Public Disclosure on Social Media of Identifiable Patient Information by Health Professionals: Content Analysis of Twitter Data.

BACKGROUND: Respecting patient privacy and confidentiality is critical for doctor-patient relationships and public trust in medical professionals. The frequency of potentially identifiable disclosures online during periods of active engagement is unknown. OBJECTIVE: The objective of this study was to quantify potentially identifiable content shared on social media by physicians and other health care providers using the hashtag #ShareAStoryInOneTweet. METHODS: We accessed and searched Twitter's API using Symplur software for tweets that included the hashtag #ShareAStoryInOneTweet. We identified 1206 tweets by doctors, nurses, and other health professionals out of 43,374 tweets shared in May 2018. Tweet content was evaluated in January 2019 to determine the incidence of instances where names or potentially identifiable information about patients were shared; content analysis of tweets in which information about others had been disclosed was performed. The study also evaluated whether participants raised concerns about privacy breaches and estimated the frequency of deleted tweets. The study used dual, blinded coding for a 10% sample to estimate intercoder reliability using Cohen κ statistic for identifying the potential identifiability of tweet content. RESULTS: Health care professionals (n=656) disclosing information about others included 486 doctors (74.1%) and 98 nurses (14.9%). Health care professionals sharing stories about patient care disclosed the time frame in 95 tweets (95/754, 12.6%) and included patient names in 15 tweets (15/754, 2.0%). It is estimated that friends or families could likely identify the clinical scenario described in 242 of the 754 tweets (32.1%). Among 348 tweets about potentially living patients, it was estimated that 162 (46.6%) were likely identifiable by patients. Intercoder reliability in rating the potential identifiability demonstrated 86.8% agreement, with a Cohen κ of 0.8 suggesting substantial agreement. We also identified 78 out of 754 tweets (6.5%) that had been deleted on the website but were still viewable in the analytics software data set. CONCLUSIONS: During periods of active sharing online, nurses, physicians, and other health professionals may sometimes share more information than patients or families might expect. More study is needed to determine whether similar events arise frequently and to understand how to best ensure that patients' rights are adequately respected.

Forty-Five Years of Civil Litigation Against Canadian Psychiatrists: An Empirical Pilot Study.

OBJECTIVES: To extract the themes pertaining to prudent psychiatric practice from written court judgments in Canada. METHODS: We searched the medical and legal literature for cases involving civil litigation against Canadian psychiatrist and reviewed all available written judgments. We completed a thematic analysis of the civil actions against psychiatrists as conveyed by those written court judgments. We classified the cases according to the disposal status and the essential lessons from the decisions on standard of care and practice by Canadian psychiatrists. RESULTS: Forty such cases were identified as involving psychiatrists over a 45-year period. A subgroup included those dealing with limitation periods and disclosure applications. Thirty of the 40 cases (75%) were decided in favour of the defendant psychiatrists, including 2 dismissed for running over the limitation period. The cases that actually went to trial suggest that documentation and obtaining second opinions are protective against claims of negligence. Inpatient cases resulting in successful litigation against psychiatrists involved fatal outcomes, but not all fatal outcomes led to successful litigation. CONCLUSIONS: The key lessons from these cases are the importance and relevance of regular best clinical practices, such as documentation, obtaining second opinions, following guidelines, and balancing competencies in the expert and manager or advocate roles. Incorporating these practices should allay concerns about litigation against psychiatrists.

Commentary: Tarasoff duties arising from a forensic independent medical examination.

The question of whether a Tarasoff duty may emerge from a credible threat by an examinee during an independent medical examination has not been extensively addressed in the professional literature. This article analyzes that question and provides suggestions for how to respond to a perceived duty.

"I can't let anything go:" A case study with psychological testing of a patient with pathologic hoarding.

Pathologic hoarding is a symptom generally recognized as related to obsessional dynamics (Gutheil, 1959). The hoarder cannot, without great anxiety, tolerate separation from or dispose of his possessions. Thus the hoarder accumulates vast amount of possessions, often in such amounts as to compromise freedom of movement in the residence. Popular in tabloid reportage, such news items portray persons found dead among floor-to-ceiling piles of old newspapers and similar detritus, while in actual clinical practice such dramatic cases are not common (Bryk, 2005; Duenwald, 2004). More importantly, such individuals are rarely available for psychological intervention or testing, both because of social isolation and injury or death caused by the hoarded materials. Additionally, a majority of the current literature regarding hoarding is linked with Obsessive Compulsive Disorder (OCD), though other major disorders have been noted. This report describes a particular individual with characteristic features of hoarding, which is explored through formal psychological testing.

Treatment Delayed is Treatment Denied.

