In our training and ethical responsibilities to patients and profession, a broad range of healthcare professionals from assistants to physicians, to psychotherapists are held to some forms of principles of do no harm and to leave [practices] to those who are trained in them – from the Hippocratic Oath – and similarly and variously in bodies of ethical mandates to practice by the principles of avoiding harm, nonmaleficence, and to avoid practicing outside of scope of competence, or scope of practice.
Scope of practice helps to identify procedures, actions and processes an individual is permitted to perform. An individual’s scope of practice is also based on specific education, experiences and demonstrated competence.
Scope of practice protects both the health care provider and the patient by providing boundaries to the provider’s individual practice.
Hippocrates and the ancient Greeks weren’t forced to contend with the complexities and powerful interests acting on modern healthcare practice, like medical and pharmaceutical industries, the concept of evidence-based practice and the complex world of research, its interpretation, distortion and messaging, its use as misinformation, with potential to drive lethal epidemics. Nor with mass and social media collaborating with powerful interests to use misinformation not to do no harm but to secure and protect power and gain despite predictable harm.
Things are different now, and despite remarkable scientific and technological advances in healthcare those eminently reasonable universalized ethical principles and oaths have not helped to prevent betrayals of public well-being and trust in ways that have created steadily worsening, lethal public health crises that seem to mock and marginalize them, words from a dead language.
My training is originally in research – in biology and ecology – with training and experience in design, completion, publication, critical analysis, and interpretation of research. Later, I became trained in substance use and its treatment, mental health and its treatment, and in the theory, models, and practice of social work i.e. biopsychosocial, patient-centered, developmental, patient-centered community reinforcement and related models.
I don’t have medical training, general or specialized. I do have the experience of working closely with medical providers under an integrated medical/behavioral health model in a primary care clinic.
Here’s something I would not do. Would never even consider doing it – practice medically by providing evaluation, diagnoses, and treatments. For example, I would never review or read medical images – X-rays, MRI images, other scans – then offer clinical impressions of condition, pathology, etc. with treatment recommendations.
I would never do that because I don’t have the generalized medical training, in anatomy, histology, physiology, pathology, medical conditions and disease states. Nor do I have the specialized training and experience to competently, within scope of practice, read medical images and provide clinical impressions and recommendations – in radiography, imaging, etc.
More importantly, I would never practice in that way because, lacking knowledge and competence in the relevant areas, I would end up killing a lot of patients. And if I made generalized recommendations for the treatment of a condition in populations of patients based on my reviews of medical imaging, I would likely kill or keep ill even more patients.
For problem substance use, mental health disorders, psychosocial problems, their intersection, and their intersections with human development, trauma, stressors – and the indicated evidence-based treatments and how they are effectively or ineffectively delivered – I am within scope of competence. And for the interpretation and critical analysis of research, having been trained as a research scientist, designed and published original research, and published critical analyses of research design and interpretation.
Problem substance use is a complex, life-threatening biopsychosocial issue that requires, in order to assess and practice competently, avoiding harm, training and competence in those areas.
The American Society of Addiction Medicine (ASAM) formulated a 6-Dimension standardized assessment approach for treatment formulation and level of care determinations based on decades of practice and research establishing that successful change for persons trapped in compulsive substance use indicates integrated therapies and supports to address the issues driving risk of continued use: emotional/behavioral/belief disturbances; motivational state; environmental stressors; psychosocial and environmental triggers for return to use (“relapse”); acute intoxication/withdrawal; and biomedical conditions (like chronic pain, other stressors) influencing risk.
Astute readers will note that of the six dimensions one is transient (intoxication/withdrawal) and four of the remaining five are addressed by indicated evidence-based psychotherapies and psychosocial supports for gains in emotional and mental health, community and life functioning and security (like relationships, family functioning, housing, employment).
