Introduction

Psychologists’ presence in medical settings continues to expand across diverse patient populations and health care contexts. The field’s growth in medical settings has occurred in parallel with a shift towards integrated health care delivery models (American Psychological Association, 2011a). Multidisciplinary treatment teams are a common and critical way to address complex issues such as management of chronic illnesses, disease prevention, and non-adherence to medical regimens. Psychologists’ participation on such treatment teams presents opportunities for providing collaborative, holistic care, yet also presents unique ethical challenges.

Psychologists’ practices are guided by the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (Ethics Code; 2002), the American Psychological Association (APA) Guidelines for Psychological Practice in Health Care Delivery Systems (2011a), state and federal laws, and regulations specific to the organization in which they practice. Despite all of these guidelines, the intricacies of practicing in a health care setting frequently present unique ethical dilemmas that fail to correspond to specific standards. Specifically, psychologists must look closely at their multidisciplinary interactions with other health care professionals to ensure that they reflect optimal service to their patients. Currently, there is a lack of clarity regarding how psychologists can simultaneously serve the needs of their patients and their multidisciplinary teams in an effective and ethical manner. This review will outline the issues that may arise, regulations that are in place, and ethical action steps for clinical psychologists, health care organizations, and training programs.

Ethical Challenges

A multidisciplinary team approach to patient care represents a fundamental reconceptualization of health care delivery, such that a team-patient relationship replaces the traditional doctor-patient relationship (Kirkpatrick, Vogel, & Nyman, 2011; Lopez & Prosser, 1999). Such teams of health care professionals, considered a foundational aspect of modern health care, manifest differently across medical settings and populations (Greiner & Knebel, 2003). For example, an outpatient obesity treatment program may have a physician, clinical health psychologist, dietician, and physical therapist each working separately to address the common health issue of weight loss. Alternatively, physicians and psychologists in a family practice clinic may provide services concurrently in an effort to treat the patient in an integrated manner. Whether practicing independently or side-by-side, professionals in both of these examples apply their unique expertise while promoting a mutual goal of improved patient health. Under both approaches, treatment decisions may be made together and clinicians often conceptualize themselves as part of something broader than their own actions (Greiner & Knebel, 2003). The complexities of the ethical challenges faced by clinical psychologists, however, differ based on contextual factors such as the particular medical setting or specialty and the nature of the psychologist’s role on the treatment team.

Communication on Multidisciplinary Teams

Although a range of multidisciplinary team models exist, a defining factor is the ability to streamline and coordinate across providers and disciplines to provide continuous patient care. This collaborative approach inherently involves communication between treating professionals. During in-person multidisciplinary collaboration, providers discuss patients during case consultations or team meetings. Due to differential ethical standards across disciplines, however, the same conversation could be ethically permissible for one of the providers to have, but violate another provider’s professional standards of confidentiality (Steinfeld, Ekorenrud, Gillett, Quirk, & Eytan, 2006). For clinical psychologists working in medical settings, tension between protecting their patients’ confidentiality and contributing as part of the treatment team often emerges (Mason, Williams, & Vivian-Byrne, 2002; Norris, 2002; Richards, 2009; Steinfeld et al., 2006). This tension requires the clinical psychologist to consider the “balance between restraint and release of information,” such that a certain degree of information-sharing facilitates care coordination, while sharing too much information threatens patients’ privacy rights and violates professional ethics of confidentiality (Knowles, 2009, p. 72).

APA Standards

The APA encourages psychologists in medical settings to maintain their distinct professional identity as a psychologist, while also being an active part of an integrated care team (APA, 2011a). Psychologists on multidisciplinary teams are guided by ethical standards related to maintaining privacy and confidentiality during their face-to-face consultations with other professionals. To minimize intrusions on patient privacy while still facilitating cross-discipline communication, psychologists must only report information that is appropriate, in both purpose and extent, to the communication or consultation being made (APA, 2002). For example, if the dietician on the previously mentioned obesity team asked the psychologist if the patient reported any difficulties with family support for their dietary changes, the psychologist should answer that question yet should not expand on other psychosocial information the patient shared. This ethical recommendation, however, assumes the patient has provided consent for their information to be shared across the team of providers. In the absence of a patient’s consent, psychologists on multidisciplinary teams can only disclose the patient’s information to provide necessary services or to protect the patient or others from harm (APA, 2002). In the multidisciplinary obesity care team, for example, the psychologist would be ethically permitted to tell the physician if the patient disclosed that they were not regularly taking their medication. Due to the deleterious medical consequences of non-adherence, sharing this information would help the team provide necessary services to the patient.

