today . First session is titled the dual roles of military psychiatrist , ethical considerations of the military command . Exception presented by Navy Lieutenant Megan Quinn . Lieutenant Megan Quinn M . D . Is a graduating psychiatry . Resident in the national Capital Consortium psychiatry residency program . She is a graduate of both the uniformed Services University of the Health Sciences or U . U . S . U . And the University of Maryland College Park . She has authored four peer reviewed journal articles and presented at multiple conferences with national and international attendance . Please join me in welcoming Lieutenant Quinn . Good morning , everyone from Bethesda Maryland and Good afternoon . Good evening . Good middle of the night , I suppose for some of you who are calling in from all over the rest of the world . Um And thank you Captain Gorman for the introduction . Um Before we get started , some disclosures , I do not have any relevant financial or non financial relationships to disclose relating to the content of this activity . The views that I am going to express in this presentation are my own and they do not necessarily reflect the official policy or position of the Department of Defense nor the United States Government . This continuing education activity is managed and accredited by the Defense Health Agency . J seven continuing education program . Office D H . J J seven C . E . P O C H A . J seven C . E . P . O . And all accrediting organizations do not support or endorse any product of service mentioned in this activity . B A . J . J seven E . P . O . Staff as well as activity planners and reviewers have no relevant financial or non financial interest . To disclose uh commercial support was not received for this activity for our learning objectives . At the conclusion of this activity , participants will be able to explain the basis for disclosing personal health information to military chains of command even in the absence of a release of information , describe the situations in which behavioral health information may be disclosed to military commands and what information may be disclosed and discuss the ethics of dual agency . When active duty physicians and clinicians must consider both the individual and the service in their clinical recommendations . Since it's in the name of the talk itself , I would like to briefly introduce the Health Insurance Protection and Accountability Act of 1996 . More commonly known as Hipaa . This defines personally identifiable information and establishes guidelines for how that information must be protected by any of a wide variety of health care settings and organization known as covered entities in the act . In addition to guaranteeing protection of information , it also establishes clear procedures for how any disclosure of information must be addressed and forward whether it is accidental or intentional related to that . It also established several situations in which protected health information may be disclosed without first obtaining consent in the broader medical world . These exceptions are present in a variety of different areas of life and practice and some of them may be so common or ingrained that you don't even realize that HipAA has afforded us the authority to disclose information in these cases such as with ongoing patient care or building insurance plans . Some of the other common exceptions include information that is disclosed to a mandatory reporter in the healthcare setting related to abuse or neglect any of the variety of public health concerns which can include school immunization requirements , worker's compensation , communicable disease tracing and more and death identification . While information may be disclosed in these cases without a release of information , it's still important that the patient understands that you are going to be sharing their health information and specifically what information you will be sharing you . Despite the fact that individuals do not need to agree to disclosure of information in these cases , you've probably signed releases of information yourself in some of these circumstances in the civilian sector , there is understandably a considerable amount of focus on adhering to the privacy standards . As repercussions can be quite significant for the organization if they are not followed . Now , if we keep digging through the Burbage of itself , we will eventually come across this section which establishes the basis that healthcare information about active duty service members can be shared without required consent for the purpose of the military mission . Uh this incredibly vague statement does require that the Department of Defense establish additional regulation surrounding this to specify what information may be disclosed to whom and to what in what setting . Ultimately , this led to the development of two D . O . D . Instructions , you D . I 60 25 Tak 18 and D . O . D . 64 90 Taco rate within these documents . We finally get to be practical rules and guidance surrounding surrounding medical information disclosure in active duty patients For the purposes of today . I'm going to focus on V . O . D . I 64 90 Techo eight . Generally speaking , people are more concerned about their command finding out that they've got mental health concerns or have been seen in the mental health clinics than they are about their command . Becoming aware that they they're PCM or been treated for the flu . The O . G . I 60 to 90 established a situation in which in which mental health information can be disclosed to military change of command . The first two situations are fairly standard with respect to mental health and working in that setting . If there are serious concerns about harm to self or harm to others , information may and in fact must be disclosed to address safety concerns . However , the similarities between HipAA for civilians and HipAA for active duty service members and their if there are concerns about missions or if patients are enrolled in any special personnel programs such as the presidential support programs . Mental health information may be disclosed in the event of inpatient care , acute medical conditions that interfere