Longstanding evidence – all lines of relevant evidence – invalidate compulsive substance use as explained by and treated based on brain chemistry, a disease state, a “hijacked brain”. Instead, longstanding and increasing evidence establishes that the compulsive behavior of substance use is driven by complex, individualized experience of inner distress, maladaptive thoughts, distorted beliefs, especially beliefs about self that influence motivation, confidence, self-efficacy, and mental states, most often inner states that are linked to early experiences. Understanding the nature of compulsive substance use and formulation of evidence-based practice and public health treatment policy requires training and competence in those areas, as well as competence in understanding and contextualizing the relevant research, applying the relevant material from human behavioral sciences in critical analysis of research.
More simply and fundamentally, because problem substance use is established by longstanding research as neither a medical condition, nor disease, nor psychiatric disorder, nor condition of any sort, instead the behavioral symptom of a complex picture of the inner psychological map and connected psychosocial environment unique to each individual’s pain, distress, inner needs driving the compulsive use – the understandings and capacities defining scope of competence for healthcare practice and policy formation for substance use are those in related fields of psychotherapy, behavioral sciences, mental health, psychology, developmental psychology and related areas. Not from unrelated areas such as medicine, psychiatry, or public health. The fundamental ways in which these boundaries and limits of scope have been distorted and violated in large part explain the steadily worsening lethal epidemics taking American lives.
As explained in detail in this post, with links to primary research and material, scope of competence for treatment and treatment policy for compulsive substance use is defined as knowledge and competence in human behavior, psychology, mental health, social ecology, and psychosocial history including early experiences. It is unrelated to medical understanding and practice, as evidenced partly by the lethal outcomes of decades of diversion of public health resources to medical approaches.
There are a thousand ways that research conclusions can be compromised, unsupported, equivocal, off – all related to design of a study, from sampled population, to randomization and selection of subjects for treatment groups, to relevance of outcome measures, to statistical significance, clinical significance and multiple, complex factors competent consideration of which is required in order to conclude with confidence that the reported results can be expected to predict benefit of a treatment or effect in the real world.
We have a “medical misinformation mess” because the medically-trained authorities, the popularizing writers, the healthcare experts providing authoritative assertions about substance use epidemics, about problem substance use, and its treatment – without background and training in the critical areas including research design and interpretation – lack competence in those areas. They are out of scope of competence, generating predictable results.
(from The Guardian – November 29, 2018)
The deficits in capacities to competently understand, evaluate and think critically about the related research, contextualizing it in the relevant behavioral and psychological sciences, are pronounced enough to have generated lethal, worsening public health epidemics over past decades.
And without oversight, a functional investigative press, accountability, or learning, the overtly incompetent generation of public health misinformation, with predictably lethal consequences, continues.
And stop belaboring the obvious. When individuals clearly outside of scope of training and competence in the critical and required areas – human behavioral sciences, development, mental health, psychosocial and related models, and most importantly understanding and thinking critically about research and its interpretation – make clinical interpretations, judgments and recommendations for courses of treatment, we would confidently predict harm, predict that lots of patients would remain ill or die as a result of practice out of scope of competence.
Individuals like popular writers, science writers, medical professionals, public health professionals, celebrities, individuals “in recovery”, others.
Oh yeah . . . wait . . . that’s exactly what’s been happening. For some time. Lots and lots of vulnerable Americans have been kept ill and have died. Enough that we’re calling the trends epidemics.
Medical professionals interpreting research and driving treatment approaches for non-medical problems like chronic pain, the compulsive behavior of substance use, depressed mood
= predictably worsening epidemics of illness and death.
Me or someone with my background and training interpreting medical imaging and providing brain surgery
= predictable illness and deaths.
So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time.
– Hippocratic Oath
The statement we need from a modern Hippocrates, a leader in medicine for our times –
In the medical field, we’ve gotten off track and made fundamental errors in overapplication of our scope of competence and practice. We have unreflectively overapplied our model and training to problems that are not medical at all in nature – like common chronic pain – helping to create and then meet demand by a misled public for a pill for every ailment, every distress. That created a tragic opioid crisis.
We’re making the same error by attempting to rely on a medical fix for the opioid crisis we created, instead of supporting the fields of psychology and behavioral health in treating compulsive substance use – another problem that is entirely non-medical in nature and cause, as evidenced by decades of application of medical and disease models with no public benefit.
It’s time for change.