Friday, March 16, 2012

Goldman Sachs, Corporate Culture, and Medical Ethics

When Greg Smith, an executive director at Goldman Sachs, and head of the firm's US equity derivatives business in Europe, the Middle East, and Africa, explained why he resigned from the company in a remarkable New York Times op ed piece two days ago, the story went viral. Here's the essence of what he had to say:
After almost 12 years at the firm...I believe I have worked here long enough to understand the trajectory of its culture, its people, and its identity. And I can honestly say the environment now is as toxic and destructive as I have ever seen it....I have always taken a lot of pride in advising my clients to do what I believe is right for them, even if it means less money for the firm. This view is becoming increasingly unpopular at Goldman Sachs...I attend derivatives sales meeting where not one single minute is spent asking questions about how we can help clients. It's purely about how we can make the most possible money off of them. If you were an alien from Mars and sat in on one of these meetings, you would believe that a client's success or progress was not part of the thought process at all.
Years ago, my friend Marc Bard, a brilliant consultant, taught me the aphorism - "culture beats strategy every time." This is perhaps especially true in health care, which is so strongly mission-driven. If the shared culture of a health organization is truly patient centered every action will express the organization's values.

I experienced how culture works especially clearly 19 years ago, when my father, near the end of his life, was a patient at the Lahey Clinic. In my distracted and distressed state, I locked my keys in my car. I went to the building services office to get help. A staff member (a) picked the car's lock with expertise, but also (b) conducted excellent common sense psychotherapy with me around how we get forgetful when we're upset, and (c) said he would pray for my father. Remembering the incident and writing about it here brought tears back to my eyes. I'm happy that I wrote to the CEO to report on the excellent care I received from his non-clinical staff and to congratulate him on the culture of the organization.

I'm lucky that the four health organizations I've been part of during my career - the Massachusetts Mental Health Center, Harvard Community Health Plan/Harvard Vanguard Medical Associates (HCHP morphed into HVMA), the Harvard Pilgrim Health Care insurance company, and the Harvard Pilgrim Health Care Institute,  have all had cultures and evinced values I've been proud to be associated with. I doubt, however, that the people at those organizations were intrinsically more ethical than the colleagues Greg Smith is writing about.

When one's colleagues and the leaders of an organization share core values they reinforce each other. Newcomers are selected for fit with the culture, and the culture (what educators call the "hidden curriculum") brings out the best in us. It's easier for a health organization than for Goldman Sachs to cultivate a positive culture because the mission of caring for people who are suffering encourages empathy. I'd like to believe that I'd leave as Greg Smith did if I found myself part of an organization with a environment that is "toxic and destructive" and was unable to influence it, but knowing the human capacity for self-delusion, I can't be smug and certain that I wouldn't follow the same playbook Greg Smith discerned at Goldman Sachs.

Aristotle conceptualized "character" as an inner state or way of being that shows itself in the patterns of our actions. "Culture" is the organizational equivalent of "character." Culture is partly formed by the characters of those who constitute it, but the influence goes both ways. In trying to understand our human natures, we need to consider "culture" and "character" along with "nature" and "nurture."

Monday, March 5, 2012

Is This Doctor-Patient Marriage Unethical?

I shouldn't have been surprised that the most read posts on this blog have been about doctor-patient sex. When I recently had occasion to review these posts a comment I received on April 23 last year caught my attention:

Let us face it squarely. There are only 4 women that a newly qualified overworked doctor intern is exposed to: a fellow doctor (usually out of reach), a nurse (may lead accusation of sexual harassment) a bar waitress (usually not of the best social character) and the patient. I chose the latter and am happily married to her for 8 years. Did I breach the ethics? Can a distinction be made between sexual attraction and real love?
In my response I made an initial sortie into the connection between professional ethics and the ethics of personal relationships. But in retrospect I wish I'd been clearer:
Congratulations on 8 happy years of marriage. I don't know what area of medicine you're in, and what its code of ethics states. In my own specialty - psychiatry - the code asserts that sex with current or former patients is unethical. So if you're a psychiatrist, the code answers your question - you did breach the ethics of the specialty....

So - you may have violated the ethics of your area of medicine, but I'm guessing that you and your wife distinguished right from the start between "real love" and "sexual attraction." You have 8 years of evidence that you got it right! For you as individuals the professional ethics precept would have been a bad guide. 
Suppose the ethics committee of the former intern's medical specialty were asked to review the ethics of the relationship he formed with his patient 8 years ago. For my specialty (psychiatry), the answer would be unambiguous. Forming a romantic or sexual relationship with a current or former patient is defined as unethical.

Given that he violated the ethics of his specialty, should he be disciplined?

If there had been no problems in his medical practice in the subsequent 8 years I think the right outcome would be (a) to reaffirm the correctness of the ethical standard but (b) to find a way of not disciplining him intern, while (c) being careful not to set a precedent that undermines the standard.

