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Title: Competency Problems: Managing Performance, Attitudinal, Ethical, and Legal Issues with Interns and P


1
Competency Problems Managing Performance,
Attitudinal, Ethical, and Legal Issues with
Interns and Postdoctoral Fellows
  • Nadine Kaslow, Ph.D., ABPP, APPIC Past-ChairJeff
    Baker, Ph.D., ABPP, APPIC Vice-Chair/CoA Rep
  • Mona Koppel Mitnick, JD, APPIC Public Member

2
ACKNOWLEDGE PROBLEM STUDENT WORKGROUP
  • Nadine Kaslow, Ph.D. Sue Jacobs, Ph.D
  • Nancy Rubin, Ph.D. David Miller
  • Stephen Behnke, Ph.D. Laurie Mintz, Ph.D.
  • Sherry Benton, Ph.D. Victor Pantesco, Ph.D.
  • Steve Dollinger, Ph.D. Rebecca Schwartz-Mette
  • Nancy Elman, Ph.D. Craig Shealey, Ph.D.
  • Linda Forrest, Ph.D. Beverly Thorn, Ph.D.
  • Catherine Grus, Ph.D. Barbara Van Horne, Ph.D.
  • Steven Huprich, Ph.D. Kristi Van Sickle

3
GUIDING PRINCIPLE 1
  • Define key terms (competence, competencies,
    capability, impairment, benchmarks), establish
    benchmarks for performance, and develop a
    categorization schema

4
COMPETENCE
  • Personal ability, adequacy, capability, capacity,
    efficacy, efficiency, and proficiency

5
COMPETENCE
  • Habitual and judicious use of communication,
    knowledge, technical skills, reasoning, emotions,
    values, and reflection in daily practice for the
    benefit of the individual and community being
    served that involves habits of mind, critical
    thinking and analysis, professional judgment in
    assessing situations and ascertaining appropriate
    responses, and evaluating and modifying decisions
    via reflective practice
  • (Epstein Hundert, 2002)

6
COMPETENCIES
  • Knowledge, skills, and attitudes, and their
    integration
  • Correlate with performance
  • Can be enhanced through training and development

Attitudes
Knowledge
Skills
7
CAPABILITY
  • Extent to which individuals can adapt their
    skills, generate new knowledge, improve their
    performance, and engage in life-long learning
  • Fraser Greenhalgh, 2001

8
IMPAIRMENT
  • Historically, has described interference in
    professional functioning associated with
    substance use, mental illness, or personal
    conflict

9
IMPAIRMENT
  • Recently, characterized as a condition that
    interferes with professional functioning to the
    extent it negatively impacts clients/patients or
    makes effective service delivery impossible
  • APA Board of Professional Affairs Committee on
    Colleague Assistance, 2006

10
IMPAIRMENT
  • Impairment has a specific meaning in the context
    of the ADA (medical or mental health disability)
    and thus legal implications ensue for its use
  • Some trainees with competence problems also have
    impairments according to the ADA

11
BENCHMARKS
  • Reflect standard for measurement of performance
    that can be used for comparison and to identify
    where needs for improvement exist
  • Connote task or performance indicators
  • Can capture minimal level of each competency for
    each stage of professional development

12
COMPETENCE PROBLEMS
  • Indicate interference in professional functioning
  • Can be observed though maladaptive patterns of
    behavior or performance or via critical incidents
  • May occur when performance fails to meet expected
    benchmarks, repeat patterns of mistakes occur, or
    as acquired incompetence or impairment in the
    form of diminished functioning

13
COMPETENCE PROBLEMS
  • Can be categorized based on
  • Origin (situational, developmental, problematic
    personality and interpersonal dynamics)
  • Severity and chronicity
  • Potential for remediation
  • Manifestation

14
COMPETENCE PROBLEMS
  • May be exhibited when individuals
  • Do not have adequate training, education, or
    experience opportunities
  • Are unable to acquire professional skills and
    reach an accepted level of competency
    (performance problem)
  • Are unable or unwilling to acquire and integrate
    professional standards into their behavior
  • Fail to respond to feedback or remediation
    efforts
  • Do not continuously grow, change, or make
    progress

15
COMPETENCE PROBLEMS
  • May be exhibited when individuals
  • Lack self-awareness with regard to weaknesses
  • Have problems with professionalism and/or
    interpersonal interactions
  • Exhibit prejudicial attitudes and values
  • Lack high levels of integrity
  • Have personal problems, emotional reactions, or
    distress that they are unable to control and that
    affect their professional functioning (conduct or
    emotional problem)

