members of our professional organizations are often the ones who advise on matters of ethics, as opposed to the people doing really great clinical work (or teaching how to do really great clinical work).  (Please don’t misinterpret this as a disparaging comment against those who advise on matters of ethics.  I believe they are wonderful colleagues.  I just think our focus – as a field – is misplaced.)  If we focused on data-driven science, questions of professional conduct would be answered quite differently.  But given the realities of our profession and the decisions we (collectively) have made, we are where we are.

2.)  The second reason is that many experts don’t understand the difference between “most ethical” (whatever that means) and “standard of care.”  In my opinion, the way ethics should be taught/dispensed is as a barometer for what most people are doing.  So in other words, when you consult on matters of professional conduct your ethics expert should give you advice on the standard of care.  Ethics experts should be really well-connected colleagues who know what most people are actually doing.  For example, if you go to an ethics expert and ask how to handle emails from a patient, the expert should say something like, “here’s what most people are doing……”  Unfortunately, the reality is that when most psychologists go to an “ethics expert” they receive the most conservative advice possible, and that advice is often totally independent of what people are actually doing.  To that extent, it’s very poor advice because it makes people think that practice standards are based on what people should be doing, as opposed to what people are actually doing.

So, to answer the rhetorical question, I think the answer is that for a licensing board complaint in medicine you are much more likely to get an expert that says “providing 911 on an answering machine is a good (or bad) idea because we know that…..”

In contrast, an expert in a psychology licensing board action is more likely to say that “Dr. ____, by not providing a reference to 911 on his/her answering machine, violated the APA Ethics code section __, was acting unethically, and therefore violated the standard of care. The best course of action would have been to………..”

I hope this clears things up.
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What is the “Standard of Care,” and why should you want to know about it?


​What is “the standard of care?”  Do you know?  Odds are, even if you’ve never heard the term, you’ve found yourself wondering about it.  If you’ve ever asked yourself, “what is the right thing for psychologists to do when ________?”, you’ve asked about the standard of care.  The standard of care is the answer to most of the “should” questions in our profession.

“How should we handle emails from patients?”
“How should children be interviewed?”
“Which norms should be used?”
“Should I see the cousin of a patient?”

The answer to all of these is that, no matter what you decide to do, you must at least meet the standard of care.  This begs the question, “what is the ‘standard of care?’”

The standard of care is a legal concept that is used to evaluate whether a professional’s activities meets the “standard.”  In a nutshell, if the things you are doing are as good as the standard of care, you are doing just fine.  As you might guess, there are standards of care for just about everything.  There are standards of care (thresholds of professional conduct) for recordkeeping confidentiality, etc.  Almost everything.

To put it bluntly, the standard of care is what most reasonable psychologists under similar circumstances do.  If you do what most of your colleagues do, you are meeting the standard of care.  Note that this isn’t want most of your colleagues think they should do, or what an expert has identified as a “best practice.”  It’s not an aspirational standard.  The standard of care is what most of your colleagues are actually doing.

Naturally, there are advantages and disadvantages to such an approach, but all things considered, the metric of “what a reasonable psychologist under similar circumstances would do” is a fairly good benchmark for what you should be doing.

A significant problem, however, is that many of our colleagues who are trying to be helpful don’t articulate the difference between the standard of care and “best practices.”  Experts offer opinions on all sorts of things, particularly on matters of professional conduct and ethics, without specifying that they are articulating (what they believe to be) an optimal approach.  This is unfortunate because when we conflate “the standard of care” with “best practices,” the perception can become the reality.  It’s important to state the difference.

An example might help to illustrate the point.  Suppose I offer the following (hypothetical) ethics opinion:

“Any psychologist that offers an ethics or professional standards opinion, without articulating whether a difference exists between his/her proffered opinion and the standard of care, may be acting unethically.  The failure to articulate whether a difference exists potentially violates several provisions of the APA ethics code.  Because a “best practice” might be misconstrued as a “standard of care,” § 1.01 requires experts offering opinions to take steps to mitigate this risk.  Ethics experts that fail to articulate this difference because they are not aware of this difference are potentially acting outside the scope of their expertise, and thus may also be in violation of § 2.01, which requires psychologists to act within the boundaries of competence.  Similarly, psychologists that offer an opinion on the standard of care or a best practice must state the basis for such an opinion.  Section 9.01 of the Ethics Code requires that psychologists substantiate their opinions/findings; any ethics expert who articulates an opinion on a standard of care is required to substantiate such a finding (i.e., how does he/she know what most reasonable psychologists in similar circumstances are doing).  Failure to abide by these sections of the ethics codes when offering an opinion on ethics may, inandof itself, be a violation of the ethics code.”

