Policies/Guidance on Treating Co-Workers
Hello All – I imagine this has come up on the list-serve a number of times, so I apologize if I’m re-hashing.
I’m wondering if anyone has an explicit SOP on how to handle staff and/or medical providers seeking treatment from a BHC. In lieu of that, general guidance/heuristics/etc. are very appreciated. One of my direct reports recently received a warm-handoff that turned out to be one of the MAs in the clinic. The BHC & MA discussed the multiple relationship & decided that, at least for the initial consultation to assist the PCP, there was no harm in it. The BHC asked me later how to approach any follow-up care.
Frankly, having “grown up” in the PCBH model, I don’t know that I trust myself to be entirely objective here. I see the concept of rotely refusing to treat co-workers as antithetical to the model, as being more concerned about CYA than the patient, as being insensitive to the norms of medical culture, and as reinforcing the stigmatization of mental health. That being said, it’s very easy for me to say this because I’ve never actually been in the situation! I can certainly think of plenty of reasons to consider whether seeing co-workers would be appropriate in a given case, and certainly would never do so without that careful consideration. I also acknowledge and validate the natural discomfort that would inevitably come in such a situation.
I’d appreciate any and all wisdom you all are willing to provide! Thank you very much; have a great one.
I recently looked into the ethics literature around this topic for a manuscript that I just submitted, and I found a fairly wide range of opinions. I’d recommend reading all three of the articles below yourself (backchannel me if you like me to send the PDFs), but based on my memory, the cliff notes version is that the Kanzler et al paper aligns closest with your own instincts (argues in favor of treating colleagues as long as the ethical implications are well considered and both parties are comfortable with it), the Williamson et al. article falls more on other side side of avoiding any treatment of colleagues, and Reiter & Runyan provide more of a middle-ground case example suggesting that it may be most defensible to provide brief assessment/intervention for colleagues in crisis or other more urgent situations but may be best to avoid engaging in longer ongoing care relationships.
Kanzler, K. E., Goodie, J. L., Hunter, C. L., Glotfelter, M. A., & Bodart, J. J. (2013). From colleague to patient: Ethical challenges in integrated primary care. Families, Systems and Health, 31(1), 41–48. https://doi.org/10.1037/a0031853
Reiter, J., & Runyan, C. (2013). The ethics of complex relationships in primary care behavioral health. Families, Systems and Health, 31(1), 20–27. https://doi.org/10.1037/a0031855
Williamson, A. A., Bignall, W. J. R., Swift, L. E., Hung, A. H., Power, T. J., Robins, P. M., & Mautone, J. A. (2017). Ethical and legal issues in integrated care settings: Case examples from pediatric primary care. Clinical Practice in Pediatric Psychology, 5(2), 196–208. https://doi.org/10.1037/cpp0000157
All the best,
I think Dr. Bruner’s question is an important one to visit, and re-visit, since it is a potentially challenging ethical dilemma.
For me, the answer to the “do I or don’t I?” question, is a solid “it depends!” While it would be comforting to have a standard “SOP” for this, I’m not sure that is really possible. On the one hand, a standard refusal to see another member of the primary care team for a BH concern or question, is likely to alienate our work from the rest of the healthcare team (in my experience in primary care, it is very much part of the culture for physicians to treat other physicians), reinforce existing silos, promote stigma, and keep BH concerns in the shadows of our culture. On the other hand, it would be potentially very challenging to treat every BH concern that is brought to the BHC and depending on where one practices (i.e. rural or smaller communities) and for how long, the overlapping relationships that can accumulate over decades can make it quite uncomfortable in some scenarios. I practiced in a rural primary care clinic for 28 years and over time one has to be increasingly mindful of keeping all the stories straight.
I’ve treated physicians in my clinic, nurses, and front desk staff. I’ve always taken the approach that I’m happy to listen, educate, answer questions, and weigh (together with the colleague) the pros/cons of being the treating provider for this particular concern (something along the lines of “if we do this, I’ll know a lot more about your personal life than you know about mine; is that ok with you? What do you see as the options?”). In many cases it is not treatment per se that is being requested, rather a professional opinion about next steps or some education about a particular topic. We just don’t know until we head into the story at least a little bit.
I would place myself firmly in the “middle ground” category of being selective about which problems I will treat and which, for any number of reasons, might be best referred to another clinician outside the walls of my clinic. But, in the spirit of integration, I try to be a resource to collaborate with my colleague to determine what is the next best step to ethically and professionally address their personal concerns.
Love to hear the wisdom of others.
My thoughts match Jeff’s exactly. I’ve been in a rural clinic for 6 years and have seen a large number of employees. I’ll admit, I don’t always love doing this and I’ve asked the question to a number of colleagues as it goes against the traditional training I received in graduate school. At the end of the day, I had to make the decision based on the culture of our organization. Our PCPs treat each other, they treat most of our staff (including myself), and so drawing a firm line would be quite opposite of our clinic culture. Those of you in rural health in isolated regions know that trust and familiarity are valued probably more than anything else (including expertise), so seeing employees honors the overall ethos of my community.
Having that said, I encourage my team to voice when they feel the dual relationship is too close, to try to triage when possible, and to set boundaries when staff are pulling for more than we really ought to be giving (e.g., using BHC as a crisis service or for clinical politics).
I have a firm rule that I will see anybody once. Then we see. At that point, I am at Jeff’s “it depends”. So many of these meetings allowed for education or redefinition of the problem or identification of resources for the person, that it was only in a few times that I was left with what could be called a request for “therapy”. A couple of times I went forward for a few meetings with very clear goals. Mostly the one time rule got things addressed with no feeling for me that I was entering a gray area.