16
COMPETENCE PROBLEMS
  • Insufficient professional competence can be
    manifested in foundational competencies, such as
  • Errors in judgment, ethicality, and
    professionalism (e.g., boundary violations)
  • Maladaptive interpersonal attributes
  • Problematic character or fitness
  • Lack of self-awareness of areas of weakness
  • Lack of progress toward achieving benchmarks
  • Lack of response to feedback

17
COMPETENCE PROBLEMS
  • Insufficient professional competence can be
    manifested in functional competencies, such that
    people do not exhibit the expected level of
    knowledge, skills, and attitudes in one or more
    domains

18
PERSONAL RISK FACTORS
  • History of childhood trauma
  • Substance use disorders
  • Major Axis I disorder
  • Axis II disorder
  • Interpersonal insensitivity
  • History of parentification
  • Wounded healer
  • False self
  • Difficulties with attachment and
    separation-individuation

19
PROFESSIONAL RISK FACTORS
  • Prejudicial attitudes and values
  • Difficulties managing multiple roles
  • The role requirement for heightened sensitivity
    to people and the environment
  • Isolation in the work place
  • Vicarious traumatization and compassion fatigue
  • Lack of time for self-care
  • Limited capacity for self-reflection and
    self-assessment

20
COMPETENCE PROBLEMS
  • Do not include a trainees behavior, attitudes,
    or characteristics that are developmentally
    normative, such as
  • Transition issues
  • Mild performance anxiety
  • Mild discomfort with diverse client groups
  • Initial lack of understanding of the facilitys
    norms
  • Lack of certain skills sets, but an openness and
    readiness to acquire them

21
CONTEXT
  • Identification of a trainees behavior as
    reflecting competence problems needs to take the
    context into account
  • Key to assess if trainee difficulties reflect a
    mismatch between the
  • Philosophy of the site and the trainees
    orientation
  • Skills and competencies of the trainee and the
    demands of the site

22
CONTEXTUAL FACTORS
  • Contextual factors in the life of the trainee
    need to be considered
  • Adjustment issues to new setting (not site)
  • Adjustment to new site
  • Separate from established support systems
  • Status change
  • Personal life events/changes
  • When the aforementioned issues appear salient,
  • Suggest options for better stress management and
    self-care
  • Provide more support to the trainee

23
GUIDING PRINCIPLE 2
  • Prepare the system so that decision-makers
    undertake appropriate assessment processes and
    make and communicate assessment decisions

24
CHALLENGES IN EVALUATING TRAINEES (Gizara
Forest, 2004 Robiner, 1993)
  • Definition and Measurement Issues
  • Lack of clear criteria and objective measures of
    and competence problems
  • Supervisor awareness of subjectivity inherent in
    evaluation
  • Apprehension about defending evaluations due to
    lack of clear criteria and objective measures

25
EVALUATION CHALLENGES
  • Legal and Administrative Issues
  • Concern that negative evaluations may result in
    administrative inquiry, audit, grievance, or
    litigation
  • Lack awareness of internship/residency or
    institutional policies and procedures involved in
    negative evaluations
  • Concern about lack of support from administrators
    and colleagues
  • Concern that failing to pass an intern/resident
    may result in loss of future training funds or
    slots or the need to find additional funds to
    extend the trainees training
  • Concern that failing to pass an intern/resident
    may result in adverse publicity that could affect
    institutional reputation and number of applicants

26
EVALUATION CHALLENGES
  • Interpersonal Issues
  • Fear of diminishing rapport or provoking
    hostility from supervisees
  • Fear of eliciting backlash from current or future
    trainees
  • Anguish about damaging a supervisees career or
    complicating or terminating their graduate
    training (in the case of an intern)

27
EVALUATION CHALLENGES
  • Supervisor Issues
  • Lack preparation for the evaluative components of
    supervision
  • Wish to avoid scrutiny of their own behavior,
    competence, ethics, expectations, or judgment of
    their clinical or supervisory practices
  • Have limited supervisory experience with trainees
    with competence problems
  • Have difficulties in imparting negative
    evaluations
  • Indifferent to personal responsibility for
    upholding the standards of the profession
  • Display inappropriate optimism that problems will
    resolve without intervention