Careful readers will note a certain irony, which is that my hypothetical ethics opinion suffers from the very problem this article addresses: it fails to appreciate the difference between a “best practice” and the “standard of care.”  I might personally believe that all ethics experts should articulate this very important difference between “best practices” and “the standard of care,” and that failure to do so is an egregious error.  But if most reasonable psychologists in similar circumstances (i.e., ethics experts) fail to make the distinction(s) that I wish they would make, then by definition my opinion on what constitutes the standard of care for ethics experts is inaccurate.  Citing to the ethics code doesn’t change the fact that if very few psychologists do what I think they should do, then my assessment of the standard of care is just plain wrong.  I should have labeled my “ethics” opinion as a tip for “best practice,” or even an aspirational wish.
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So let’s be careful out there.  Remember to be aware of the standard of care and to not mistake a “best practice” for the minimal bar of competence.

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This is a particularly troublesome dilemma and one that most clinicians dread.  We take great care to avoid such a situation, and in the event that a fax or letter gets to the wrong person most clinicians are unsure about whether the unintended recipient has any legal responsibilities to avoid further disclosure.  Another common question is whether unintentional disclosures such as these render the information non-confidential.

There are a few different ways to look at this question because there are (at least) a few different things happening. First, there is the question of  mistakenly sending confidential health records.  Second, there is the question of whether the unintended recipient has a duty to keep the records confidential.  And third, there is the question of whether the unintended recipient may publicize the information.  It might seem odd, but these second and third questions are more than semantic differences.  Let’s discuss them in order, below:

The first question is the easiest.  When clinicians mistakenly send confidential information that is a breach of the duty of confidentiality.  That is relatively simple and likely not a surprise to anyone.  However, it’s important to remember that the duty of confidentiality arises out of the psychotherapist-patient relationship and absent this relationship this same duty does not exist.  The unintended disclosure of confidential information doesn’t invalidate the duty of confidentiality; it violates the duty of confidentiality.

The second question is about whether the unintended recipient then has a duty of confidentiality.  I doubt that very much.  The information is probably still confidential, and the fact that the clinician mistakenly sent the information to the wrong party doesn’t eliminate the original sender’s duty of confidentiality.  But the duty of confidentiality attaches to the clinician and not the records; it typically doesn’t transfer unless there is an existing relationship between the clinician and the recipient.

So if there is no duty of confidentiality (because it usually arises out of a psychotherapist-patient relationship or connection thereto), that begs the question of whether there are any restrictions on what can be done with those very private records that went awry? There are restrictions, but they probably don’t arise out of a duty of confidentiality that the unintended recipient owes to the patient. There is no relationship between the unintended recipient and the patient that would give rise to such a duty.  But the lack of a duty doesn’t mean that they are off-the-hook.  One source of the restrictions is likely in statutes surrounding medical records. Another (better) source is in the old common law, which provided for a cause of action for invasion of privacy where there is a publication of private facts; this is an old-fashioned tort claim.

Because of concerns that information might go astray and land in the hands of an unintended recipient, many clinicians include a paragraph in their communications as a precaution.  These “confidentiality notices” put recipients on notice that the information is private.  The real purpose of the disclaimers isn’t to remind the unintended recipient that they have a legal duty to keep the information confidential, but rather to tell them that the information is private and that the continued distribution of it could constitute a cause of action.  It’s a subtle but important difference; instead of having an affirmative duty to do something, they should instead refrain from taking further action with the sensitive data.

This raises the point that I made in another article, which is that these notices are really not very helpful if they are used all of the time.  The information that they accompany really should be private or else it looks like you don’t mean it.
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Huge numbers of clinicians have disclaimers at the end of email messages that say something like this:

“The information contained in this email is CONFIDENTIAL. If you have received this message in error or without the express direction of the original author, please notify the sender and delete this email immediately.”

But what does that mean? Should you have one of these disclaimers? And if you do, does it have any effect?

This raises the following questions:

1. Should confidential information be sent via email?

2. Are these disclaimers enforceable?

3. If they aren’t enforceable, why append them to emails?

With regard to the question of whether confidential information should be sent via regular email, the answer is “probably not.” The answer includes the word “probably” because some clinicians may have secure email.

In California, mental health clinicians owe a duty of confidentiality to their patients. This means, among other things, that clinicians must safeguard the privacy of patient data and not expose those data to unauthorized persons. The use of email to transport patient data is problematic because it is insecure, and the use of insecure methods when it comes to confidential information is likely in violation of that duty of confidentiality.