with duty requirements or formal substances . Treatment commands do need to be involved . Generally speaking in these cases , a service member's ability to go to work and perform to baseline requirements would be impacted so their command would need to be apprised of this information for multiple reasons including accountability . The results of command directed evaluations may also be shared with the command that requested the evaluation in the first place And finally what is likely the most ambiguous situation in this policy . Other special circumstances is defined by an 06 or higher . They be disclosed to the command harm commission and the other special circumstances are fairly vague situation with limited concrete definitions surrounding them . Conflict and questions can easily arise here between command and the mental health clinicians in these settings when there are differing opinions about whether or not the situation meets the criteria for disclosure . If anyone were to sit down and actually read through the complete limit of confidentiality that we ask all patients to sign before their first minute visit in the mental health clinic . These nine situations are actually explained pretty well . This certainly doesn't absolve anyone from having a discussion with patients about the limits of confidentiality at the start of a course of treatment . But it does help answer some of the questions that might arise and it goes beyond the basics of what is covered in 64 90 tech 08 and mentions other circumstances and situations such as potential future . You see MJ proceedings . So going through all of the information to this point , I've referenced the idea that information should be released to command if patient needs any of the criteria laid out in D . O . D . I . 64 90 pack 08 but I haven't discussed what specific information can or should be released under this instruction . Generally speaking the standard is that we should be releasing the minimum necessary information about mental health condition to the patient's command . We've tried to make an effort to really clarify what that information is , what truly constitutes the minimum necessary information . As a starting point . Command should have an idea of what the diagnosis is . They don't necessarily need specify IRS but they do need a general idea of what's going on with their service member the treatment and it's also something that should be shared in this case , commands don't need to know the details such as the specific medication that's being trialed for the therapeutic modality that is being tried and true thing but they should broadly know if their service member is starting medication engaging in weekly therapy appointment , participating in a date for entering a 30 day program . For example the next considerations encouraged expand to remain involved with their service number man should be sold out . A sentiment about time that's about things to be recommendations , checking in good commands tend to have a lot of questions here they want to but generally on that house . Finally we share some particularly necessary information . Canadians need to know their investigations for restrictions for their service members as a result of medical treatment . Maybe they can't stand a 24 hour watch or goes to the world . In addition to verbally conveying this information uh profile like beauty chip for Lynn do should be started to actually document these restrictions . Ultimately , this is to protect the patients and to ensure that they are not exposed to anything . It makes you work in their health expectations . Um , and most importantly , any safety concerns that shared this oftentimes is the general precautions but as risks associated and depressed mood or interactions that might trigger a safe behavior if patients have threats towards anyone man or work with this does need to be disclosed . Generally when we're considering the information that will be shared with man , we should share information that will help the command support the service number , think about they need to know to be supported and involved as well as understand certifications of the service members , health conditions for their mission and the National Health Center reconcile and I found it to be particularly helpful in my IT standard and provide helpful guidance on how to have the college people the entire policy and it has also been a great way to introduce this policy and standards . People who are new to working in the it's also helpful to write and review . They're aware of what the criteria required and medication . Now stepping back from the policy guidance , let's consider some of the that is no , the department , their employer is not only focused on the provision of medical care , but also on a greater operational mission . In this setting , we have duties to both the military and to our individual patients , just like it says at the bottom of all of these slides , military health care is focused on medical readiness of the fighting force . In this , there are 22 expectations and obligations the duty to provide the best most appropriate medical care possible to each individual patients and the duty to support the overall success of the military mission . At times , these obligations can seem duty to provide the best care for the patients and the duty to simultaneously do what is best for the military organization . That's a conflict at the time , I'm going to discuss a few here but would love to see any additional conflicts that you have encountered or thought about in the participant shad patients in the military may want very different things . Participants may want a full career or a medical retirement . They may want a certain billet or to attend a specific service school . On the other hand , the military may want to only have the service members on their role . They may want all members of the unit to meet certain standards with respect to treatment and retention . What is in the best interests of the patients and the military may be divergent . A patient may want or need prolonged courses of medical treatment . The military may want to avoid retaining someone whose health could be negatively