Record Keeping in Medical Settings

In addition to in-person collaboration, providers increasingly share information through the use of electronic health records (EHRs). It is estimated that 90 % of doctors and 70 % of hospitals will be using EHRs by 2020 (Richards, 2009). By design, most EHRs do not provide the level of confidentiality typically afforded to psychological records, nor do they address the confidentiality and coordination of care balance faced by psychologists (APA, 2007; Steinfeld et al., 2006). It is quite possible, for example, that a variety of professional and non-professional staff could read psychological treatment information in a patient’s EHR. Therefore, it is essential that psychologists consider who has access to the EHR before keeping records in this format. During this transitional time of increasing electronic documentation, psychologists are “ethically obligated to be proactive” in creating ethical standards for confidential care in medical settings (Hanson & Sheridan, 1997; Richards, 2009).

APA Guidelines

The APA’s most recent Record Keeping Guidelines, released in 2007, recognize that EHRs “expose psychologists to risks of unintended disclosure of confidential information,” and recommend that psychologists aspire to create them in a way that protects their “security, integrity, confidentiality, and appropriate access” (APA, 2007, p. 1000). Furthermore, the APA acknowledges that a psychologist’s practice setting, legal requirements, and institutional policies affect the nature of record keeping. In organizational settings such as hospitals, for example, the APA recommends that psychologists attempt to follow the record keeping procedures of both the organization and the Ethics Code, while acknowledging that a team approach to care intrinsically restricts the psychologist’s ability to control the record. In accordance with the fact that “multidisciplinary records may not enjoy the same level of confidentiality generally afforded psychological records,” the APA suggests that psychologists record only information necessary to describe the services they provided and to meet the record keeping requirements set by their organization (APA, 2007, p. 1000). Psychological records in medical settings should describe service provision, rather than patient history, and maintain a primary focus on information relevant to the medical condition.

Confidentiality in Practice

When sharing information, psychologists must remember the patient best knows what is in the patient’s best interests. Inappropriate disclosures are more likely to occur when a professional assumes that sharing the information is in the best interests of the patient. Not only does this reinforce the outdated, paternalistic, “doctor knows best” model, but it also abuses patient autonomy and collaborative patient-provider relationships (Paterson & Mulligan, 2003). Making information-sharing decisions for patients, however innocuous they may seem, is unprofessional and unethical.

Psychologists’ standards of practice often differ from those of other healthcare professionals and from the health care organizations in which they work. Across communication and record keeping circumstances, the APA Ethics Code holds psychologists to high standards of confidentiality. These standards, however, assume a practice setting where psychological services are provided independent from concurrent health care services, and do not directly address confidentiality in multidisciplinary and institutional practice settings (Norris, 2002). The APA recognizes that psychologists’ ethical standards regarding patient confidentiality are “more stringent than, or qualitatively and/or procedurally different from, other rules governing the exchange of health information among providers within the health care delivery system” (APA, 2011a, p. 7). As a result, the APA Guidelines for Psychological Practice in Healthcare Delivery Systems encourage psychologists to be cautious during both informal discussions with colleagues and formal documentation in patient records (APA, 2011a).

From 2000 through 2004, the APA Ethics Committee opened 10 cases involving confidentiality as a factor in the complaint (Pope & Vasquez, 2007). This represents less than one percent of all ethics complaints opened during this five-year time frame. The historically small number of allegations regarding confidentiality appears to continue, as no cases involving confidentiality were opened in 2010 (APA, 2011b). Despite accounting for a small portion of formal ethics complaints, psychologists have indicated that confidentiality dilemmas are at the forefront of their practices. A national survey of APA members found that respondents struggle more with confidentiality than any other ethical dilemma, with issues of confidentiality comprising 18 % of member-reported critical incidents (Pope & Vetter, 1992). Therefore, discussions of confidentiality are warranted and perhaps particularly relevant to psychologists in medical settings who frequently collaborate with other health care providers.