According to Roger Keesee of Kinetix Technology Services, a technology support provider for medium-sized businesses, regular email travels across the Internet as easily readable text. Anyone, anywhere along the path between sender and receiver can read the email without anyone knowing. Because of this, regular email is definitely not secure. Some people have secure (called “encrypted”) email, and when this is the case it is obvious that the email is secure. Both the sender and receiver need to have their computers configured to send and receive encrypted email. Indeed, it can be somewhat complicated to set up; many email users who are not familiar with security measures choose to have an expert set up their email. The general rule is that unless you are sure your email is secure, it probably isn’t. Individuals who use the more common email providers such as Hotmail, Yahoo!, AOL, GMail, etc., without significant custom modifications are not using a secure email. Thus, email shouldn’t be used to transmit confidential information because it could violate a clinician’s duty of confidentiality.

Considering all of this, the answer to the question of whether confidential information should be sent via email is “no,” unless you are sure you have secure email.

So if most email isn’t secure, and confidential information shouldn’t be sent via email, why bother including a warning that confidential information sent to the wrong address should be destroyed? Isn’t it pointless? Well, sort of. But there are some good reasons why people choose to do so:
One possibility is that people are actually sending confidential information via unsecured email. Bad idea (see above).

Another possibility is that they don’t intend to send confidential information via email, but in the event that they make a mistake and do transmit confidential information they want to make sure that they have some sort of instruction in case the message strays. Again, it’s just not a good idea to send confidential information via email at any time.

Other clinicians do not send confidential patient data, but sometimes engage in confidential communications with parties to whom they do not owe a psychotherapist-patient duty of confidentiality. An example of this is a forensic clinician who is acting as a consultant and communicates with the hiring party. In this case the relationship between the clinician and client is not a treatment relationship per se, and the information (e.g., litigation strategy) may not be subject to the same levels of security that patient data might require, but the information nevertheless remains confidential and the clinician desires to forewarn any unintended recipient.

This inevitably raises the question of what happens when an email goes awry. Does an unintended recipient have to do what the addendum says? In a word, “no.” However, that doesn’t make the text worthless. Such an addendum effectively puts the unintended recipient on notice that such information is sensitive and that others may be harmed by the publication thereof. He or she cannot do whatever they would like with the information (e.g, redistribute it, etc.) and still claim ignorance of the possibly harmful effect of such an action.

Note that this isn’t a recommendation or endorsement of the practice of appending a “don’t-forward-this-mistakenly-sent-confidential-information” statement to the end of every email. If you put such an addendum at the end of every email it makes it look like you don’t really mean it. For example, if you are a member of a listserv and all of your posts to the list include a standard addendum, it makes your claim that the unintended recipient should have known it was a critical confidential communication much less credible.

Here’s an example of the addendum I sometimes use for my listserv posts:

“CONFIDENTIALITY NOTICE: This email and the contents thereof are not confidential because the message was sent to a whole listserv. If you received this message in error, you don’t have to destroy it or return the original to the sender. I mean, you can if you want, but really it’s not necessary to go to so much trouble. This is especially true since this email is just silly pitter-patter and not a clinical or top secret legal communication between you and me. If you want to see confidential stuff, you’ll have to break into my file cabinet after hours or rifle through my trash can. But if you do that watch out, because sometimes I throw away broken pop bottles and you could cut yourself and get a nasty infection from the week-old coffee grounds and moldy leftovers I throw in the trash too.”

Hopefully this post provides some clarification, and also a fair warning to not dig around in my trash. Feel free to post your comments or questions.

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This is a common question posed on practitioner listservs.  Some people have very strong feelings about this issue.

In California, the answer to this question is “yes.”  If you have specific concerns about how this applies to any given situation you really need to consult with an attorney.

But as a general matter, practitioners can usually use collection agencies to collect on debts owed by patients so long as (1) it isn’t otherwise disallowed by law, (2) the patient has agreed to this in the office policies/informed consent document that was signed at the outset of the treatment relationship, and (3) the information provided to the collection agency is minimal in nature and doesn’t disclose confidential material.  (Remember that the HIPAA regulations have a very good description of what information can be provided for payment purposes.)

Remember, just because you can use a collection agency doesn’t mean that you necessarily should, particularly if such a decision doesn’t necessarily comport with your personal style.  There’s nothing necessarily wrong with using a collection agency, but the likelihood for conflict with your patient will probably increase.  After all, if you’ve ever received a call from a collection agency or had to deal with these folks you probably know that it’s not a pleasant experience and it doesn’t engender good will between you and the party claiming the debt.  Be prepared to kiss your therapeutic relationship goodbye.

