Abstract
The clinical case conference has been a hallmark of undergraduate and graduate medical education for decades and affords attendees the opportunity to hear about interesting and difficult cases and to learn from a discussion of the complexities of diagnosis and treatment. In forensic psychiatry, the complexities in a case conference also extend to the formation of a forensic opinion. The application of the clinical case conference to forensic psychiatry has not been described in the literature, although many fellowship programs engage in this activity. In the forensic arena, special ethics concerns may arise regarding confidentiality, dual agency, and conflicts of interest. In this commentary, we discuss the implications of using the group approach to supervision and consultation outlined by Buchanan et al., as it relates to professional development and understanding of ethics among forensic psychiatry trainees. We also discuss the usefulness of this type of group consultation in faculty development, including the satisfaction of the Accreditation Council of Graduate Medical Education's (ACGME) Common Program Requirements and, potentially, one part of the Maintenance of Certification requirements of the American Board of Psychiatry and Neurology, Inc.
In “A Consultation and Supervision Model for Developing the Forensic Psychiatric Opinion,” Buchanan et al.1 describe clinical consultation and supervision group meetings that are used in their university's forensic psychiatry training program. The article discusses the various interests that must be protected during these meetings, as well as the principles used in determining attendance and participation. The use of these principles allows trainees to receive feedback from seasoned clinicians while protecting the interests of those involved and preventing information from being divulged to parties with a potential conflict of interest. The process of managing these conflicts also contributes to the fellows' training in ethics. The authors opine that sharing of information and ideas allows for feedback to be given, improves the quality of evaluations, and contributes to the education mission of the training program.
In addition to individual supervision by faculty members, trainees receive feedback at these consultations where the process of moving from clinical finding to legal conclusion is reviewed. These multidisciplinary meetings are attended by both full-time and part-time faculty (psychiatrists and psychologists), social work staff, nurses, medical students, psychology students, and general psychiatry residents. This combined supervision and consultation model appears to have many advantages and few negative consequences.
Supervision
In forensic psychiatry, trainees must learn to move from the role of treater/healer to that of objective evaluator on behalf of third parties. Pinals2 outlined the theoretical stages of development of forensic psychiatry fellows. Fellows are all unique, and their experiences influence the transition through these developmental stages. She outlined three stages of development: transformation, growth of confidence and adaptation, and identification and realization.
In the first stage, trainees begin to transform their primary alignment with the clinical treatment role into this new role of performing objective evaluations on behalf of third parties. They use, modify, or learn not to use skills acquired in general psychiatry as they pursue training in conducting forensic evaluations. They struggle with time management when estimating the amount of time needed to review records, conduct the evaluation, gather collateral information, and write the report. They may also lack considerable confidence in this new forensic role and their ability to formulate forensic opinions.
The trainee needs practical help from supervisors to navigate this stage effectively and develop the necessary forensic skills. Intensive individual supervision is beneficial, as the trainee must master many new skills in a short time, and it also facilitates direct observation of the trainee's ability to gather and analyze information, to conceptualize cases, to act professionally, and to communicate effectively. Given the lack of experience most forensic trainees have at this stage, a group consultation and supervision model, as proposed by Buchanan et al., may become an overwhelming experience. The beginning trainee may be aware that his forensic knowledge base is not as extensive as that of a more experienced trainee or faculty member. Thus, exposure to more advanced forensic clinicians in a group setting could lead to feelings of insecurity and consequently delay transition to the later stages of professional development.
However, the group consultation and supervision meetings outlined by Buchanan et al. may still be highly effective for fellows who have mastered their roles as evaluators and expanded their knowledge base. Having numerous providers from various disciplines may not be as daunting to a more experienced trainee who is comfortable accepting feedback from multiple sources. Seasoned trainees may benefit from the complex discussions and multiple viewpoints that group supervision fosters, especially when the supervision occurs with experienced faculty. Trainees will also discover different views of the case that might be used to prepare for cross-examination in court.
Buchanan et al. expressed concerns that, in cases where the evaluator has been retained by one party, presentation of the case may cast doubt on whether the opinion properly belongs to the presenter or to the group as a whole. We believe that professional development in the forensic context requires that forensic trainees take full responsibility for the opinion they express and feel confident to disagree at times with the views of others in the case. In addition, potential concerns could be avoided by only presenting court-appointed cases where the trainee has not been retained by either side in the case. The group supervision experience is one advantage of training in a fellowship program with a relatively large number of faculty members. It also allows fellows the opportunity to be exposed to certain forensic topics that are not typically available at many fellowships, such as court-ordered monitoring of psychiatric and correctional facilities and mental health policy development.
We note that neither the group supervision model described by Buchanan et al. nor the individual supervision approach is ideal for mentoring trainees. Mentorship encourages personal development and offers psychosocial support to a trainee in a longitudinal relationship and there may be conflicts of interest between the roles of mentor and supervisor.3 There are four main advantages to having a mentor:
a senior person whom one can rely on for advice and guidance;
someone providing support;
an informal adviser relating to training and personal matters to help and develop; and
a supportive relationship with someone not directly related to one's work.4
Mentees should take the lead in cultivating the relationship with their mentors, a role different from the accountability of supervisors.4 Clinical supervision is better confined to the specific workplace situation of a trainee and is focused on the performance of the trainee. Mentoring involves a long-term relationship over a period of training that is not solely related to a specific clinical rotation. A direct supervisory relationship with the mentee could create a conflict between the supervisor's role as an assessor of performance and the mentor's role as a supporter of the personal needs of trainees along their career paths.3
Consultation
Consultation with a colleague about a difficult forensic problem can be beneficial to both the evaluator and the retaining party. However, case consultation in the forensic arena raises certain ethics-related concerns, including confidentiality. Buchanan et al. describe the ethics principles used to conduct their supervision and consultation meetings, such as truth-telling, honesty, and respect for persons. These principles are brought to bear during the discussion of cases as well as during preliminary discussions of who should be present during the meetings. Decisions about limiting attendance at the meetings to avoid conflicts of interest or potential dual-agency appear complex, as described in their article. These matters may be more complicated at universities that allow faculty members to appear as opposing experts in the same case, a practice not allowed at some institutions. However, using a systematic approach in understanding and resolving ethics conflicts teaches forensic psychiatry fellows to navigate the potential problematic interactions that will arise in their future forensic practice.