Application of HIPAA to Multidisciplinary Teams

In addition to the APA Ethics Code, psychologists are held to the federal Health Insurance Portability and Accountability Act (HIPAA) rules regarding patient information. By establishing standards for the privacy and security of electronic health information, HIPAA improved the fluidity of healthcare delivery (Benefield, Ashkanazi, & Rozensky, 2006). Under HIPAA’s Privacy Rule, protected health information (PHI), such as a patient’s name, diagnosis, and contact information, can be disclosed to other health care providers for treatment purposes (Richards, 2009). Because other health care providers are covered entities under the Privacy Rule, PHI can be shared between providers without a patient’s consent. However, the Privacy Rule affords heightened security for psychotherapy notes. Provided that such notes are kept separate from the rest of the patient’s record (e.g., in a secure file in the psychologist’s office, in the EHR in a protected manner), only the psychologist who authored them can access the notes without patient authorization (APA, 2007; Bersoff, 2008). While multidisciplinary team members are likely quite familiar with HIPAA, they may be unaware of the increased protection for psychotherapy notes.

Critics of HIPAA have argued that, “rather than protect privacy, HIPAA removes it,” as no patient consent is required for releasing information related to treatment, payment, and operations (Freeny, 2007, p. 15). Moreover, patients cannot request a list of disclosures of their PHI to entities covered under the Privacy Rule, so they may never know about the communication that occurred between providers (Richards, 2009). Others contend that HIPAA’s Individual Choice Principle allows for more patient participation in the process of privacy protection by giving individuals the opportunity to restrict the uses and disclosures of their PHI (Benefield et al., 2006; Richards, 2009). Outside of information necessary for treatment, payment, and operations among covered entities, patients can restrict access to their information. For example, psychologists legally must document their dates of service, type of treatment, and diagnosis, but if there is additional information the patient does not want in the record, such as psychosocial history, it can be kept in a secure file in the psychologist’s office (APA, 2007; Benefield et al., 2006; Richards, 2009). Sensitive information that may have impacted the diagnosis formulation, but does not affect the patient’s current care, need not be included in the medical chart and is best kept in the psychologist’s secure patient files (Benefield et al., 2006). Despite the fact that disclosures of PHI are permissible between health care providers, psychologists can take steps to protect patient confidentiality while remaining HIPAA compliant.

HIPAA regulations acknowledge patient autonomy, as well as the highly sensitive nature of health information, by allowing patients increased control over their PHI. HIPAA can be considered a manifestation of patient-centered care, as it allows patients to tailor their consent. As such, it recognizes that patients differ in the ways they choose to utilize health care services, and that the medical experience should be focused on patients’ preferences rather than doctors’ preferences. When patients are recognized as autonomous agents, they are more likely to fully disclose and benefit from psychologists’ mental health services (Paterson & Mulligan, 2003).

Recommendations for Ethical Practice

Clinical psychologists practicing in medical settings are guided by the APA (Ethics Code, Record Keeping Guidelines, and Guidelines for Psychological Practice in Healthcare Delivery Systems), HIPAA, and policies specific to their institutional setting. How do these myriad guidelines and regulations translate into practice? How can ethical conflicts be prevented? Multi-level action is necessary on the part of the individual practitioner, the hospital organization employing them, and graduate programs training clinical psychologists for practice in medical settings.

Action Steps for the Clinical Psychologist in Medical Settings

  1. 1.

    It is the psychologist’s responsibility to educate their patients, as well as their clinical collaborators, regarding their ethical obligations to protect confidential information. At the outset of patient contact, psychologists must discuss what information they will have to put in the medical chart, who will have access to that information, the format of the medical chart (i.e., EHR or paper), what type of information they will verbally share with other providers, and the nature of their interactions with the health care organization (APA, 2002, 2011a; Benefield et al., 2006; Hanson & Sheridan, 1997; Richards, 2009). Psychologists should review with patients and team members the legal, ethical, and institutional reasons for what information is required to be in the medical chart and what may be kept in a separate secure file.

    1. a.