28
EVALUATION CHALLENGES
  • Supervisor Issues (cont.)
  • Prefer to avoid the substantial energy and time
    commitment necessary to address or remediate the
    behavior of interns and residents with competence
    problems
  • Have discomfort with gatekeeper role
  • Identify with supervisees problems
  • Pay inadequate attention to supervisees
    performance or problems
  • Presume supervisee competence
  • Minimize supervisees problem behavior

29
POLICIES AND PROCEDURES
  • Policies and practices need to
  • Be consistent with local and national
    professional, ethical, and legal standards, yet
    tailored to the program
  • Be communicated clearly and explicitly to
    trainees and others
  • Include knowledge, skills, and attitudes defined
    as professional behaviors and performance
  • Delineate minimal acceptable standards of
    professional performance and criterion signaling
    need for remediation and/or dismissal
  • Convey clear expectations
  • Give trainee a time-limited opportunity to
    improve
  • Be understood to everyone in the system
  • Articulate defensible practices for assessing
    competence

30
DUE PROCESS GUIDELINES
  • Create in a fashion that is simple and easy to
    understand
  • Communicate in writing and orally to each
    intern/post doc at outset of training
  • Apply uniformly and in a timely fashion to all
    trainees exhibiting competence problems
  • Apply to all serious performance, conduct,
    attitudinal, and ethical problems

31
DUE PROCESS PROVISIONS
  • Describe types of problems and behavior covered,
    which should be broad enough to cover all
    performance, conduct, attitudinal, and ethical
    deficiencies, and combination of deficiencies
  • Describe persons covered, making clear that all
    trainees are covered
  • State the time limits at different stages of the
    process, and whether and for what reasons time
    limits may or may not be waived

32
DUE PROCESS PROVISIONS
  • Offer informal and formal procedures for
    notifying about deficiencies and penalties,
    correcting deficiencies, and appealing
    dissatisfaction with the programs compliance
    with the procedures
  • Identify clearly at each stage the decision maker
    and the contents of the decision
  • State clearly at each stage whether and to whom
    the complainant or training program official may
    appeal the decision
  • Note when decision becomes final

33
GUIDING PRINCIPLE 3
  • Cultivate self-assessment capacity for learning
    and responding to feedback for the purpose of
    identifying and addressing competence challenges
    and preventing competence problems

34
VALUE OF SELF-ASSESSMENT
  • Reflective practice/self-assessment is a
    foundational competence and needs to be taught
    and encouraged
  • Lacking the capacity to self-assess is tantamount
    to failing to attain professionalism, missing the
    skill of thinking like a psychologist, and being
    insulated against self-corrective behavior

35
CULTURE OF SELF-ASSESSMENT
  • Must provide training in self-assessment that is
    bolstered by concurrent monitoring and feedback
    from other informants and that offers assistance
    in incorporating and integrating input from
    multiple sources
  • Training should emphasize developing the capacity
    to examine issues that elicit discomfort to
    master experiences and reduce negative
    performance impact

36
CULTURE OF SELF-ASSESSMENT
  • Cultivating a climate of trust and help-seeking
    among supervisors, mentors, and colleagues
    reduces tension that often occurs when addressing
    competency problems and this climate requires
    empathy, concern, and respect for others, and is
    best achieved if evaluators assess fairly and
    empathically

37
GUIDING PRINCIPLE 4
  • Implement remediation strategies to enhance
    performance and evaluate in a systematic fashion
    that is balanced in terms of reliability and
    authenticity and designed to maximize learning,
    and utilize gatekeeping functions when indicated

38
FULL DISCLOSURE
  • Inform trainees at outset that competence will be
    comprehensively assessed in an ongoing fashion
  • Provide
  • Rationale for such assessment
  • Specifics of assessment system
  • Implications or usage of assessment information

39
METHODS OF EVALUATION
  • Consider relevance, fidelity, authenticity, and
    validity
  • Use direct observation in actual or simulated
    situations for skills and attitudes
  • Use multiple samples of behavior, multiple
    evaluators, and multiple methods over time

40
FORMATIVE AND SUMMATIVE EVALUATION
  • Formative evaluations
  • Ongoing and regular performance feedback at
    specified intervals
  • Critical in measuring and remediating competence
    problems
  • Guide the development of learning objectives in a
    remediation plan based on strengths and
    weaknesses
  • Global rating scales, portfolios, 360 degree
    evaluations