impacted by future mission requirements . And in our health care rules , we are asking patients to disclose confidential and at times deeply personal information in a system that is run by the government and the government can have access to situationally . Of course , in addition to these conflicts between duels role of caring for a patient and furthering the military mission , there are additional unique considerations that must be in place . Some of the additional military unique considerations are listed here again . I would love if people are able to hear me with the audio issues apparently , um , I would love to see any additional military unique conflicts that you have encountered listed in the chat . I didn't see any being listed for any of these unique um conflicts that I asked for on the previous slide . No , we would all like to think that all patients get the same care regardless of their reign . But just by the existence of executive medicine alone , we know that that isn't always true practicality . The experience of trying to access healthcare is dramatically different . If you are a junior seamen or a retiring flag officer , not only does it have the potential to change interactions with the system at large , it can also change interactions with the individual physicians and clinicians . Our patients who significantly out link their healthcare team given more deference or preference . Maybe their symptoms or history are trusted or given more weight than the complaints of the junior sailor . They're allowed to dictate and direct their treatment far more moving down the list as we've seen over the past few years with the rollout of the Covid vaccine , there's a significant amount of debate and discussion back and forth over the question about whether or not medical recommendations or treatment can be mandated as the Director General order . This is an entire discussion in and of itself looking at what the military can do should do and has done as well as the policy and doctrine that underlie these decisions . We don't have anywhere near enough time to do this topic justice in the time that we have this morning . Alright , I don't see any additional military unique considerations that anyone has entered into the chat . So let's see . We've got yes . So with members under the personal reliability assurance program , we have to disclose the member's status and make recommendations . But absolutely absolutely true . They fall into that special personnel category in addition to presidential support , do this sensitivity of their the information that they work with . Um , and the high potential of risk or harm . If something were to happen . All right . So all of these questions and conflicts and disagreements ultimately bring us to one over arching question that can be used to sum up a portion of this context . Are we doing a disservice to one entity by prioritizing the needs of the other . This statement works in both ways . Um , service she was however , or maybe are we doing a disservice to the military by prioritizing the individual . So ultimately who's needs to be prioritized in military healthcare ? I would like to offer the opinion that in many cases we can prioritize the needs of the individual service member and large . So understandably , this is an incredibly charged topic , one that can be quite polarizing at times when emotions run high . It can be hard to see how certain actions and decisions may truly be in the best interest of a service member when it isn't in line with what they want . Let's do you think that in this case I'm putting the military in an overly paternalistic role . It might be easiest to liken it to a relationship between a parent and a child or an adult child , an aging parent , whether it's getting a vaccine moving or a nursing facility , just eating your peas . You can argue that these decisions may be highly charged and polarizing and yet at the same time also be made with the intent of emphasizing both individual health and some assets of the well being of the family unit at large between my military medical career and my career as a first responder . That was a footnote in my biography , uh , the concept of triage is one that well and one that military medicine emphasizes throughout our training , the broad concept of triage transit very well into the military medical setting at all times being challenged to do the most good for the most people given the current resources that we have available . This means that sometimes the best decision for this service number and their service is distinctly different based on the environment on a short tour . It makes sense and it might even be preferred to keep a service member with their unit despite their limitations due to illness or injury in a deployed setting , the same illness or injury might require a medevac for appropriate treatment . For many , the decision to proceed with a medical evaluation board or M . E . B . Is one of the most challenging decisions in military medicine . It's viewed as a punishment for getting sick or injured . A quote . Easy way to get out early and attempt that in a system , a waste of resources or an unfair bias . Just to name a few we need to remember both for ourselves and for our patients . That an M . E . D . Is not a punishment . In fact , the M E . B helps provide us with an outline when , what is best imitation no longer appears to be what is best for or allowed by the military service . We can view it as almost irresponsible to not initiate this process . What medical risks are we exposing our patients to if we don't . And initiating a medical board is not a guarantee of any outcome . Initiating the medical board lets the system examine what is best for the individual and the service for more than just a medical . Some service members end up being retained because they have critical skills that are in short supply and permanent duty restrictions or limitations are applied to ensure that they are not put in situations that would worsen or threaten their health . It's a compromise that maximizes what is best for both . The service retained the skilled sailor while the sailor won't be assigned to situations that