ETHICS IN AVIATION PSYCHOLOGY - CogScreencogscreen.com/2017Seminar/FOWLER-EthicsInAviation... ·...

ETHICS IN AVIATION PSYCHOLOGY

Joyce Fowler, Ph.D.

September 24, 2017

Disclaimer

• Nothing in this presentation should be taken as legal advice nor the representation of any legal/regulatory body.

• Handouts provided are intended to be samples and have been developed in the context of Arkansas statutes and regulations. They may not apply to other clinicians state/context and are intended as an example.

Objectives

• Identify relevant ethics codes & professional guidelines

• Identify strategies/lay foundations for ethical practice

• Describe decision-making & post-evaluation legal/ethical dilemmas• Case presentation ethical variables: informed consent,

challenges, no broader than necessary, safety concerns, health concerns

• Filter through new Occupationally Mandated Psychological Evaluation Guidelines (Approved by APA Council of Representatives, Feb. 24, 2017)

Psychological/Neuropsychological Evaluations in the Aeromedical Context

• Provide information to assist decision-makers (e.g., FAA, military, employers, regulatory bodies)

Common Reasons for Evaluation

• Medical clearance/medical certification (e.g., aviators/aircrew)

• Hiring decisions (e.g., Air Traffic Controllers)

• Suitability/functional ability to perform certain jobs/tasks

• Fitness for duty (e.g., post injury/illness, recovery from substance abuse, incidents raising concerns)

Stakeholders

• Examinee

• Examinee's family/social support system

• Referring parties/decision makers (legal/regulatory bodies, employers, physicians, treating providers)

• Co-workers/peers

• General public

• Psychologists

Professional Guidance for Aviation Psychology

• No Aviation Specialty Guidelines at present

• Annual Aviation Conferences addressing training needs

• Ethics training incorporated as part of training

Ethics Codes, Standards, & Professional Guidelines

• Ethical Principles of Psychologist and Code of Conduct (APA, 2002, 2010)

• Specialty Guidelines for Forensic Psychology (APA, 2013)

• Standards for Educational and Psychological Testing (2014)

• Professional Practice Guidelines for Occupationally Mandated Psychological Evaluations (APA, 2017)

Guidelines vs. Standards

• Differentiation of Guidelines versus Standards (e.g., EPPCC)

• Standards-obligations/violations actionable

• Guidelines-Aspirational

• Role of professional judgment

• “The Guidelines neither add obligations to nor eliminate obligations from the EPPCC, but provide additional guidance for psychologists” (Forensic Specialty Guidelines, 2013)

OMPE Guidelines & SBFP Guidelines

• “involve many of the issues typically related to the forensic evaluation process; therefore, these professional practice guidelines may be appropriately considers a specific application of the SGFP” (APA, 2017, OMPE Guidelines, pg. 8)

Legal, Ethical, & Practical Strategies:Laying A Foundation for Assessment

• Behavioral Observations

• Establish Referral Question

• Request Documentation

• Discuss Informed Consent (include Fees)

• Address Questions

• Provide with checklist & consent


• Start behavioral observations at first pilot/aircrew contact (if ATC then FAA initiates first contact)

• Train staff to document their interactions with examinee


• For pilots/aircrew, request copy of FAA letter requiring evaluation for review in order to have a good understanding of referral question

• Train staff to handle this basic request for information

• Determine what Specs you are expected to follow before proceeding


• For ATC evaluation, FAA will contact you regarding availability to do evaluation

• FAA will submit documents via email using password protected secure attachment of documents for review 1-2 days prior to instructing ATC to call for appointment.


• After review of FAA letter, call pilot/aircrew to educate on the process and determine if they want to proceed

• Less complicated with ATC as they are usually given specific directions by FAA as the next step in the post-offer medical phase, usually staff can schedule.


• Address fees & time commitment (if ATC fees paid by FAA as employer/post offer medical phase)

• Address variables that impact time commitment based on what FAA is requiring

• Review possibility of additional testing in the event examinee does poorly on CogScreen ( e.g., SSRI Specs)

• Be prepared for the “CogScreen only” expectation and know when this applies and when it doesn’t; if in doubt call Dr. Chris Front for guidance.