41
FORMATIVE AND SUMMATIVE EVALUATION
  • Summative evaluations
  • Measure endpoints or outcomes
  • Less well-suited for guiding the remediation
    process
  • Can determine success (or failure) of a
    remediation
  • Both summative and formative methods need to be
    employed in situations of competence problems

42
PROCESSES ASSOCIATED WITH COMPETENCE PROBLEMS
(Lamb et al., 1991)
  • Setting the Stage
  • Orientation
  • Communicate sites expectations about
    professional standards, skill competency,
    personal functioning
  • Communicate about evaluation guidelines and
    processes
  • Provide Due Process Guidelines

43
PROCESSES
  • Reconnaissance and Identification
  • Gather on-going evaluative information and
    observe the trainees initial response to the
    setting, training experience, and feedback
  • Discuss among all training faculty/staff
  • Identify areas of concern orally and in writing
    express concerns as hypotheses and define problem
    behaviors in concrete and specific terms
  • Monitor early and continuously
  • This process often is enough to manage many
    problems

44
PROCESSES
  • Discussion and Consultation
  • Hold discussions among all training personnel
    when problems persist regarding other
    interventions and next steps
  • Consider
  • Actual behaviors of concern (e.g., nature,
    frequency, severity)
  • Settings that behaviors occur in
  • Negative consequences of the behaviors
  • Trainees response to feedback

45
PROCESSES
  • Implementation and Review
  • Implement remediation plans
  • Review progress and response to interventions
  • Communicate with all relevant parties
  • Provide ongoing feedback
  • Document all problem behaviors and changes in
    behavior
  • Hold ongoing meetings of faculty/staff for review
  • Consult with other training personnel
  • Consider possible alternative actions
  • Seek external consultation

46
PROCESSES
  • Anticipating and Responding to Organizational
    Reaction in Cases of Termination
  • Support trainee and help him/her consider
    alternatives
  • Support training personnel
  • Determine how to communicate what and to whom
    (e.g., other current and future trainees, staff)
  • Manage clinical services

47
PROCESSES
48
REMEDIATION PLANS
  • Implement to assist the individual in gaining the
    requisite competence and to avoid gate-slipping
  • Craft a written document with a constructive and
    educative tone
  • Identify specific deficits and relate these to
    previously communicated benchmarks

49
REMEDIATION PLANS
  • Delineate explicitly expectations for
    improvement, including
  • Contexts in which the behaviors occur
  • Level at which sufficient competence will have
    been deemed to have been achieved
  • Projected time line for the achievement of the
    objective and/or re-evaluation of both the
    competence and plan efficacy
  • Present objectives, followed by descriptions of
    the training methods for achieving the objective,
    as well as roles and responsibilities for all
    parties and for the institution (if applicable)

50
REMEDIATION PLANS
  • Incorporate one or more strategies to remediate
    problems
  • Increase supervision, either with the same or
    other supervisors
  • Change the format, emphasis, and/or focus of
    supervision
  • Reduce and/or shift the trainees workload
  • Require specific academic coursework
  • Provide additional mentoring
  • Recommend personal psychotherapy

51
REMEDIATION PLANS
  • Incorporate one or more strategies to remediate
    problems
  • Recommend, when appropriate, a leave of absence
    and/or a second internship or residency
  • Collaborate with the graduate department on the
    remediation plan in accord with the CCTC
    Communication Guidelines

52
REMEDIATION PLANS
  • Personal Psychotherapy
  • Convey that therapy may help with understanding
    why issues reflect competency problems or
    overcoming the psychological barriers that hinder
    the making of required changes
  • Consider ethics and due process rights in
    ascertaining if a referral is appropriate

53
REMEDIATION PLANS
  • Personal Psychotherapy
  • Be mindful of informed consent, avoid dual
    relationships, attend to cultural background, use
    qualified providers, clarify confidentiality,
    tend to financial concerns, and clarify the
    manner in which therapy contacts will be used in
    the evaluation process
  • Establish written plans regarding recommending
    psychotherapy and strategies for evaluating the
    outcomes of personal psychotherapy

54
REMEDIATION PLANS
  • Use measures and methods of assessment of
    competence problems that complement and can be
    integrated into such plans (e.g., behavioral
    observations, review of work samples)
  • View objectives, assessment, training, and
    evaluation as a continuous process
  • Discuss and agree upon the plan

