AAPL Practice Resource for the Forensic Evaluation of Psychiatric Disability.

(Reprinted with permission from The Journal of the American Academy of Psychiatry and the Law).

AAPL Practice Resource for the Forensic Evaluation of Psychiatric Disability.

Full Document: Anfang SA, Gold LH, Meyer DJ: AAPL practice resource for the forensic evaluation of psychiatric disability. Journal of the American Academy of Psychiatry and the Law Online Supplement 2018, 46 (1). Available at: http://www.jaapl.org/content/46/1_Supplement.

Should AAPL enforce its ethics? Challenges and solutions.

Ethics enforcement in psychiatry occurs at the district branch and American Psychiatric Association (APA) levels under the guidance of American Medical Association (AMA) and APA ethics documents. Subspecialty ethics consequently have no formal role in the enforcement process. This reality challenges practitioners to work according to guidelines that may not be sufficiently relevant and challenges ethics reviewers to apply frameworks not intended for the subspecialties. This article offers the theoretical and practical support to amend APA Procedures to permit formal consideration of subspecialty ethics during ethics complaints and to include forensic practitioners on panels reviewing them. This is the first step toward an integration of two conflicting models of ethics enforcement, regulatory and aspirational, that bring together specialty and subspecialty ethics.

Peer review and psychiatric physician fitness for duty evaluations: analyzing the past and forecasting the future.

In the United States, oversight of health care practitioners is delegated to a matrix of health care entities including but not limited to the state medical board which licenses physicians in the relevant jurisdiction. Typically, these organizations have their own codes of professional conduct. When a physician joins one of these health care organizations, legally the physician has entered into a contract with the organization and agreed to be bound by its regulations and procedures. The organization's peer review of a member physician for reasons of investigating questions of health care quality may require a psychiatric fitness for duty evaluation. That assessment is a forensic psychiatric examination to assist the peer review body much as an expert witness would assist the trier of fact in a criminal or civil law adjudication. Experts can better perform these functions if they are familiar with the legal differences that define these agencies' service under administrative as compared to civil or criminal law and procedures.

"Certainty" and expert mental health opinions in legal proceedings.

This pilot study addresses the legal and scientific ramifications of the "certainty" expressed by mental health professionals when functioning as expert witnesses in criminal and civil proceedings. The sporadic attention paid to "certainty" in the professional literature has typically taken the form of general policy oriented analyses as opposed to empirical, data-driven investigations. In the current study, 25 doctoral and master's level mental health professionals were provided with 53 different statements. Some statements addressed "certainty" itself in the typical fashion (e.g., "Reasonable Degree of Scientific Certainty," "Reasonable Degree of Medical Certainty," and "Reasonable Degree of Psychological Certainty"). Other statements were confined to specifically legal standards of proof (e.g., "Beyond a Reasonable Doubt," "Preponderance of the Evidence," and "Clear and Convincing"). Additional statements included those that bore at least some direct forensic relevance (e.g., "Based upon All the Data at My Disposal," "In My Medical Opinion," and "In My Clinical Judgment"), as well as those of a non-forensic nature (e.g., "I Would Bet My Life Savings," "On My Word of Honor," and "I Am Personally Convinced"). Ratings were provided on one form as if the participant had uttered the statement, and on another form as if another expert witness had uttered the statement. Overall, participants did not tend to identify traditional legal terms as expressing the highest level of "certainty," and respondents tended to ascribe more "certainty" to the same terms when uttered by themselves as opposed to when uttered by other expert witnesses. Those providing forensic testimony will do well to accommodate the court's traditional requirements while developing and preparing to justify their own notions of just what "certainty" denotes in this context.

Peer review committees and state licensing boards: responding to allegations of physician misconduct.

Although physicians tend to be more concerned about malpractice actions, adjudication of complaints of alleged physician misconduct by peer review organizations and state licensing authorities can have equally serious consequences. Unlike medical malpractice, no patient injury is necessary to support the claim of alleged misconduct. Unlike malpractice, in which a plaintiff must be the injured party, in administrative peer review, colleagues, family members, and patients may all qualify as potential complainants. Unlike malpractice, where the standard of care is what the average prudent practitioner would be expected to do in similar circumstances, in peer review, the standard of care is the code that the organization has endorsed and to which the individual practitioner has agreed by choosing to join the organization. Forensic psychiatrists who may serve either as experts for a peer review or state board investigation or as peer review committee members must understand the legal foundation of the process and the attendant psychological and sociopolitical forces affecting the different parties.