would threaten or worsen their health . Military or not . These four terms form the backbone of medical efforts , though at times it can seem almost impossible to fully uphold in the military setting . Leaning back on some of the discussion earlier , I hope that it's a bit easier to see how this is possible . Magnificent is acting in the best interests of our station and while in the military setting , we must balance the best interests of our patients with the best interests of the military . We can attempt to reach a balance in the happy medium where we ultimately are not exposing our patients to greater harm . Additionally , we must do no harm . That's kind of a foundation of medical ethics and this really applies to considering what additional risk or harm we may be . Um subjecting our patients to if they were to use military service , even with health care conditions , um , illness or injury that could expose them to increasing disability as they continue on in their service , we also must act in the best interests of our patients . Again , this can be challenging when you balance against the idea of acting in their best interests , but it's something that we have to balance our patients all deserve fair and equitable treatment and they need the freedom to make their own health care decisions . You mean the freedom to having the freedom to make their own healthcare decisions is one that's been particularly challenged recently with covid vaccination requirements . Um , and it is a reminder to us that there is always an alternative , though , the alternative may include additional requirements that are not palatable for the individuals involved done so , we are recognizing that there's a huge amount of nuance present in military medicine . Uh , as a result of this , a set of medical ethics for operating within the military health system was proposed by Thomas at all in 2020 , some of these are nearly identical to the principles of Medical ethics outlined in the American Medical Association . However , others reflect the unique consideration in military medicine listed here are excerpts from just a few that highlight the unique situations and considerations that we have in military medicine . As you notice these principles , all recognize the greater law and authority that is present within the military . Additionally , some of them described situations that civilian physicians might never even think about as healthcare providers in the military system . We are responsible for advocating for the best possible health consists of our patients . While we are respecting the law and the lawful military authority . Similarly , we must respect the rights and safeguard patient confidences and private with even the constraints of the law , which would include C O D I 64 90 tech 08 and what the military being necessary and appropriate in the military system . We need to remember that patient responsibility is primary . However , there may be extraordinary circumstances sort of created with the mission or with military necessity that may require additional consideration and ethical consultation . This can be applied to many of those situations where the concept of triage is fully employed , where there are limited resources and difficult decisions need to be made to maximize the overall health of the group at large in the military health system . We also are tasked with considering the context and sustainment of our overseas humanitarian and disaster relief activities And we need to determine how to use available resources to achieve the greatest good for the greatest number innovated 16 with environment and ultimately , we have to uphold the legal responsibilities that we have as health care providers when you're caring for enemy combatants . That's certainly not something that the A . M . A addresses in their principles of medical ethics . There are a huge number of policies out there uh , that go to inform these principles of military medical ethics and just a few of them are listed here . The Geneva and Hague conventions inform lots of the principles of military medical ethics that move into the battlefield spaces and international laws , just war theory and the laws on context also go to support these United Nations itself has a medical ethics office and each individual military service has specific codes of context that we can lean back on in order to determine some of the ethical principles that we need to be considering as prioritizing . We understand though that there are a ton of ethical dilemmas that we get into in health care every single day . And at times people feel like they don't have access to enough resources to help them comfortably make that decision . While plenty of local installations have an ethics committee in their clinic or hospital mps . There are also situations where you may not have that sort of access . Since the principles of military medical ethics were proposed in 2020 , the D . O . G . has also created a medical ethics program . The medical ethics program has created the medical ethics healthcare portal . Uh , this is posted through the uniformed services university and is capable of receiving free and for medical level , the entire military health system into the actual region . For the portal . Also thanks to a policy I didn't laws offers courses of education and on training and help provide easy access to the codes of ethics of the military method . This is a new resource that has been recently stood up and it is very much still evolving but it is really exciting option to know that we have to give access to some really wonderful people who work in the ethics line um at this more organization wide level . So looking at our key takeaways from this presentation , there are scenarios when we should and in fact must notify patients chain of command about their confidential healthcare information . Um Generally this is when their health in some way threaten the condition overall . D . O . G . I 64 90 text 08 is the document that provides us the guidance on command notification in cases of behavioral health education and ethical decision making in military setting may challenge ethics and the rules of those military