• Address documentation needed for review (if ATC, FAA will send their documentation upfront)

• Give general “how to” instructions/checklist for pilot/aircrew and review informed consent (see handouts):

• Pilot/Aircrew Pre-Evaluation Documentation Checklist

• Consent for Aviation Related Psychological/Neuropsychological Evaluations


• Wait to schedule (at a minimum get FAA letter & establish Specs to be used)

• Suggest waiting to schedule until checklist parts 1 & 2 are complete


• At time of scheduling, give timeframe examinee needs to make self available

• Suggest to be well rested in order to do their best on testing


• If examinee still has questions or concerns, encourage them to contact whomever they need to help them make decision about proceeding/not (e.g., AME, attorney, family, a different aviation psychologist, etc.).

• Providing copy of consent ahead of time allows opportunity to process


• Addressing the above satisfies many aspects of ethical practice;

• lays a foundation for informed consent;

• provides valuable data regarding examinee’s attitude/approach to the process;

• establishes some level of commitment.

• Keep documentation of all above.

Informed Consent

What type of informed consent?

• HIPPA informed consent used with patients

• FAA Specific Informed Consent

• Based on FFD model with emphasis on Regulatory Mandate for Medical Certification

• Some states indicate a limited doctor-patient relationship exists

• ATC Specific Informed Consent for Post-offer Medical Phase Psychological Evaluations

• ADA procedural statute/”bright line” between pre-offer medical phase & post-offer medical phase

Questions to Consider

• Who is the client?

• Who pays for the evaluation?

• Who owns the report?

• Is the examinee considered a patient?

• What information is provided? To whom?

• Can examinee get copy of evaluation? Who provides?

• Feedback or no feedback to examinee?

• What if treatment recommendations are indicated?

• What are Limits to Confidentiality

The Evaluation Process:Employer/Regulatory Body

vs Pilot/Aircrew Responsibilities

• Guidelines for Occupationally/Regulatory Mandated Psychological/Neuropsychological Evaluations (see handout)

• Pilot/Aircrew Pre-Evaluation Documentation Checklist (see handout)

• Consent for Aviation Related Psychological or Neuropsychological Evaluations (see handout)

Assessment Day: 1st Things 1st

Informed Consent form review:

Review & discuss

Sign & notify FAA & AME immediately (document how done such as fax, mail) & then proceed;

or if Declined to sign Stop

Additional Release of Information forms requested:

Review & discuss (e.g., collateral contacts such as employer, supervisor, Chief pilot, treating providers, family, peers)

Sign & then proceed;

or Declined to sign & consider whether to proceed or stop

Proceed with AssessmentClinical Interview & Mental Status Exam

Conduct testing required: See appropriate FAA Spec Sheet

Plus additional testing as indicated by clinical judgment

Behavioral observations (ongoing)

Option to reschedule if factors interfering

Additional review of records

Option to withdraw from processPrevious notification of engaging in assessment on record during informed consent

Send new notification withdrawn consent

Communication of Findings• Feedback session or not?

• In most cases, yes; less likely with ATC

• Use of email?

• Encryption

• Release of report, to whom?

• FAA

• AME (see FAA letter and Specs for guidance; call if need clarification)

• Copy to examinee?

•Sometimes yes, sometimes no

•Alternate: provide summary and recommendations in letter form

• Other physician/treating providers (e.g. neurologist, psychiatrist)

Post Evaluation Scenarios

• Report sent for review by FAA consulting psychologist

• Examinee Appeal Process

• Request for records by other parties for non-aviation purposes

• Subpoena/court order

• Examinee post-evaluation objections to being evaluated & attempts to override

Dealing with Subpoenas

• Consult with attorney as needed

http://www.hhs.gov/hipaa/for-individuals/court-orders-subpoenas/index.html

• Court Orders and Subpoenas

• Court Order

• A HIPAA-covered health care provider or health plan may share your protected health information if it has a court order. This includes the order of an administrative tribunal. However, the provider or plan may only disclose the information specifically described in the order.

• Subpoena

• A subpoena issued by someone other than a judge, such as a court clerk or an attorney in a case, is different from a court order.

• A HIPAA-covered provider or plan may disclose information to a party issuing a subpoena only if the notification requirements of the Privacy Rule are met. Before responding to the subpoena, the provider or plan should receive evidence that there were reasonable efforts to:

• Notify the person who is the subject of the information about the request, so the person has a chance to object to the disclosure, or

• Seek a qualified protective order for the information from the court.

