Psychological testing for physicians; ethics of discounting

Scenario: Should psychological testing be required to practice medicine?

Many public service positions require that applicants and employees complete psychological testing. Why do physicians not have such requirements? Should medical students undergo psychological tests before graduating? Should such tests be instituted for physicians to hold a license?

Reply:

In order to provide effective patient care, physicians must possess strong psychological adaptive and coping capabilities. These skills allow physicians to apply their medical knowledge, deal with the stresses of the profession, and communicate with patients, peers and staff.

As part of a forthcoming report, Colorado Personalized Education for Physicians analyzed data from a population of practicing physicians who had been referred for an evaluation of their clinical competence between 1996 and 1998.

Physicians are usually required to participate in CPEP's program because their clinical knowledge and decision-making have come in question. However, 8% of physicians in this cohort had been sent to the program for a complete, structured assessment because of problems with their behavior. Behavioral concerns, such as inappropriate professional interactions with colleagues, ethical or sexual misconduct, were a secondary issue for 39% of the referred physicians. These data confirm that psychological functioning is an important consideration for the practice of medicine. Problems in this area can have a long-term impact on all aspects of a physician's professional career.

Testing psychological function is a complex process that occurs at various stages.

Diagnostic testing is used to determine the cause of observed problems and can serve to direct treatment.

Requiring physicians to complete a psychological test prior to training or licensure constitutes screening and is used to identify individuals who will not be allowed to continue in a job because they have failed the screening test. This assumes that there is a threshold with a logical connection to the abilities, attitudes and skills needed for the work.

It is our opinion that psychological screening tests in medical school or prior to licensure would be unjust, of little benefit and possibly harmful. Given the extended education that physicians receive in medical school and postgraduate training, comprehensive observation and educational processes would be superior to a screening examination.

In particular, behavioral competence of physicians-in-training can be assessed by observation in a number of clinical settings. Educational institutions generally should be able to provide ways for trainees to improve when skills need to be upgraded.

Unfortunately, some physicians with behavioral skills deficits do manage to go on to practice medicine, rekindling arguments for psychological screening.

We suggest an alternative solution that would help assure public safety and encourage physician diversity. Medical schools and postgraduate programs are already working to include methods for evaluating behavior and psychological aptitude during training. Many schools and programs are expanding their curricula to better address and verify communication skills, professional behavior, and psychological stability.

A number of medical training programs use personality profiles or some psychological testing. However, tests do not measure actual behavior. Training programs need to be accountable and ensure that graduates have the necessary skills and abilities for all aspects of medical practice.

As to psychological screening tests, they do not reflect the complex interaction of skills needed for the practice of medicine.

Physicians must have the medical knowledge necessary to practice. But, knowledge alone is not enough. Physicians also must be able to organize knowledge, problem solve on their patients' behalf and excel in both written and verbal communication. These complex and interwoven factors in physician performance are influenced by genetic heritage, life experiences, current stresses, illness or impairment, professional network or connections, values, priorities and practice environment.

If there were a comprehensive psychological screening test for medical students, then the community could potentially benefit by the exclusion of psychologically unfit students who are at high risk to become unfit physicians. But both individuals and the public would occasionally be harmed when the exclusion was not justified. Some individuals would not be allowed to become doctors because they did not fit a preconceived pattern.

We cannot assert with reliability just what kind of person, with what psychological profile, should practice medicine.

In fact, different specialties vary in their demands. For example, the skills required of a family physician differ from those required of an interventional radiologist. If a screening test were instituted without evidence for its use or reasonable expectations that it was a successful predictor of professional behavior, there might be no benefit and much potential for harm.

Medicine is in the midst of a culture shift. Together, the Pew Commission report of 1998, the American Board of Medical Specialties/American Council on Graduate Medical Education requirements of 2001, and the AMA Principles of Medical Ethics call for professionalism, ongoing competency-based evaluations, and attention to human factors. But psychological screening tests cannot effectively identify and accomplish what can and must be observed throughout the long educational process.

To maintain diversity and recognize the unique skills needed for various practice specialties, medical schools, residencies and professional organizations will continue to be the most effective means of ensuring public safety.

--Martha Illige, MD, Joel Dickerman, DO, Clydette Stulp de Groot, EdD, Debbie Waugh Colorado Personalized Education for Physicians, Aurora, Colo.

Scenario: Is it ethical to discount fertility services in exchange for donations?

At some fertility clinics, patients may be offered a substantial discount if they agree to donate unused eggs or embryos that remain at the end of a treatment cycle. We invited an expert on ethical issues in reproductive medicine to comment on the concerns raised by such agreements.

Reply:

The ethical and legal acceptability of fertility clinics offering discounts in exchange for unused eggs or embryos hinges on how this practice is implemented.

As explained more fully below, if fertility procedures are not affected by the prospect of "extra" eggs or embryos, and if the progenitors' donation decisions are fully informed and voluntary, the discounts may be an acceptable means for enhancing access to infertility services and/or promoting research.

For the most part, ethics literature, court cases and statutory law affirm that the gamete provider maintains dispositional authority with respect to sperm and eggs, and that decisions about the disposition of unused embryos should be made jointly by the gamete providers.

Accordingly, couples seeking infertility treatment frequently are asked to execute a written agreement in which they specify, in advance, a choice from among a variety of possible uses of their spare, cryopreserved embryos, including donation for research purposes or for "adoption" by other infertile couples.

If the choice of donation for research or for "adoption" by other infertile couples comes with a discount on fertility service fees, several conditions should be satisfied to assure protection of patients' health interests and decision-making rights.

First, optimal fertility treatment, not the prospect of donation, must determine the number of eggs extracted and embryos produced. Women undergoing infertility treatment, from whom eggs are extracted via a minor surgical procedure, must first take hormones in order to stimulate their ovaries to produce sufficient numbers of eggs suitable for fertilization and subsequent implantation. Their treatment, which subjects them to risks, must not be influenced by the interests of researchers or other infertile couples who may benefit from donated unused eggs or embryos.

Second, the amount of the discount must be reasonable.

An excessive financial incentive might tempt some individuals to lie about their medical or genetic history, or it might become an undue inducement that compromises the voluntariness of the donor's decision. (In addition, to avoid legal complications, discounts for unused embryos should be characterized as compensation in return for the donor's services -- i.e., for the time, discomfort, inconvenience and risks undertaken -- as opposed to compensation for the embryo itself.)

Third, the progenitors must be fully informed about the use to which their eggs or embryos will be put.

The ethical principle of autonomy, or respect for persons, requires that decision-making is not only voluntary but also fully informed. It is likely that the option of a discount on expensive fertility services will be attractive to many infertile couples. Before they choose that option, in order to assure that their decisions about the disposition of their unused eggs and embryos are truly autonomous, they must be thoroughly informed about how their "donated" eggs or embryos will be used.

Rapid progress is sweeping through reproductive medicine, a field that is remarkably insulated from regulation in this country. In this environment, voluntary guidelines are critical to protect against abuses. With these described protections in place, discounts on fertility services in exchange for donation of unused embryos or eggs may appropriately further important research and/or promote the reproductive interests of infertile individuals and couples.

--Robyn Shapiro Director of the Medical College of Wisconsin's Bioethics Center, Ursula Von der Ruhr Professor of Bioethics, and partner at the law firm Michael, Best and Friedrich