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: 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. 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.
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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. 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. 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. |
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