The rationale for defining romantic/sexual relationships with current and former patients as unethical is twofold: to protect patients from the harms that these relationships can cause, and to prevent the loss of trust in the profession that would accrue if the public concludes that physicians are prepared to exploit patients for personal gain, as by "hitting" on them. The former intern's happy marriage isn't evidence against the standard. The standard doesn't claim that every doctor-patient romantic/sexual relationship will result in harm, just that we know that harm is a significant possibility and is difficult to predict. And the happy marriage says nothing about the overall trustworthiness of the profession.

If this was a current question for a physician with no pattern of exploitation, an ethics committee might require an extended period of supervised practice. Assuming the former intern has practiced in exemplary fashion for 8 years, that would exceed what a probationary period would entail. As a member of the specialty society it's important for him to understand and support the ethical precepts of the society. As a response to the violation that occurred 8 years ago, the ethics committee might ask the former intern to write an essay on how he would respond to a colleague who asked him: "Look how well your doctor-patient relationship worked out - why should I follow the ethical standard on this?"

If the intern's medical specialty and medical society held the same standard as the American Psychiatric Association, the relationship he formed with his patient violated the ethics of the profession. But his report of 8 years of happy marriage suggests that the ethics of his personal relationship is excellent. The professional and personal domains overlap, but not totally. Four years ago I argued that the Karolinska Institute in Stockholm did the right thing in expelling a medical student who had been convicted of murder 8 years earlier, even though he performed competently in his student role.

In the U.K. the medical profession does not have a blanket ethical rule against romantic/sexual relationships with former patients. The General Medical Council (GMC), whose role is to "ensure proper standards in the practice of medicine," has formulated guidance about professional boundaries in terms of personal ethics. Recast to eliminate reference to the doctor-patient relationship, the values in the GMC espouses could form the basis of a high school or college class on relationship ethics:
  • You must not pursue a sexual relationship with a former patient, where at the time of the professional relationship the patient was vulnerable, for example, because of mental health problems or because of their lack of maturity.
  • Pursuing a sexual relationship with a former patient may be inappropriate, regardless of the length of time elapsed since the therapeutic relationship ended. This is because it may be difficult to be certain that the professional relationship is not being abused.
  • If circumstances arise in which social contact with a former patient leads to the possibility of a sexual relationship beginning, you must use your professional judgment and give careful consideration to the nature and circumstances of the relationship, taking account of the following:
       (a) when the professional relationship ended and how long it lasted
       (b) the nature of the previous professional relationship
       (c) whether the patient was particularly vulnerable at the time of the relationship, and whether they are still vulnerable
       (d) whether you will be caring for other members of the patient's family

Saturday, March 3, 2012

Wartime Heroism and Personal Ideals

I'm sorry I never met Dr. Tina Strobos, whose obituary I read in this morning's Boston Globe. But I have a new hero.

Dr. Strobos was a 19 year old medical student in Amsterdam when Nazi Germany invaded in May, 1940. When she and her fellow students refused to sign a loyalty oath to Adolf Hitler, the school was closed.

Dr. Strobos joined the Dutch underground, initially ferrying arms and supplies to resistance fighters. Then she turned to helping her Jewish friends and ultimately others to escape. She and her mother had a secret room constructed on the third floor of their Amsterdam home, just a short walk from the home that sheltered Ann Frank and her family. It became part of an underground railroad for escapees. During the war they helped save 100 Jews, for which, in 1989, the Yad Vashem Holocaust Museum in Jerusalem honored her and her late mother as "righteous among the nations."

 After the war Dr. Strobos came to the U.S. and studied child psychiatry. Despite extensive Google searching I haven't been able to learn much about her career. She appears to have run a treatment facility in Rye, N.Y. One listing said it was for people with chronic psychiatric ailments. Another site said she'd helped Katrina victims. I like to think that her work as a psychiatrist carried forward the same values she lived by during her years of wartime heroism.

I've thought a lot about the concept of health care as a "calling." For religious persons the call may come from their God. But what about agnostics and atheists? Dr. Strobos answered this way: "I never believed in God, but I believed in the sacredness of life." This outlook ran in her family. Her mother and maternal grandmother were also athiests, socialists, and activists. During World War I her grandmother had also hidden refugees! And all three of her children work in helping professions.

Dr. Strobos seems to have been a practical idealist. During the war, along with her work in the resistance, she also sought opportunities to continue her medical studies. "You have to be a little bit selfish and look after yourself; otherwise you just die inside, you burn out. There's just so much you can do for other people."

I'm proud to be part of the same psychiatric profession as Tina Strobos!

(For a moving video of Dr. Strobos receiving an award from the Holocaust and Human Rights Education Center in 2009, see here. For additional details on her life, see here, here, and here.)