Commentary: legislators how did the deciders decide? Who shall serve as their experts?

Weisleder presents a retrospective empirical inquiry into the decision tree of state legislators who chose the age at which minors could consent to substance abuse treatment in their respective jurisdictions. Current medical practices and the developmental research into the cognitive capacities of adolescents did not figure prominently. Readers, including current and future political advocates, are provided with an informed window into the political processes of the making of a law that affects the practice of medicine. Weisleder is reminded that politics and science are uncomfortable bedfellows.

Molecular diagnostics in sepsis: from bedside to bench.

BACKGROUND: Based on recent in vitro data, we tested the hypothesis that microarray expression profiles can be used to diagnose sepsis, distinguishing in vivo between sterile and infectious causes of systemic inflammation. STUDY DESIGN: Exploratory studies were conducted using spleens from septic patients and from mice with abdominal sepsis. Seven patients with sepsis after injury were identified retrospectively and compared with six injured patients. C57BL/6 male mice were subjected to cecal ligation and puncture, or to IP lipopolysaccharide. Control mice had sham laparotomy or injection of IP saline, respectively. A sepsis classification model was created and tested on blood samples from septic mice. RESULTS: Accuracy of sepsis prediction was obtained using cross-validation of gene expression data from 12 human spleen samples and from 16 mouse spleen samples. For blood studies, classifiers were constructed using data from a training data set of 26 microarrays. The error rate of the classifiers was estimated on seven de-identified microarrays, and then on a subsequent cross-validation for all 33 blood microarrays. Estimates of classification accuracy of sepsis in human spleen were 67.1%; in mouse spleen, 96%; and in mouse blood, 94.4% (all estimates were based on nested cross-validation). Lists of genes with substantial changes in expression between study and control groups were used to identify nine mouse common inflammatory response genes, six of which were mapped into a single pathway using contemporary pathway analysis tools. CONCLUSIONS: Sepsis induces changes in mouse leukocyte gene expression that can be used to diagnose sepsis apart from systemic inflammation.

Psychiatry malpractice and administrative inquiries of alleged physician misconduct.

Practicing psychiatrists face a range of professional liability from malpractice litigation and from inquiries and hearings conducted by health care agencies. The causes of an action and the standards by which physician conduct is measured vary widely between these two processes. Many psychiatrists do not appreciate sufficiently the gravity of the risks they may face from an administrative sanction. Understanding the legal and administrative expectations of practicing psychiatrists serves practitioners' professional risk management. Those psychiatrists who choose to participate as expert witnesses for courts or administrative agencies need to familiarize themselves with the applicable legal standards and the respective roles of experts in these two different settings. The courts and administrative agencies have different social missions and correspondingly differing expectations of the expert opinions admitted.An expert's function as educator about the application of psychiatric knowledge and treatments to legal contexts is optimized when that expert clearly understands the function of the opinion that is sought. As educators about special knowledge to the adjudicating body, experts are advocates for their objectively generated and scientifically grounded opinion. Psychiatry is increasingly under the purview of regulations from multiple sources private and public. This article has reviewed medicolegal concepts and terms of psychiatrists' exposure to liability from a comparative point of view. Familiarity assists psychiatrists in navigating the complex legal arena in which they practice and provides a foundation for psychiatrists to work to change the multitude of laws and regulations when doing so is in the best interests of their patients and of their discipline of medicine.

Forensic psychiatric assessments of behaviorally disruptive physicians.

Forensic psychiatrists may be requested by a wide range of agencies and committees to assess physicians alleged to be behaviorally disruptive. Many of the adjudicatory procedures and questions of these agencies differ substantially from the familiar ones in civil litigation. Proximate cause and patient harm are not essential elements of the forensic questions raised by these health care agencies. In addition to assessing past professional conduct, the examiner is asked to opine about the examinee's present and future professional health and fitness for duty and what treatment or professional supervision, if any, may be needed to ensure the continuance of those professional capacities.