      Although information sharing among multidisciplinary team members is a common practice in modern medical settings, this is not something that patients typically expect (Paterson & Mulligan, 2003). Thus, psychologists should ensure that patients know the members of their medical team and their specific roles, and document patients’ consent to these relationships (APA, 2002). Without explicit informed consent, it cannot be assumed that patients either expect information to be shared or approve of this practice, however common it may be in collaborative care settings (Paterson & Mulligan, 2003). Educating patients regarding the information exchanges that may take place on their behalf may serve to increase patients’ confidence in the health care system and foster positive provider-patient relationships. However, in delineating their role as part of a multidisciplinary team, psychologists inherently face the possibility that patients may not disclose as freely as they otherwise would. Regardless of the potential impact to the psychologist-patient relationship, the APA Ethics Code requires psychologists to ensure patient understanding and agreement with the way that their information will be shared.

    2. b.

      Furthermore, psychologists must ensure that other health care providers understand and respect the sensitivity of psychological information (Dubois, 2002). Other providers may not be aware of the specifications, above and beyond HIPAA, that apply to mental health information. Specifically, psychologists need to inform their team members that they will be releasing mental health information on a need to know basis only, thus sharing the minimum amount necessary to facilitate ongoing collaborative care (APA, 2002; Knowles, 2009). Additionally, psychologists are responsible for only communicating information relevant to the patient’s immediate care. Historically, health care providers have been frustrated by not receiving further information after referring a patient to a psychologist (Steinfeld et al., 2006). Psychologists should clarify the nature of the referral relationship and the limitations imposed by the Ethics Code, while also affirming their commitment to professional cooperation (APA, 2002). Additionally, other providers on the health care team may consider it paradoxical for the EHR to include a detailed history of sensitive medical information, yet omit psychosocial history. Educating treatment teams about psychologists’ ethical obligation to limit disclosures to the minimum necessary for the professional purpose will help other providers understand psychologists’ practices regarding patient information.

  2. 2.

    When charting information, psychologists should keep in mind how their words could be interpreted by other individuals accessing the chart. At a basic level, clinicians should use language that can be easily understood by someone outside of the profession, and thus should avoid discipline-specific references or jargon (APA, 2011a; Benefield et al., 2006). Additionally, psychologists should only include information relevant to the patient’s current medical care and presenting concerns, rather than providing a full psychosocial history. Writing psychological notes in terms of treatment for the medical condition is ethically advisable, and yields more effective communication by preventing the over-burdening of medical staff with surplus information (Benefield et al., 2006).

    Medical providers and staff may lack extensive training in interpreting psychiatric diagnoses. Benefield et al. (2006) suggest supplementing psychiatric diagnoses with descriptions of patients’ communication or behavioral tendencies that could affect medical treatment and providing staff with recommendations for effective encounters with the patient. Such practices ensure that the information provided to the medical team is factual, likely to assist in their interactions with the patient, and at a decreased risk for biased judgments.

  3. 3.

    Psychologists practicing on multidisciplinary teams must also consider how they will use patient information obtained from collaborating professionals. Knowing a patient’s medical history is essential to a psychologist practicing in a medical setting. Unfortunately, ethical guidelines focus on psychologists’ release of information and fail to address ethical practices regarding receipt of information disclosed by other professionals. While referring providers may indicate a patient’s problem area upon involving the psychologist in treatment, the psychologist must observe patient behavior independently and avoid basing their assessment and intervention on team members’ reports. Obtaining patient information based on other providers’ interactions puts psychologists at risk of biasing their opinions of patients (Norris, 2002).

Additionally, collaborating providers may share other non-essential information that could impact the psychologist’s perception of the patient. Psychologists risk exposing their extra knowledge to the patient, who may not want non-medical information being shared between providers. For example, Dubois (2002) presented a case from a multidisciplinary pain management clinic where a patient, despite being informed that her providers would share information about her case, became enraged that her neurologist knew of the marital problems she discussed with another provider. Because this was not a medically relevant information exchange, she felt it should not have occurred between team members. In recognition of these potential pitfalls of knowing “too much” patient information, psychologists are encouraged to not seek out superfluous information and to separate patient statements from other providers’ opinions.

Action Steps for Health Care Organizations

Although clinical psychologists must individually strive to uphold their ethical obligations, there are aspects of their work environments that can negatively or positively affect their realization of ethical practice. Pope (1990) questioned whether hospitals “authorize, allow, and enable” psychologists to “assume the professional roles and to carry out the professional tasks that are necessary to fulfill [their] clinical responsibilities and ensure the welfare of [their] patients” (p. 1066). This statement, made over twenty years ago, remains relevant today. Aspects of the modern hospital setting, such as electronic records and multidisciplinary work, threaten the ability of psychologists to ensure patient confidentiality.