and medical professions . This is a challenge point where we really do need to reach out to those ethics committees and other resources that we have to figure out how we can be the best location and the military service overall . Um And into some Okay , um there are a variety of government documents that i in in addition to actually leading through large sections of the Hipaa act um and the ethical guidelines and practices for us military medical professionals . There are also several instructions that have been published by the Defense Health Agency and the Department of Defense um as well as some may be specific instructions that I referenced . Um None of them are necessarily easy reading or fun read but there is a lot of really good information included in these documents . Um Really important information for everyone who works in the realm of mental health in our military setting to be aware of . Um I think that I had broken a little faster than I thought I would and um and ending a little bit in advance so I would love to take questions and it looks like there are quite a few in the screen . So let's be starting from the top . The Hitler exception allowed for the closure of th i to the family are only designated military personnel . Um So in in the case of the military command session , this only applies to designated military personnel um and they try to specify it . So it's only specifically the chain of command or the chain of command designated . So this should not be , you know the lPO that's getting this information that really should be ideally going to a ceo or a CIO designated at a high level . Um Once this information is disclosed to the command it should also be safe regarded and not broadly distributed or disseminated among the rest of the command . Um Can I describe the situation where I had to disclose personal health care information to a military command um happens quite frequently in the mental health setting . Um I think one of the more recent examples that I've had was taking a patient who had a severe alcohol use disorder and stating that you know they really needed to go to a residential substance use program in order to adequately treat their disease and hopefully return them to a reasonable beauty status . And that's a conversation that you have to sit down and have with their chain of command because ultimately the chain of command is involved in that decision to send them to that treatment program . And for accountability purposes . As I mentioned earlier , they need to know where their service number is going to be for 30 days or however long it takes . Well there's folks on the line who are are not military . So maybe we started some of those questions . Can you explain what a medical evaluation board is for folks who are not familiar with that ? You said it was not a bad word . So please please give a quick overview of that . Sure . So the medical evaluation board is the mechanism when military healthcare professional says this service member no longer meet the established requirements for medical retention on active duty . And at this point we say officially , this person doesn't meet the standards . We have concerns about their ability to fully fulfill their job as the military has asked and we refer their medical case to a committee as senior positions as well as line officers in the military who evaluate the case , evaluate their current duty limitations and impairment as well as , you know , their ability to do their current job and make determination about whether or not their disability is something that the military can and should be able to support and the activity population , this is something that's so severely limits their ability to do their job , that they should be either medically separated or medically retired from activities . Thank you . And also question from our non military behavior health folks , is there ever a situation where a non military behavior health clinician would need to divulge something to the military unit when they're taking care of a military service number . So the military command um exception policy actually applies to the patient being military , not to the provider seeing military . So that is a case where if you are treating an active duty service member um out in the community particularly . That's a challenge where people get started on medications or have diagnoses that could be severely limiting to their ability to do their job in the long term . Um then they need to provide that information to the command because it really can bring up some significant safety concerns for those patients . It's something that we see a lot in the care that's put out to the community and also care that's provided to our reservists and National Guard members do receive the bulk of their care in the community . Thank you . Um Now I made some practical question in your own practice when you have a patient who has suicidal ideation who's the first person you contact um uh in your practice . So it depends on how severe the suicidal ideation is , if I think that someone is an acute danger to their self , um I am talking to my clinic front desk and we're escorting them to the emergency room . Once they get to the emergency room , then it is notifying their chain of command . Um or sometimes it's their medical officer if they're in um an operational unit that has a designated medical officer that they have been brought to the emergency room or that . Um But definitely patient care and patient safety trump making any of these administrative notifications understood and when you when you do just need to disclose to the command or something about a patient , you know , do you , what are the specific information ? Do you try to limit it to the bare minimum um necessary information ? And how do you navigate figuring out exactly what is relevant for the command , you know , as you thread that needle on your your dual loyalty surprise to the patient and your duty to the command ? Yeah , so it's it's definitely challenging . Um really keeping focused on what you think the command needs to know to take care of their service member or what you think is ultimately going to impact their mission . So saying , you know , this service members then started on a medication , we don't need to be specific , but maybe , hey there are some concerns that while they're getting started on this medication , it might not be a good idea for them to be operating heavy machinery or standing overnight watches until we see how they respond to react to that . The command doesn't need to know the specific medication . Um , and a lot of line units , the specific medication wouldn't actually mean anything to that chain of command . But those risks of precautions are what's important to them to be able to continue to operate and take care of their service members . Um , Similarly with treatment , the idea is communicating the treatment requirements . Treatment concerns that are going to have a significant impact on their ability to do their duty . So if we have someone who is in a special personnel program and they just need weekly counseling , that's kind of what you would disclose . Whereas if it's someone who's a regular sailor who doesn't have any sort of special clearance or enrollment in a special program thing , that's not necessarily something that you need to notify the command about . It's only once it gets to the level that it's impairing their ability to operate and fulfill their mission . You have to be pretty knowledgeable of all the various military occupational specialties and what their duties involved and your clearance , uh , probably you need to consult other people's , I'm sure hard to understand all the duties that each of our , you know , millions of service members do look around for that is , uh , you know , besides suicidal ideation , which I think would be fairly obvious , uh , you know , what other conditions , you know , we're the kind of top conditions you see where besides suicidal ideation where um you might have to disclose this again based on their clearance or based on their specific occupational duties and within your practice and that of your colleagues . Yeah . So one of the , one of the big things is looking at the medications that we prescribed . So if we're prescribing any medication that would have in contact on deploy ability long term . So if we're starting an anti psychotic or lithium , a mood stabilizer , that's something that the command would need to know about because it's something that is going to significantly restrict where their service member can operate in the long term . Um psychotic spectrum disorders are a big one for us that not only immediately gets disclosed to the command , but also immediately do start the medical board process because that is um something that's really difficult for us to maintain on active duty given the health concerns as well as the medications that are necessary to um appropriately treat and support someone who has those medical concerns . Um Beyond that , it is not so much condition specific as it is severity . So any sort of disease or disorder that requires treatment more often than a weekly appointment . So any sort of day program enrollment , whether that is for substance use or depression or PTSD , see if it's going to be significantly taking them away from their duties , That's something that command needs to know about . Um If they have a specific anxiety or PTSD trigger that's directly related to their line of work . That's something that's important to their command to know because it's limiting their ability to do the work that they are being tasked with doing for the military . Do you ever use um you know of equivalent treatment options whether that's medication or counting or therapy ? Um Anyone that are more amenable to continuing in your military duties um than another that that that may be only a military behavior health clinician will consider . Yeah , I think that um within military behavioral health we are definitely more likely to try using our therapy modalities um more exhaustively just because that's something that is not necessarily limiting your duty options . Um things like if someone has trouble sleeping were far less likely to say here take Ambien or Lunesta because that can have some significant limitations and instead try CBT I CBT for insomnia or other less sedating , not sedative hypnotic medications to help manage that insomnia . Um If someone has an anxiety condition again that behavioral management rather than immediately giving them a significant course of benzodiazepines . Alright , great . Thank you . Well when you do need to notify uh command um you know the commander she or he may need to involve other members of their staff operations officers and senior enlisted um whose responsibility is to make sure that those folks you know verify can receive information . Is that on the commander or or are you involved in the process on how far that um that information can spread from the commander . So we certainly educate the commander um but we cannot control what they do or who they tell . So emphasizing the importance of the confidentiality of the information , the limited scope of where that information goes . Um And kind of the idea of who do you think really needs to know ? Um Ultimately though I can't control what a commander is gonna say or do right . Do you know a situation though ? I feel like a provider could be in a tough situation when the patient comes back close the loop with you and uh you know and they report that now my platoon mates know about this and my uh my platoon sergeant , things like that and you have uh figured out that there was a breach of confidential once it got to the command um you have any duty to follow back up to the commander and let them know the breach and and and if so are there any recourses for corrective action over so I do not know the specific policies around this . I know that for me as an individual um I would both want to reach back out to that command just to share the concern um to see you know who it was coming from . Was this coming from the Ceo , in which case you know , that's one issue is coming from lower down in the line , in which case that's an issue that the Ceo can certainly address . Um but additionally , every healthcare organization needs to have a hippo office and the