But then again, if you worked with someone and they promised to pay you for your services, why shouldn’t you be able to collect what you are owed?  I can think of plenty of reasons to pursue payment, just one of which is that you work for a living and that if you don’t get paid, you aren’t able to pay your bills.

Chief among the cautionary reasons to avoid using collection agencies is the concern that the patient will file some sort of complaint against your license, which you will then have to spend time defending.  It’s possible that this might happen.  I’ve heard of (and defended other psychologists from) bogus complaints.

In most respects this is a business decision.  How do you want to run your practice?  How comfortable are you with conflict?  Do you want to collect as much of what is owed to you?  Are you willing to forgive debts and walk away from income you have earned?

If your personal style is conflict-averse, and/or for other reasons you decide that collection agencies aren’t services you want to use, perhaps this guideline might be of help: never let debts accrue that you aren’t willing to walk away from.  Insert a line into your practice policies document where your patients agree that you will stop treatment upon unpaid bills of ______ (insert time/amount).

But whatever you decide to do, make it a conscious decision.  You probably work with your patients to take ownership over their lives, so why can’t you?  Chart your own course for your practice.
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The following article was authored by A. Steven Frankel, Ph.D., J.D. and myself.  It was published in the Fall 2010 issue of The California Psychiatrist, a publication of the California Psychiatric Association:

Professional Wills:  Protecting Patients, Family Members and Colleagues
A.    Steven Frankel, Esq., & Adam Alban, Esq.,

This paper addresses events that most don’t want to consider.  If and when these events are considered, anxiety usually follows, as both the events and the act of planning for them are so daunting.  The events?:  unanticipated interruptions or terminations of practice due to death or disability. (There!  We said it out loud.)  So please take a few deep breaths, perhaps a warming cup of coffee or tea, and stay with us while we take up an increasingly important aspect of “good practice.”

First issue:  in the event of one’s unanticipated termination of practice, who bears the responsibility for the preservation, maintenance, provision and ultimate destruction of a psychiatrist’s records and business concerns, thus serving the interests of the psychiatrist and his/her patients?

Patients certainly have an interest in their records.  Some might want them to support disability claims, to support litigation, for continuity of care, or for any number of reasons that our legislature views as important enough to grant liberal patient access.  If patients find that their psychiatrist has unexpectedly terminated practice, they make inquiries as to how to obtain their records.  Many may contact the California Medical Board. The Board’s website offers the following information:

“How do I get my medical records if my doctor moves away/retires/dies?

“…If the doctor died and did not transfer the practice to someone else, you might have to check your local Probate Court to see whether the doctor has an executor for his or her estate. You could then contact the executor to see if you can get a copy of the records. Depending on how much time has passed, whoever is appointed as the custodian of records can have the records destroyed.”

In effect, the Medical Board is informing patients that a physician’s executor, trustee or “personal representative” bears the responsibility for preserving, maintaining, providing and, after an appropriate period of time, destroying records.

Assuming that you have already done the type of estate planning that protects family members and other beneficiaries after one’s death, is your personal representative aware of and competent to perform the duties and responsibilities required of him/her?  Will your estate provide for funds that are needed immediately to manage the closing of practice?  And if, rather than terminating practice due to unanticipated death, the actual cause is unanticipated disability, who will then take responsibility for these duties, with the appropriate training and knowledge?

Second issue: protecting psychiatrists’ family members:

Sadly, we receive many calls from the spouses/partners of psychiatrists who are not themselves psychiatrists, but who find themselves in the terrible predicament of having an unexpected termination of their spouse’s/partner’s practice.  They tell us that the office landlord is demanding rent payments and threatening to place office furniture in the streets and records in the trash, that calls are coming in from patients seeking records (and wishing to express condolences), etc.  All of this is happening at times of grief and loss.  Where their spouses/partners have not implemented a professional will, with designated executor(s) competent to manage the closing of the practice, the management of the records and the business details, they feel lost.

Third issue:  protecting colleagues:

The colleagues of psychiatrists often find themselves thrust into situations in which they feel some responsibility and interest in assisting colleagues whose practices have been interrupted by unanticipated death or disability.  Unless there has been a thorough preparation of a professional will, with instructions as to how to find records, keys to the office, computer passwords, financial records, etc., the helpful colleague also becomes overwhelmed and at a loss in the midst of grief and loss.

The Professional Will: a lot of work that can save a great deal of pain.