  1. 1.

    One way that organizational medical settings can demonstrate respect for the differential confidentiality of mental health information is to create a split-note EHR. This can be manifested in multiple ways, but the intention is to restrict access to sensitive and/or detailed mental health information to certain types of providers. This strategy allows all EHR users access to basic data, such as appointment dates and corresponding providers, but makes subjective and objective psychological notes accessible only to behavioral healthcare providers (Knowles, 2009; Steinfeld et al., 2006). One way to share mental health information with team members, while maintaining a restricted access EHR, is for the psychologist to send the necessary documentation to specific providers’ EHR inboxes (Richards, 2009). This approach enables multidisciplinary communication without widespread sharing of patient information to everyone with EHR access. Provided that patient safety and quality of care are not threatened, special accommodations for even less information to be part of the widely accessible record are possible (Benefield et al., 2006; Richards, 2009; Steinfeld et al., 2006).

  2. 2.

    Additionally, organizations should clarify their parameters of patient consent. For example, a patient could sign one consent form broadly covering all treating providers in that medical setting. Alternately, organizations could require patients to sign a separate mental health provider consent form to underscore the confidentiality of that data (Knowles, 2009). Regardless of an organization’s specific policy, their practices should be made explicit to patients and providers to prevent confusion. Notice of informed consent policies, as well as HIPAA privacy regulations, should be provided in patient-friendly formats.

Action Steps for Training Programs

The profession of psychology is accountable to the greater public through an implied social contract. As such, the public assumes that the field will provide the education and training necessary to produce qualified psychologists, as well as regulate the practitioners it puts forth. Graduate training programs are an integral part of ensuring competent psychologists. If their graduates plan to enter medical settings, training programs must assist in developing specialized competencies relevant to these environments.

  1. 1.

    At the most basic level, graduate student competency in multidisciplinary interactions, collaborative teamwork, and confidentiality must be addressed (Belar, 2004; Brown et al., 2002; Kaslow, Dunn, & Smith, 2008; King, 2004; Tovian et al., 2003). The Institute of Medicine identified multidisciplinary teamwork as a core competency for all health care clinicians, regardless of discipline (Greiner & Knebel, 2003). Additionally, programs must offer multidisciplinary training to be eligible for receipt of certain federal funds (Belar, 2004). Proficiency in basic group skills, such as communication, understanding another’s perspective, shared decision-making, and conflict resolution, is foundational for multidisciplinary competency and should be interwoven into graduate training programs. It is clear, therefore, that a demonstrated ability to effectively interact with other professionals is an essential part of being a clinical psychologist in medical settings.

  2. 2.

    Although it is ambiguous when or how to introduce ethical multidisciplinary collaboration into graduate education, training programs must expose students to such models of health care delivery. One proposed strategy is ‘interprofessional ethics,’ a model for conceptualizing emerging health care dilemmas across disciplines (Clark, Cott, & Drinka, 2007). Browne et al. (1995) proposed a specific cross-discipline graduate course as an avenue for giving future health care professionals an opportunity to study ethics together. This allows individuals who will need to make decisions together as future professionals an opportunity to develop a team approach to working through ethical dilemmas. If such a cross-discipline course is not feasible for a training program to offer, there are multiple ways to supplement existing ethics courses. For example, ethics courses could expose students to the ethical guidelines of the disciplines they will likely work with in their professional futures. This could be further extended by inviting a panel of health care professionals to represent their respective disciplines in an interactive format. Additionally, existing ethics courses could review case studies relevant to practice in medical settings (e.g., Hanson, Kerkhoff, & Bush, 2005; Kessler & Stafford, 2008). This case study approach serves as an effective way to expose students to realistic clinical situations, utilize the Ethics Code to inform multidisciplinary decision-making, and understand both medical and psychological perspectives of cases.

Conclusion

Psychology’s expansion as a health care profession and inclusion into multidisciplinary teams has brought challenges and opportunities alike. While psychologists have specialized knowledge to offer medical patients and providers, they also have strict ethical standards for protecting mental health information. Psychologists’ differential standards need not restrict them from full integration into multidisciplinary health care teams, however. Through informed action taken by individual psychologists, health care organizations, and graduate training programs, multidisciplinary collaborations can be both ethical and effective.