It has been questioned whether psychiatrists have anything to offer the courts, whether they would not inevitably deceive either the legal system or the evaluee, and whether it is possible to resist the seductions of the adversarial system.5 However, Appelbaum6 has suggested two broad principles that govern the ethics of forensic work: truth-telling and respect for persons. In regard to truth-telling, there is a two-pronged obligation: subjective truth-telling (i.e., forensic psychiatrists should testify to what they believe to be true regardless of whether such testimony favors or disadvantages the parties employing them) and objective truth-telling (i.e., testimony should accurately reflect the scientific data on the subject at hand and the consensus of the field). Appelbaum also added that when the testifying expert goes beyond the data generally accepted by the field, that deviation should be made clear.6
In the course of truth-telling and attempting to offer useful knowledge to the courts, forensic psychiatrists occasionally overstep their bounds and proffer seemingly definitive opinions on matters about which they are unsure (e.g., grossly overstate the causal links between various aspects of brain function and crime). The consultation and supervision group meetings that are used at this university potentially serve as a check on erroneous findings or overreaching opinions that are discussed in the forum. In addition, participants from different disciplines can provide feedback to the evaluator in cases where the evaluator derives conclusions from methods and practices that are not accepted within the particular field. In other venues, interprofessional collaboration has been shown to improve professional practice and health care outcomes.7 It is likely that such collaboration would also lead to improvement in the quality of forensic opinions. Having multidisciplinary input can also assist the presenter in identifying adjunct information (e.g., psychometric assessment, additional collateral sources) that can be subsequently obtained to solidify the credibility of the forensic opinion before finalizing a forensic report.
In an attempt to gather the truth, forensic psychiatrists may be tempted to deceive evaluees to gain the desired information (e.g., not disclosing the side of the case for which they are working). However, the search for truth is limited by the principle of respect for persons (i.e., respect for the humanity of the evaluee). Thus, forensic psychiatrists do not engage in deception or unnecessary invasion of the privacy of the people whom they evaluate or about whom they testify.8 The consultation and supervision meetings as described create an atmosphere where the interests of the person being evaluated are protected. These meetings appear to emphasize that the information gathered from the evaluees will be treated with appropriate respect, that the future care of evaluees will not be unnecessarily jeopardized, and that the ability to obtain an independent expert opinion in the future will not be unduly compromised. Some faculty participants may be recused from these meetings to ensure that information is not disclosed to unauthorized individuals, with the result that future psychiatric care or evaluations of the evaluee are not compromised. A potential problem caused by the recusing of participants is that the discussion suffers the loss of those individuals' valuable input. Although a larger training program could have a number of faculty sufficient to offset this obstacle, a smaller training program with a limited number of faculty may have difficulty sustaining such a group model of consultation and supervision.
Other Potential Benefits
In addition to the aforementioned benefits of the group supervision and consultation model, there may be other benefits. The Accreditation Council for Graduate Medical Education (ACGME) has common program requirements that residency programs in all specialties are required to meet to remain accredited. One of the common program requirements is that the program director track and monitor faculty development.9 The consultation that fellowship faculty members receive when they present forensic cases at the group consultation and supervision meetings would be a perfect example of one model of faculty development. Documentation of the consultation and supervision meetings could assist program directors in meeting this ACGME requirement. The ACGME common program requirements for one-year training programs ask that the program director ensure that fellows are integrated and actively participate in interdisciplinary clinical quality improvement. The group supervision and consultation meetings should also satisfy this requirement.
The American Board of Psychiatry and Neurology, Inc. (ABPN), as one part of its Maintenance of Certification (MOC) program, requires that psychiatrists engage in self-assessment.10 Diplomates engaged in MOC must earn 24 hours of Self-Assessment Continuing Medical Education (CME) credits every three years. The ABPN, in an effort to increase flexibility in the MOC program, has recently approved alternatives to traditional CME activities that can be used to waive up to 16 of the 24 hours of Self-Assessment CME requirement every three years.11 Four hours of supervision from a supervisor or peer with written feedback about the diplomate's clinical performance, medical knowledge, and patient care can be used to waive eight hours of the required Self-Assessment CME. More important, as it relates to group supervision and consultation, a formal institutional peer review committee with written feedback about the diplomate's clinical performance, medical knowledge, and patient care can also qualify for a waiver of eight hours of the Self-Assessment CME requirements. The model described by Buchanan et al. uses verbal feedback to presenters at the group consultation and supervision meetings. However, if verbal feedback were augmented with written feedback, it could be used by faculty members engaged in MOC to waive eight hours of the required 24 hours of the Self-Assessment CME every three years.
Conclusion
The ability to receive group peer review at a point in the evaluative process where it can have a positive effect on the forensic opinion is invaluable to forensic trainees and faculty members. Applying the ethics principles outlined by Buchanan et al. may assist other forensic psychiatry fellowship programs in developing a similar experience for their trainees. Finally, these group supervision experiences lead to an expansion of the case material to which trainees are exposed in their single year of forensic training. The hope is that they will learn things that will be useful when similar cases appear in their future practice.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2016 American Academy of Psychiatry and the Law