55
FORMAL ACTIONS
  • When a combination of the above interventions do
    not, after a reasonable time period, rectify the
    problem, or when the trainee seems unable or
    unwilling to alter his/her behavior, the program
    may need to take more formal action in accord
    with their due process guidelines

56
FORMAL ACTIONS(Lamb et al., 1991)
  • Probation
  • In writing,
  • Identify specific behaviors or areas of
    professional functioning of concern
  • Relate these behaviors to written evaluations
  • Provide specific ways deficiencies can be
    remedied
  • Identity specific probationary period
  • Stipulate how functioning will change at site
    during probation, of applicable
  • Reiterate the availability of due process
    procedures

57
FORMAL ACTIONS
  • Give the trainee a limited endorsement, including
    the specification of those settings in which
    he/she could function adequately
  • Terminate the trainee from the program and
    communicating this to the appropriate parties
  • Recommend and assist in implementing a career
    shift for the trainee
  • All of the above steps need to be documented
    appropriately and implemented in accord with the
    due process guidelines

58
TERMINATION(Lamb et al., 1991)
  • Steps to take prior to notifying trainee
  • Review agency and institutional implications of
    the decision
  • Determine how and when the trainees status will
    change at the site
  • Review proposed action and corresponding written
    statement in consultation with relevant internal
    and external parties
  • Consult with legal counsel at the facility
  • Notify up the chain of command

59
TERMINATION
  • Once these steps have been taken
  • Hold meeting between the trainee and relevant
    training and site personnel
  • Inform trainee of the decision
  • Provide a written statement to trainee and other
    relevant parties reiterating probationary
    conditions, trainees response, and reasons for
    dismissal
  • Provide statement of revised responsibilities
  • Remind trainee of due process guidelines and
    appeal options

60
GUIDING PRINCIPLE 5
  • Consider the impact of beliefs, values, and
    attitudes about individual and cultural
    differences on decisions regarding problem
    identification, assessment, and intervention

61
DIVERSITY AND COMPETENCE PROBLEMS
  • Must attend to diversity in remediation and
    dismissal to not perpetuate divergence between
    cultural and professional norms
  • Must be cognizant of the role that individual and
    cultural differences may play in identification
    or action taken with students perceived as having
    competence problems

62
DIVERSITY AND COMPETENCE PROBLEMS
  • Be mindful of over- or under-identifying
    problematic behavior due to
  • Cultural naivete
  • Fear of appearing racist or sexist
  • Difficulty addressing the complexity in the
    intersection of cultural difference and
    competence problems
  • Inverted positional power
  • Differential standards based on bias
  • Fear of litigation

63
GUIDING PRINCIPLE 6
  • Communicate across levels of training,
    professional organizations, and credentialing
    boards as appropriate

64
ETHICAL ISSUES
  • Supervisors should outline their roles at the
    outset of supervision, which aids in the building
    of trust relationships (Principle B Fidelity
    and Responsibility)
  • Supervisors should define a trainees areas of
    growth and make clear that their behavior
    (positive and negative) is fair game for
    evaluation within supervision and for reports to
    training programs
  • Respect for student rights is important and
    judicious, balanced, thoughtful communications
    are essential

65
LETTERS OF RECOMMENDATION
  • Tendency to inflate letters of recommendation,
    despite the fact that the receiver of letters
    want truthful and complete evaluations
  • May want to consider adopting the CCPPP
    guidelines for competency-based letters that ask
    for attention to core competencies, skills (work,
    communication, interpersonal), personal
    resources, and professional conduct, as well as
    areas for growth and development

66
INCREASED COMMUNICATION
  • More frequent and direct communication across
    levels (e.g., graduate school internship) is
    desirable
  • Graduate schools and internship trainers should
    collaboratively address students insufficient
    professional competence

67
GUIDING PRINCIPLE 7
  • Maximize transparency through the identification
    and communication of limitations to the
    individuals rights to privacy and confidentiality

68
ETHICAL, LEGAL, REGULATORY STANDARDS
  • Limitations to individuals rights to privacy and
    confidentiality need to be publicly identified in
    advance of any actions and must be appropriate
    and sensitive to ethical, legal, and regulatory
    standards
  • Family Educational Rights and Privacy Act (FERPA)
  • Americans with Disabilities Act (ADA)
  • Health Insurance Portability and Accountability
    Act (HIPAA)