ability to address these hipAA violations , even though it's not technically a hipAA violation , if it's coming from someone outside of the health care system that is still um you know , a situation where bringing those folks in and asking for their guidance and advice , potentially , you know , the ability to offer some more formal education going forward would be something I would lean quite heavily on . Great . You mentioned the question , where do your presentation about divulging information to family members ? Um We talked about violence to self , you know , what about threats of domestic violence um that that you have a duty also to warn family members , command um law enforcement and the community . How do you navigate that when , when that comes up in the course of your evaluation ? Yeah . So the the standard um and the tariff soft law is kind of the thing that governs this in the civilian world is um generally the standard is a clear and present danger to self or others . Uh So if they are making defined threats , if they are saying I want to hurt or kill someone else and they're telling you who it is , You do have a duty to notify that person um with their position in the military . If they are making um definite threats against another person um You know that falls within what we are allowed to disclose the command in 64 paco eight . Um So bringing them in depending on the degree of safety concerns that may be more appropriate at that point to reach out to police or based security . And if you have a genuine concern that there is a legitimate threat to someone else that is well within your right to do so and you're not going to be faulted for doing that . If you can justify your true concern . Yeah . As a physician you're just one member of a very large inter professional team when it comes to behavior . Health and military social workers , counselors , enlisted behavioral health technician Caplin um um etcetera . So if a non physician , someone else on your team um you know discovers a clear and present danger or recognizes that this is something that needs to go to the command . Do they always come to you as a physician ? Is your only your responsibility to identify the command ? Um Or can one of the other members of the professional team who's not a physician , nurse practitioner ? P . A . Um What are their duties or do they funnel enough to the physician um who is responsible in the end for that ? Well chaplains are their own special category . Um And they do have complete confidentiality . So if someone were to disclose homicidal ideation to them that is not something that they would be allowed to disclose , they could absolutely encourage that person to report to share with someone else . Um And they can encourage them strongly . But it is that is there they are completely confidential . If someone is to disclose in a behavioral health setting , if that's in an appointment with their nurse practitioner P . A . It's whoever is their designated care provider then that individual who's providing the care needs to make the report . Generally if it's a behavioral health test , they are someone who's working under and directly reporting to a physician or nurse practitioner , P a psychologist , other member of that health care team . Um And so they would inform you and generally you would be the one who would make that report . Okay well that's a lot of weight on the shoulders or folks who take care of the mental and behavior health needs of our troops and family members um retirees uh heavyweight . Indeed . So can you talk a little bit about their moral distress , moral injury in navigating this process ? Uh talk about how you take care of yourself . And is that an issue for you and your colleague ? Uh So one of my supervisors very early on made the comment when people asked about kind of how do you , how do you manage this ? Was she looked around and said have you seen whose offices are all around me . I'm surrounded by shrinks . Um And so knowing that we are in an environment in a situation where I can and I have leaned very heavily on my colleagues and said , hey this is the situation , you know , either is it just something that's really distressing that I need to talk out with you or is it something where I would love some guidance um and kind of some pointers , what would you do reaching out to um particularly as residents in the clinic . The residents are very strongly encouraged to reach out to senior doctors who are here and say , hey , I've got a situation , I've got a case , can you come in and talk to this person ? Um I think that's one of the biggest challenges of some of the like behavioral health practice that you have in the military at large is that we're so frequently in one of ones and so you don't necessarily have that community right there to lean back on and to give you the support and also kind of be on the fly consultation . Excellent , well thank you Lieutenant Quinn and thank you uh participants for all your great questions . You know , patient privacy is a key foundation of clinical practice uh in trying to no less than Hippocratic oath thousands of years ago with just being the most recent expression of that principle . Um and balancing our duty to respect the privacy of our patients with their duty to the military unit requires the deliberate applications of the considerations you presented today . Lieutenant Quinn um I'm personally glad we have experts like Lieutenant Flynn to provide consultation for these uh subject . That's why they're experts and specialists . Um and also , you know , the D . O . D . Medical Ethics Center and its portal , I'll put in a plug for the D . A . K . Advisor system which puts experts like Lieutenant Quinn but also experts in hematology , oncology , nephrology , you name it um at your fingertips for an immediate consult , no matter where the D . O . D uh stations you around the world . You know , we are a large brotherhood and sisterhood of folks taking care of our service members and so you know , we should reach out to folks . And I hope Lieutenant Quinn , you and your colleagues are available to do that for us . Absolutely . That's that's what we're standing by for .