• See 45 C.F.R. § 164.512(e) and OCR's Frequently Asked Questions.

http://www.hhs.gov/hipaa/for-individuals/court-orders-subpoenas/index.html

http://www.hhs.gov/hipaa/for-individuals/faq/index.html

Sample Response to Subpoena (after chance for objection exercised)

Dear __________,

Pursuant to the HIPAA releases provided, I am attaching a certified copy of the report I prepared regarding a fitness for duty examination on _________. I was never _____________’s treating psychologist, so this is the extent of the information that I maintain on him/her. Please note, however, that a privilege log is attached relating to the testing materials that were used during the fitness for duty exam. Also, attached is a records affidavit. I believe this information is also responsive to the subpoena duces tecum left with my office staff last week.

Sincerely,

Joyce Fowler, PhD

The Fowler Institute

Privilege LogDOCUMENT DESCRIPTION PRIVILEGE REASON

Psychologist copyrighted “TestMaterials,” which includesmanuals, instruments, protocols,or test questions.

American Psychological Association Ethical Guidelines: 9.11Maintaining Test Security: Psychologists must makereasonable efforts to maintain the integrity and security of testmaterials and other assessment techniques consistent with lawand contractual obligations, and in a manner that permitsadherence to this Ethics Code. This information should onlybe released to another psychologist with the same obligationsto maintain the security and integrity of the test.

Medical Records AffidavitAFFIDAVIT OF MEDICAL RECORDS CUSTODIAN

STATE OF ARKANSAS

COUNTY OF PULASKI

Affiant, _________________________, is the duly authorized custodian of medical records a The Fowler Institute and has the authority to certify said records. Affiant states that the attached copies are a true and correct copy of the medical records relating to the care and treatment of ______________ as generated in the regular course of the practice of psychology and a fitness for duty examination.

_______________________________

Medical Records Custodian

SWORN TO AND SUBSCRIBED before me on this ____ day of _____________, 2016.

________________________________

NOTARY PUBLIC

My Commission Expires:

P & P Case: PTSD

• Incidental test findings triggers Neuropsych• Airmen’s Post Evaluation Objections

Case Presentation: Mr. Purple• 78-year-old, married, male, retired, with

college degree (business)

• presents as very affable

• jokes a lot, and tells long detailed stories about himself & even his ancestors; borders on tangential and needs redirection

• Tells war stories; proud of his service

• Wears shirts & hats reflecting Purple Heart

Seeking 2nd Class ”Renewal”

• Last held 2nd Class in mid 1990’s

• Renewed interest in flying in past year

• Bought Cessna 152, refurbishing

• Bought hangar

• Reports recent flying with instructor & “did well”

• Enjoys flying & also social time with other pilots

FAA Letter Review

• History of diabetes, glaucoma, hypertension, prostate cancer, & PTSD (records also show Agent Orange Exposure & high cholesterol)

• Requests for further medical evaluations/documentation from treating physicians

• Requested treatment records for PTSD from VA

• Referred for P&P secondary to PTSD with specs attached

Military History & Flight Experience

• National Guard age 16-60

• US Army 1960-1968

• Flight school 1963 & became flight instructor

• Completed helicopter school 1964

• One tour of duty (1966/67) Vietnam, section commander of airborne platoon/assault helicopter, insert & extract combat units, usually “hot”; logged 1,085 combat hours

Medals

•Distinguished Flying Cross•Air Medal with OLC•Bronze Star•Purple Heart •Vietnam Service Medal•Republic of Vietnam Service Medal•Air Medal (Oak Leaf Cluster)

Clinical Interview & Collateral Interview with Wife

• Some PTSD symptoms while in Vietnam, but worked through it. • Wife reported increase in symptoms noted in 2009; nightmares,

talking in sleep. She thought triggered by son becoming age of co-pilot who died in action.