69
ETHICAL, LEGAL, REGULATORY STANDARDS
  • APA Ethics Code provides guidance on the
    conditions under which students may be required
    to disclose personal information (i.e., program
    identifies in its materials when such an
    exception might occur and the information is
    needed to evaluate or obtain assistance for
    students whose personal problems may prevent them
    from competently performing or pose a threat to
    others (7.04)

70
ETHICAL, LEGAL, REGULATORY STANDARDS
  • Appropriate use of confidentiality should not
    interfere with sufficient assessment and
    intervention
  • Limits on confidentiality protect the public and
    the profession
  • Profession needs to distinguish between real and
    presumed constraints on confidentiality that
    apply to the training of psychologists

71
TRANSPARENCY
  • Enhancing transparency measures we should not use
    the cloak of confidentiality to create barriers
    to assessing and remediating competence problems
  • When problematic professional behavior
    jeopardizes professional standards, the right to
    confidentiality needs to be limited due to
    substantial consequences to the public and
    profession
  • When rights to confidentiality conflict with
    professional standards, confidentiality
    automatically becomes limited

72
CONFIDENTIALITY INTERVENTION
  • Concerns about protecting the confidentiality of
    individuals with competence problems frequently
    contribute to a failure to intervene in a way
    that prevents or remediates problems until they
    are severe and/or have caused harm
  • When psychotherapy is part of remediation,
    assumptions about confidentiality often keep key
    information from being usable in remediation
    outcomes (not necessary for specific information
    to be disclosed, but attestations of gains in
    understanding and modifying professional
    competence are helpful)

73
CONFIDENTIALITY INTERVENTION
  • Ethics Code addresses
  • Balance between concerns about privacy and due
    process rights and need for accountability to
    protect the profession and the public
  • Fact that students do not have to disclose
    personal information unless it is a program
    requirement or the information is needed to
    ensure competent functioning
  • Fact that if therapy is mandated then students
    can opt for therapists unaffiliated with the
    program and that those who evaluate students can
    not serve as their therapists

74
CONFIDENTIALITY INTERVENTION
  • Consider (Behnke et al., 2003)
  • Law of no surprises people are informed in
    advance what will be disclosed and to whom
  • Parsimony principle What is disclosed is
    limited to what is required to achieve the
    purposes of the disclosure (i.e., issues related
    to professional competence and only to those who
    need to know)

75
CONFIDENTIALITY INTERVENTION
  • Concerns about protecting the confidentiality of
    individuals with competence problems frequently
    contribute to a failure to intervene in a way
    that prevents or remediates problems until they
    are severe and/or have caused harm
  • When psychotherapy is part of remediation,
    assumptions about confidentiality often keep key
    information from being usable in remediation
    outcomes

76
GUIDING PRINCIPLE 8
  • Ethical, regulatory, and legal implications must
    be considered

77
ETHICS
  • Competence is the cornerstone of ethics (APA
    Ethics Code)
  • Only by practicing in a competent manner can one
    fulfill the 1st principle (Beneficence and
    Nonmaleficence)
  • Psychologists strive to benefit those with whom
    they work and take care to do no harm
  • Psychologists provide benefit and avoid harm by
    being competent at what they do conversely,
    incompetence increases the risk of harm and
    minimizes the likelihood of benefit

78
REGULATIONS
  • Competence is central to the regulations of many
    jurisdictional psychology boards
  • Regulations emphasize competence in 3 ways
  • Set forth the conditions by which to determine if
    applicants for licensure have achieved the
    necessary competence to practice independently
  • May provide continuing education requirements for
    maintenance of competence and identify areas for
    specific attention
  • Dictate the adjudicatory processes that govern
    allegations of incompetence in the provision of
    services and the consequences that follow when
    psychologists fall below the necessary standard
    of competence

79
LEGAL IMPLICATIONS
  • Actions in malpractice or negligence lawsuits are
    based upon breach in the standard of care
  • Psychologists owe a duty to their
    clients/patients to exercise reasonable care
    (legal gold standard)
  • When psychologists fall below the standard and
    cause harm, they may be liable in malpractice
    actions
  • To practice in an incompetent fashion would be to
    fall below the standard of care

80
LEGAL IMPLICATIONS DISABILITY ISSUES
  • A great deal of confusion has arisen among
    interns/postdoctoral residents and their sites
    /programs as to what constitutes disability, as
    defined by the Rehabilitation and Americans with
    Disabilities Acts and what, if any, obligation
    an internship/program site has to provide
    reasonable accommodation to an applicant or an
    intern/postdoc after selection

