Conflict of interest in psych residency

[wellbutrin.girlfriend]

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Has anyone encountered anything like this scenario?

You are an attending/someone involved in a psychiatry residency program. An immediate family member of one of your PGY1s is admitted to the unit on an involuntary hold. This PGY1 is halfway through their 3-month inpatient psych block. You are the only facility in the county that takes involuntary psych holds. How do you/the program proceed?

Anecdotes and speculation welcome.

 

[Sushirolls]

PGY-1 stays
They don't look in the chart of the family member.
Attending gets all "calls" or tylenol or PRN or any issues after hours, when the PGY-I is on call or covering for that patient.
i.e. PGY-1 already knows family is there.
They just don't get any more info.
Team meetings or list runs, they step out.

Emphasize to PGY-1 that IT will be alerted if they click on the chart and will be failed etc.

If PGY-1 wants to socialize with family on unit, they need to do it during official visitation times. They also need check in same fashion, and not wearing badge/white coat when doing so.

If patient appraochs resident, all are to remind patient, resident is on clock, and can only socialize during visitation hours.

 

[mistafab]

Given it is involuntary in nature, the best approach similar to highlighted above is to extricate the PGY1 from any direct care for this known family member. Given it is a PGY1, the attending presumably could care for this patient on their own during that time, and the resident can continue as normal for all other patients.

If there is enough flexibility in the program, they could also offer to swap the resident to another rotation, and later in the year complete the other half of their inpatient time. Lots of programs would probably have trouble accommodating that however. Not a requirement, but always try to facilitate accommodations for these things if possible. I imagine there is a range of situations where this would make more sense than others, I.E. if this was their mom then that's probably more important than if that was their uncle. I'd probably have a very difficult time focusing for example if it was my sibling/child/parent yet very little if it was an uncle/aunt/cousin

If in the real world, you may or may not be able to swap with a colleague. But even where I work, there is typically enough bandwidth in a hospital system to have a physician/caregiver swap with another provider if there is a conflict of interest such as this. In most cases we'll try to avoid situations like this where possible.

 

[Bartelby]

I agree with the above. Do whatever you need to to keep the pgy1 from accessing protected health information for their family member, including having them step out of any relevant team discussions or swapping them out to another rotation. Given that there is not a reasonable alternative and EMTALA (and professional ethics) would forbid discharge of this unstable patient I don't think anyone could fault your program for keeping and treating them.

 

[comp1]

The PGY1 should trade rotations while the family member is admitted. Everything else above is way too complicated, draw too much unneeded attention to the situation and honestly not really be practical in the communal setting of inpatient psych. This shouldn't be a huge or even significant issue. I'm not aware of any 1 person residencies. Further, inpatient is not like a month of gero or addictions, the resident will still meet the required time.

 

[J ROD]

PGY-1 stays
They don't look in the chart of the family member.
Attending gets all "calls" or tylenol or PRN or any issues after hours, when the PGY-I is on call or covering for that patient.
i.e. PGY-1 already knows family is there.
They just don't get any more info.
Team meetings or list runs, they step out.

Emphasize to PGY-1 that IT will be alerted if they click on the chart and will be failed etc.

If PGY-1 wants to socialize with family on unit, they need to do it during official visitation times. They also need check in same fashion, and not wearing badge/white coat when doing so.

If patient appraochs resident, all are to remind patient, resident is on clock, and can only socialize during visitation hours.

This. Unless one can easily be switched out but I doubt it. Schedules have to line up and the block is already in progress.

I had the same things happen to myself while a pharmacy student on rotation. My first cousin was in horrible car accident and was in the ICU in a coma for over a month. I just had to step away and not participate in their care. Did not answer questions about his condition. It was tough for sure not talking with family. I was given ability in afternoons to come down and be around family when work was done. Being a student, they did not harp on where I was as long as my work was done and I was prepared.

 

[Sushirolls]

The PGY1 should trade rotations while the family member is admitted. Everything else above is way too complicated, draw too much unneeded attention to the situation and honestly not really be practical in the communal setting of inpatient psych. This shouldn't be a huge or even significant issue. I'm not aware of any 1 person residencies. Further, inpatient is not like a month of gero or addictions, the resident will still meet the required time.

Disagree. The cat's already out of the bag. The resident is already aware of patient X being on the unit.

Now if during oncall at night a resident/attending gets wind in advance that they are about to admit patient X, then, they might have been able to pre-emptively re-arrange the schedule and it would be added value. But changing this late in the game? No real benefit.

 

[comp1]

What do you mean no benefit? It's a short term trade until the family member is off the unit. The benefit is helping maintain boundaries during the admission. Of course the resident is aware that the person is on the unit already, that's not the point. And in terms of trading, I have residents pulled from my inpatient service with less than 24 hours notice REGULARLY. It's usually because some other psych intern got sick on medicine.

 

[calvnandhobbs68]

I don't understand the inability to trade short term as long as the resident is okay with it. Almost every residency has jeopardy/backup of some sort anyway and honestly psych residencies have wayyyy more flexibility than a lot of other ones with this kind of stuff...all your 3rd and 4th years are on electives or outpatient stuff they can easily be pulled from half the year in most programs.

I do think it matters who it is too and how close of a relationship they have with them. Mom/dad/sister/brother is way different than an aunt you see once a year during christmas.

This is an immediate chief resident/PD level discussion but I would have sat down with the resident right away and said hey what do you feel comfortable with here? Do you realistically think that you can keep yourself totally separate from the rest of the team with this and not feel tempted to look up any info or interact with this person while you're on the unit? I would also be totally sympathetic to someone saying yeah can you just swap me while they're admitted, I don't know if I can handle seeing them like that. Involuntary also means to me that this may not be a pretty situation overall.....I would hope my senior residents would be understanding to this as well.

I would also hope the inpatient attending would be extremely sympathetic to this situation and help out in any way they can. I think it's very difficult to separate the resident totally from their care unless the attending takes over for literally everything...for example in my program we rotated "late" days throughout the week, which means the resident would be getting signout at some point about this person. Then you'd have to count on all the nurses knowing 100% not to say anything to this resident at all about this patient while they're the "late" resident or on call or whatever depending on how the programs structured.

It's also much less of a HIPAA issue to just swap this person for a week or two for a "medical emergency" or something (where basically only your chiefs/PD, the inpatient attending, the senior or whoever is covering and the PGY-1 know what's going on) than try to do this weird convoluted PGY-1 stays on the unit but there's this one patient nobody can tell them about....like you're basically broadcasting that they're associated with this person somehow.