• Son disabled secondary to TBI; Airman guardian/primary caretaker • Wife suggested Airman get treatment for his PTSD. In treatment for

several years at VA. Thought to get worse when went through what sounded to be CPT protocol. Backed off & continued supportive therapy. Encouraged to get out & do things for self, e.g., flying

• Wife did not seem thrilled with him flying “realistically how many more years can he fly”, but was supportive

Psychological Core Battery Results

WAIS-IV • Verbal Comprehension 75th percentile

• Info. SS = 12; 75thpercentile (Pilot norms: mean = 13.1, SD =2.1)• Perceptual Reasoning 50th percentile

• Block Design SS = 9; 9th percentile (Pilot norms: mean = 12.3; SD = 2.1)• Picture Completion SS = 6 (Pilot norms: mean = 11.3, SD 2.1)

• Working Memory 55th percentile• Arithmetic SS = 9, 37th percentile (Pilot norms: mean = 13.1,SD 2.2)

• Processing Speed 18th percentile• Symbol Search SS = 7, 16th percentile (Pilot norms: mean 10.5, SD 2.3)• Coding SS = 8, 25th percentile

Psychological Core Battery Results(continued)

Trails A: no errors; tremor noted; .1st percentileTrails B: one error ( 2 to C); tremor noted; 7th percentileBehavior observations: Very slow, fumbled, forgot itemsPCL-5: 9/80MMPI-2 (took over 3 hrs. to complete—blamed computer mouse messing him up; switched to paper/pencil but did not improve speed);

• All validity scales within normal limits except S (T = 68)• L, T = 52; K, T = 64; all clinical scales within normal limits

Additional Testing?

• Per Specs: “Findings suggesting deficits in the Intellectual/Neurocognitive domain, the examiner should ”….“Refer the airman for a neuropsychological evaluation”……..

• Would you do neuropsych?

Cogscreen: US Pilots > age 54

• LRPV = 1• Base Rate T Scores <40 for all domains at both 5th & 15th

• Analysis per domain:Domain Scores @/<

5th

percentile

Scores @/< 15th

percentile

Base RatePercentile

Speed 12/19 14/19 </= 1

Accuracy 4/19 11/19 </= 7

Thruput 11/16 14/16 </= 2

Process 4/10 4/10 </=2

Taylor Factors

• Attribute identification: T = 31.82• Motor Coordination: T = 68.23• Visual Association Memory: T = 32.89• Speed/Working Memory: T = 28.08• Tracking: T = 32.73

G.A. Norms Ages 75-86

Domain Scores @/< 5th

percentileScores @/< 15th

percentile

Speed 12/19Accuracy 2/19 7/19Thruput 3/16 10/16Process 4/10

GA Norms Calculator (age 76-81)

• WAIS Coding: T = 10.5

• Trails A: [ T = -70.9? (120 seconds)

• Trails B: T = 25.16 (159 seconds)

• Trails C: T = 37.89

• Multitasking

• Divided Attention Test Ind. Speed T = 22.71

• Divided Attention Premature Hits T = 38.29

• Divided Attention Comp. Accuracy T = 35.47

Interpretation (GA Norms)

• Problems with visual scanning/visual perceptual processing speed, motor functioning, math deficiencies, and impulsivity

• Intact attentional, working memory and information processing skills

Thus far, Airman explains away performance as

• computers the problem;

• denied/has not noticed any motor problems/tremor;

• stated he’s always been slow, his “sisters have said so” since he was a kid, does not believe interferes with flying;

• recounts vast flying experiences as veteran, including details of emergency landing leading to medals

• joked after Cogscreen saying evaluator could state he passed

• could have done better, but tired

Language

• COWA: WNL

• BNT: WNL

RAVLT

• Trials 1-5: Very Superior

• Trial B: Average (5oth percentile)

• Delayed: Recall Very Superior

• Recognition: High Average

RCFT

•RCFT

•Compared to age-related peers performance within normal limits

•Compared to pilot norms all trials at the 5th

percentile

•Also, tremor noted again

Motors (right dominant)

• Tapping: Right = 5th percentile; Left = 8th percentile

• Grooved Pegboard: 10th percentile bilaterally

• Hand Dynamometer: Right = 31st percentile; Left = 21st

percentile

WCST: Impaired

• 1/6 categories

• 12 trials to complete first category

• 3 instances of FMS

• 13% Perseverative Errors

• 13% Perseverative Responses

• Compared to Pilot norms below 5th percentile

Stroop: Slow Overall

• Word Score: T = 29

• Color Score: T = 19

• Color-Word Score: T = 31

CPT-II: Impulsive

• Large number of Commissions Errors (T = 59; 83rd

percentile)

• Hit RT (Overall Hit Reaction Time) was fast (T = 40; 18th

percentile)

REACTION @ FEEDBACK

• Did not accept findings as relevant to flying

• Recounted he is experienced pilot, retold stories to prove point

• Blamed computers

• Upset he had to do testing because issue that triggered referral was PTSD

• Adamant that he is safe to fly, regardless of not having flown in almost 25 years & really very little flying in last 50 years since left service

• Said he could have done better if not tired (specifically Cogscreen and WCST)

• Wanted to retake tests; discussed Cogscreen repeatable & could replace WCST with CT;

• Wife suggested he was upset & wait to reread report together & then decide (she is retired school counselor; she seemed concern about his flying, but was trying to be supportive)

Recommendations1. Continue current treatment plans for maintenance.