The past few decades have witnessed the steady development of a mental health jurisprudence dedicated to the preservation of human rights. Self-determination and personal autonomy are critical aspects of this perspective, pervading every facet of institutional psychiatric care. Of considerable concern, however, are those cases in which rote procedural approaches produce unintended consequences for the very persons such maneuvers were designed to protect. Delays-inherent in court-based procedures-may ironically lead to an acute illness becoming chronic, and to a single bout of inpatient services being transformed into a lifetime of revolving-door psychiatric admissions. This discussion is not about lawyers or lawyering; rather, it is about the proposition that a better system can and should be devised for advocates who must make do with the options they are dealt. A particularly problematic example is the "Rogers Guardianship" model currently prevalent in Massachusetts. Laws that effectively place on counsel and courts the challenge of second-guessing medical treatment decisions-with minimal latitude for counsel to exercise measured professional judgment-will inevitably generate, and empirically do generate, a degree of delay that ironically deprives patients of the liberation from illness that is the common goal of all stakeholders. Possible solutions to these difficulties are also suggested.

The problem of evasive testimony: the expert "waffle".

Confronted with a difficult, unexpected, or confrontational question, an expert witness may answer by attempting to overwhelm the questioner with words, sometimes highly evasive ones, that avoid, rather than actually address, the question asked. Such a discursive response is sometimes called a "waffle," as in "The expert's answer was a waffle." This review notes some examples of this phenomenon and attempts to categorize them in a meaningful way. An ancillary goal of this discussion may be to aid experts in focusing their answers.

Common pitfalls in the evaluation of testamentary capacity.

The examination for testamentary capacity poses several unique challenges to the forensic evaluator, especially when performed, as is often the case, postmortem. Forensic experience reveals that a series of common pitfalls awaits the unwary witness. This brief review identifies the more common pitfalls and suggests how to avoid them.

Psychiatric expert witnesses in the new millennium.

We may anticipate changes in who is the expert in terms of gender, ethnicity, and professional discipline. We anticipate elaboration of training approaches. We foresee emergence of the "forensic tutor" role. We expect expansion of expert roles outside the courtroom. We expect demands for more constraint of expert roles, increased rigor, and empiric support. We expect vast expansion of technologic approaches to assessment and presentation. We expect evolution of ethical issues with preservation of core forensic values but changes in confidentiality, due process, and the nature of assessments. We expect extreme expansion of hard sciences in relation to understanding psychopathology.

Commentary: Systems, sensitivity, and "sorry".

This commentary first addresses the moral atmosphere necessary for a systems view of adverse outcomes and discusses the theory of accidents. Patients suffering adverse outcomes are described as needing acknowledgment, remorse, and remedy. Apologizing and informing patients or families about what actually happened are important risk management approaches.

Attorneys' requests for complete tax records from opposing expert witnesses: some approaches to the problem.

As part of an impeachment attempt on cross-examination of opposing expert witnesses in trial or deposition, the cross-examining attorney may request the complete tax records of the expert. It is widely believed that expert witnesses may be expected to express opinions that favor the parties who engage them and who pay their fees. Theoretically, the purpose of this request is an attempt to paint the expert as a "hired gun" whose major source of income is forensic work. The different issues, statutes, and case law citations that bear on requests for tax records are reviewed, and the strategies for coping with this tactic are suggested.

Pejorative testimony about opposing experts and colleagues: "fouling one's own nest".

Circumstances sometimes require expert witnesses under oath to express opinions about opposing experts or professional colleagues who work within their own professional, geographic, or organizational circle. This requirement poses some common problems that have not been well discussed in the literature. This article addresses some of those problems and suggests some useful solutions.

Clinicians' perceptions of boundaries in Brazil and the United States.

Although there has been considerable discussion of boundary excursions in clinician-patient relationships, little empirical research exists. This pilot study adds to the existing theoretical discussion by comparing perceptions by mental health professionals in Brazil and the United States of what may constitute boundary violations. Participants rated each possible boundary violation according to its degree of harm and professional unacceptability. Three distinct groupings of boundary violations were found: (1) core, consisting of the most serious violations; (2) separation of therapist and client lives, involving encounters between therapists and clients outside of therapy; and (3) disclosure and greeting behavior, involving disclosure of information about the therapist and greeting behavior. The U.S. and Brazilian perceptions were found to be surprisingly similar, with only a few differences.

A pilot Rasch scaling of lawyers' perceptions of expert bias.

How seriously do attorneys consider the biases of their retained mental health experts? Participants in this pilot study included 40 attorneys, randomly selected from a pool of members of the Pennsylvania Bar Institute, who rated-for their biasing potential-several situations that might affect the behavior of an expert. A Rasch analysis produced a linear scale as to the perceived biasing potential of these different items from most to least biasing. Among other results, the study suggests that attorneys do view mental health experts who work on both sides of cases as being more balanced in their testimony. However, they also indicated that they have a preference for using individuals who repeatedly testify for one side. Working for only one side in both civil and criminal cases yielded large scaled values. Additional comments offered by respondents indicated that: (1) an opposing expert also serving as the litigant's treater and (2) an opposing expert being viewed as a "hired gun" (supplying an opinion only for money) were viewed by subjects as not being very biased. A discussion of the results raises the need for future research in this area.

A Proposed Model for Assessing Defendant Competence to Self-Represent.