81
CLAIMING AND PROVING DISABILITY
  • Qualified
  • Responsibility for Determination
  • Toyota vs. Williams
  • Rehabilitation Act or ADA
  • Correctible

82
ACCOMMODATION
  • When and to What Extent Reasonable Accommodation
    is Required
  • Reasonable Accommodation
  • Establish Meeting the Definition

83
HANDICAP DISCRIMINATION
  • Avoiding a Successful Claim of Handicap
    Discrimination

84
REFERENCES
  • Rehabilitation Act of 1973, as amended (29 U.S.C.
    sec. 791 et seq. and Americans with
    Disabilities Act of 1990 (ADA (42 U.S.C. sec.
    12101 et seq. 29 C.F.R. sec. 1630 1997 EEOC
    Enforcement Guidance on the Effect of
    Representations Made in Applications for Benefits
    on the Determination of Whether a Person Is a
    "Qualified Individual with a Disability" Under
    the Americans with Disabilities Act of 1990 (ADA)
    (Feburary 12, 1997) Enforcement Guidance
    Reasonable Accommodation and Undue Hardship Under
    the Americans With Disabilities Act (March 1,
    1999).

85
REFERENCES
  • Sutton v United Airlines, 527 U.S. 471 (1999)
  • Murphy v U.S. Parcel Service, 527 U.S. 516 (1999)
  • EEOC Enforcement Guidance on ADA and Psychiatric
    Disabilities (1997) Addendum (2000)
  • Instructions for Field Offices Analyzing ADA
    Charges after Supreme Court Decisions Addressing
    Disability and Qualified (1999)

86
APPIC RESOURCES
  • Informal problem resolution and consultation
    process
  • Formal complaint process (ASARC)

87
APPIC TRAINING RESOURCESwww.appic.org
  • Training Resources
  • By Subject
  • For Trainers
  • Reference Lists

88
VIGNETTE 1
  • The intern has been slowly withdrawing from their
    cohorts and you as the TD notice this. When
    asked, her response is they just seem to be on
    different wave lengths. You also are getting a
    couple of complaints from patients that the
    psychology intern is rude. She seems pleasant to
    you and has denied this problem with patients and
    you acknowledge that patients with chronic pain
    can be difficult to work with. On further
    inquiry, the secretary in the office notices that
    the psychology intern is very short with her and
    other office personnel. What do you do?

89
VIGNETTE 2
  • The postdoc has very good clinical skills and
    seems to have good work habits the first 6
    months. You have noticed that he is not taking
    much initiative lately and seems to be slacking
    off. He has begun looking depressed and lacks
    energy. This problem was addressed 1 month ago,
    but the number of sick days have increased and
    non attendance at grand rounds and other
    functions has become non existent. He always
    seems to have a good excuse. What do you do?

90
VIGNETTE 3
  • The intern is a quad that ambulates in a
    motorized wheelchair. She is eccentric in her
    dress, has fingernails that draw attention, has
    visible body piercings that she is proud of, and
    discusses the importance of her individuality at
    length. Her skills are average. She has
    recently received complaints about racing her
    wheelchair through the hallways of the rehab unit
    sometimes startling patients. What do you do?

91
VIGNETTE 4
  • The postdoc has several research projects going
    on and has not been very good about following
    through on their responsibilities. You are not
    sure if they are overwhelmed, just a poor
    organizer or poor research skills. What
    interventions might you consider before it
    becomes a major problem?

92
VIGNETTE 5
  • The intern has been unusually helpful during the
    year and has always completed tasks in a
    reasonable fashion. He is very independent and
    you sometimes wonder if he is expressing contempt
    for his colleagues and supervisors. Several
    things have happened to initiate you taking a
    closer look
  • 1) An MMPI was returned by mail from the prison
    system and he claims the hospital inmate had
    taken it while they must not have been looking.

93
VIGNETTE 5
  • 2) One patient called to express dissatisfaction
    with the way she was treated by this intern,
    stating he lashed out at her by tearing up her
    MMPI and saying it was worthless. He states that
    never happened.
  • 3) The secretary went to lunch with him and
    reported that the intern had made disparaging
    remarks about the program, the training director
    and one supervisor, stating the supervisor had
    made sexual advances toward the intern. The
    intern and the secretary met with the TD and the
    intern claimed he never made those remarks, that
    everything was fine.
  • How would you proceed?

94
QUESTIONS?
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