2. Findings aeromedically significant & predictive of problems flying. Suggest review findings with AME for further advice. Final determination rests with FAA.

3. Recommend consult with physician to rule out any underlying disorder contributing to deficits in motors skills and executive dysfunction.

4. Due to level of enjoyment from flying, continue to enjoy plane with another pilot and continue to interact with other pilots via his hangar business.

5. Option to retest on 2 measures (Cogscreen & CT) when well rested. Continue to take flying lessons in interim.

A parting poke.

No Joke!

Post Feedback Actions

• Consulted with colleague (Dr. Kay)

• Followed up with Airman by phone regarding retesting decision

• Shared talk with instructor; advised talk to AME to help

• Considering reaching out to Congressman

• Consulted with AME

• “No rock unturned” option; will encourage to fly with buddies

Follow-up with AME• AME talked to Airman over phone & he vented. He decided to wait & see what FAA/OKC does

• Per AME “this one weighed heavy on my mind & heart”; decorated veteran with experience put in position to have to prove himself

• Took Airman’s view that PTSD resolved. Thought that should be end of story/end of psychology role

• Sitting at a computer taking tests not relevant & it should be the bailiwick of the pilot examiner to determine if safe to fly

• Educated regarding Specs, data triggering further testing, poor performance predictive of flying errors, red flags, referral back to AME for advice (i.e., making his recommendation regarding pilot examiner an option), and final decision with FAA

• He decided all data is good, but a “hard no” from OKC is harsh; should be room for discretion

• Clarified the totality of information taken into account by FAA & they make determination re: safety

• Psychological/neuropsychological evaluation data part of the data to assist in making determination. Re-clarified findings of concern. Ultimate decision with FAA, not psychologist

• Discussion re: process & opportunity to for AME to vent helpful. He qualified his thoughts a bit “well maybe he doesn’t need to fly, but I felt he didn’t get his day in court”.

Role?

• Airman Advocate

• Public Safety

Use OMPE Guidelines (1-13)

1. Authority & legitimacy of a particular referral 2. Referral question criterion defined by regulatory source, relate to “essential functions” and “business necessity” (narrows scope)3. Understand psychologically relevant demands & working conditions4. Support conclusions about relevance of a psychological condition with established scientific & professional knowledge

OMPE Guidelines (continued)

5. Understand & meet responsibilities to referral source, examinee, & other relevant parties. Impartial evaluation vs limited doctor-patient relationship. Address issues through informed consent.

6. Mindful of maintaining competence; seek appropriate training/competence

7. Strive to ensure impartiality-remain dispassionate advocates for the evidence-based findings & relevant inferences


8. Select & rely on assessment tools validated for use with population

9. Recognize individual & group differences/cultural competence

10. Use multiple sources of relevant & reliable information


11.Opinions & recommendations directly relevant to referral questions

12.Document basis for opinions in language clear & appropriate to the targeted audience

13.Referral source/another party responsible for determining the ultimate issue, strive to educate & inform rather than answer the ultimate question

References• American Education Research Association, American Psychological

Association, & National Council on Measurement in Education (2014 Ed.) Standards for Educational and Psychological Testing. American Education Research Association: Washington, D.C.

• American Psychological Association (2002, 2010). Ethical principles of psychologists and code of conduct. APA: Washington, D.C.

• American Psychological Association (2017). Professional practice guidelines for occupationally-mandated psychological evaluations. APA: Washington, D. C.

• American Psychological Association (2013). Specialty guidelines for forensic psychology. American Psychologist, Vol. 68(1), 7-19.

Thank you!

Joyce Fowler, Ph.D.The Fowler Institute

415 N. McKinley, Suite 500Little Rock, AR 72205501-664-6632 Office

501-664-1441 FaxEmail: [email protected]

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