The increasing number of criminal defendants who are choosing to self-represent poses special challenges for legal systems with regard to the types of limits that should be placed on a defendant's basic human right to defend himself without the assistance of counsel. While courts strive to respect the dignity and autonomy of the defendant that are encompassed in this right, they also want to ensure that justice is delivered and the dignity of the courtroom is maintained. The Supreme Court of the United States, in its opinion in Indiana v. Edwards (2008), held that while the right to self-represent recognized in Faretta v. California (1975) remains, states and trial judges can place limits on a defendant's right to self-representation when a defendant lacks the mental capacities needed to prepare and conduct an adequate defense. Following the court's lead, we first examine the types and range of tasks that a defendant who chooses to self-represent must perform. Based on this analysis, we propose a five-part model that forensic practitioners can use as a conceptual framework for assessing whether a defendant has deficits that would affect his competence to perform critical self-representation tasks. The five areas that the model recommends practitioners assess are whether a defendant can engage in goal-directed behaviors, has sufficient communication skills, can engage in constructive social intercourse, can control his emotions in an adversarial arena, and has the cognitive abilities needed to argue his case adequately. It is recommended that practitioners use the model in their testimony to provide the trier of fact with a comprehensive report of the areas in which a defendant has deficits that will prevent him from protecting his interests in receiving a fair and equitable trial.

Comparative study of forensic psychiatric system between China and America.

Laws and regulations about the forensic psychiatric systems in China and America were compared, and suggestions for improving the forensic psychiatric system of China were provided. There are many differences regarding the role of the forensic psychiatrist, the initiation of the assessment and the admission of expert opinion because of elements in the legal systems in China and America. The Chinese system has the advantages of objectivity, cost saving and high efficiency; but it has deficiencies in procedural justice and the admission of expert opinion. China can persist with the current system while taking measures to give more rights to the litigants to participate in their assessment, and while improving the quality and utility of the expert opinion; however, this review article will compare broadly the two systems without addressing human rights issues or procedural justice issues, nor will it presume to address the entirety of Chinese systems. In addition, China is developing its legal system for dealing with the mentally ill defendant in situations involving the criminal justice system and civil commitment. Although China enacted new laws regarding the mandatory treatment for the mentally ill, both in criminal and civil systems, there remain many aspects to be improved, including but not limited to a system of review of the decision to detain a patient on psychiatric grounds, and the need for provisions in the laws preventing indefinite detention. From this viewpoint, America's laws and regulations are instructive for us, in matters such as the method of dealing with the mentally ill defendant who is "incompetent to stand trial", "not guilty only by reason of insanity" or "guilty but mentally ill". The conditional release of the committed mentally ill person and the special programs in the forensic security hospital are all worthy of study by China in order to manage the mentally ill offender and to reduce the recidivism rate.

Boundary issues and personality disorders.

The author first presents an overview of the basic elements of boundary theory and clarifies the distinction between boundary crossings and boundary violations. The concepts of context dependence, power asymmetry, and fiduciary duty as they relate to boundary problems are also discussed. The intrinsic and extrinsic consequences of boundary problems are reviewed. The extrinsic consequences fall into three major categories: civil lawsuits, complaints to the board of registration, and complaints to professional societies. The author then reviews types of boundary issues that arise in relation to histrionic, dependent, antisocial, and borderline personality disorders. Countertransference issues that arise in working with patients with personality disorders are discussed, as well as cultural differences that may affect the perception of boundary problems. The article ends with a list of risk management principles and recommendations for avoiding boundary problems in the therapeutic relationship.

Boundaries, blackmail, and double binds: a pattern observed in malpractice consultation.

A scenario common to several boundary violation/sexual misconduct cases is reviewed and discussed. Common features include an articulate patient whose high functionality concealed more primitive dynamics that arose in the therapy; boundary problems, often on an "attempted rescue" basis; and eventual litigation in some form. The patient's high functioning appeared to cause the therapists to underestimate the severity of the patients' disturbances. Drawing on forensic experience, the author analyses the cases and suggests risk management approaches.

Narcissistic dimensions of expert witness practice.

The authors review narcissism as it relates to expert witness practice. The review addresses stable versus unstable narcissism, normal confidence, perspective taking, the effect of flattery, the will to win, mirror transference, narcissistic excitement, narcissistic rage, narcissistic injury, and post-traumatic stress disorder (PTSD). The article closes with recommendations for resisting narcissistic pitfalls and achieving the egoless state.

Non-sexual boundary crossings and boundary violations: the ethical dimension.

The ethical principles relative to nonsexual boundary issues derive from the first principle of respect for the dignity of the patient. Using a case vignette, the authors have explored the mutual derivation and inter-relations of these principles, with clinical approaches to patient care. Clinicians should be aware of the ethical underpinnings of sound therapeutic techniques that manifest respect for the patient.

Suicide, suicide litigation, and borderline personality disorder.

In the category of malpractice liability affecting mental health practitioners of all disciplines, malpractice based on suicide is the leading claim by a significant margin. Our discussion here will be organized in two sections. First, we consider the theory, practice, and psychology of malpractice litigation itself in relation to suicide. Second, we describe how those basic principles apply to patients with borderline personality disorder.