The mental health field in general has provided an arena for the development of a plan for the managed termination of practice in times of need.  Among non-physician mental health professionals, all national professional societies have enacted ethical standards requiring advance planning for unanticipated terminations of practice. In some states, physicians are mandated by law to make such preparations.  For example, Iowa physicians are subject to the following statute:
“2004.
a. A physician shall retain all medical records, not appropriately transferred to another physician or entity, for at least seven years from the last date of service for each patient, except as otherwise required by law.
b. A physician must retain all medical records of minor patients, not appropriately transferred to another physician or entity, for a period consistent with that established by Iowa Code section 614.9.
c. Upon a physician’s death or retirement, the sale of a medical practice or a physician’s departure from the physician’s medical practice:
(1)    The physician or the physician’s representative must ensure that all medical records are transferred to another physician or entity that is held to the same standards of confidentiality and agrees to act as custodian of the records.
(2)    The physician shall notify all active patients that their records will be transferred to another physician or entity that will retain custody of their records and that, at their written request, the records will be sent to the physician or entity of the patient’s choice.”
And in New York:
`“The Rules of the Board of Regents on Unprofessional Conduct, §29.2(a)(3) `require that professionals who retire from or sell a practice must make provision for records to be maintained and accessed, if requested. The obligation to maintain records is not changed by the retirement or sale of practice.
Further, professionals should also make provision for the maintenance and destruction of their patients’ records in the event of the professional’s death.”

While such legislation has not as yet been enacted in California, the considerations discussed above strongly support the view that it is good practice to create a professional will.  If you are like most colleagues in California, and if anxiety and/or denial hasn’t caused you to look for another article to read, please read on.  This is a solvable problem.

We are aware of a number of resources available for those interested in putting together a professional will or contingency plan.  Since non-physician mental health professional societies have enacted relevant ethical standards, there are some local non-physician professional associations which have standing committees on these matters.  One such example is the San Diego Psychological Association, which has been assisting members through its “Psychologist Retirement, Incapacitation or Death” committee.  This may be a valuable model for psychiatry’s district branches. Other local associations may have similar resources, and this is yet another reminder to join your local district branch, as this service, by itself, is worth the cost of membership.

While local organizations can provide useful templates and how-to guides, psychiatrists don’t necessarily have to go through these organizations to construct a valid professional will .  You may choose to work with a colleague to achieve much the same result.  Professional wills are essentially a list of instructions that answer the following questions:

1.) In the event you are unable to fulfill your professional responsibilities, either through incapacitation or death, who is the professional colleague you designate to assume responsibility for your practice?  This should be someone you trust, who has agreed to undertake the responsibility, and who you feel comfortable discussing professional matters with your patients.  Because your designee will need to make professional communications, they should be similarly licensed (i.e.,  not an attorney, accountant, etc.).

2.) What administrative tasks does your designee need to know to be able to wind down or pause your practice?  Where are your keys?  What are the passwords on your computer(s)?  Where do you keep patient information?  How do you manage billing and what critical financial transactions must be completed (e.g., rent, communications with 3rd party payors, etc.)?  For forensic practitioners, do you have retainer balances that should be returned?  Do you have a password on your voicemail?

3.) How do you want your designee to communicate this information to your patients?  Should the notifications be made in person, letter, and/or email?  Remember that these notifications must be made sensitively.

4.) Are there colleagues you want your designee to contact?  Who is your professional liability carrier and how should they be notified?  How about any managed care panels on which you serve?

5.) Do you have an attorney for your practice?  If so, and if your attorney does not already know about your incapacitation and/or death, he/she should be notified immediately.

6.) How is your designee to be paid?  Have you set aside funds to help your designee with these time-consuming tasks?  Consider purchasing a very small life insurance policy with your designee as the beneficiary and/or set aside some funds from your estate for this purpose, with instructions to your estate-planning attorney to make the funds available as soon as possible.

7.) If your designee cannot be found or is unavailable, who are your second and third backups?  Do they know they have been named?

8.) What are the circumstances under which your professional will springs into effect?  Death surely springs your professional will, but what about injury?  How will your designee be notified that s/he is  “on duty?”
Other things to remember:

A.) If you have any questions, your professional will should be reviewed by an attorney experienced in mental health law to ensure that your professional will does not conflict or expose your personal will.

B.) You should periodically review your professional will with your designee to make sure the information contained in it is current.

C.) Your professional will should be signed by you and your designee(s).
We hope that you’ve made it this far and that you actively consider the issues we’ve discussed, as do your patients, families and colleagues.



IMPORTANT: This website is for basic information only. Nothing in this website should be construed to be formal legal advice, nor does it create an attorney-client relationship. Please see the “Important Information” page at the top of the screen.