Dear Drs. Mossman and Weston:
In my psychiatric practice, I sometimes provide pharmacotherapy for patients treated by psychotherapists who practice independently. Am I liable for what these therapists do or don’t do—for example, not contacting me if a patient is suicidal or experiences a medication side effect? How much communication should occur between us? Sometimes—after a patient signs a release—I call the therapist and leave messages, but my calls are not returned. What should I do?—Submitted by “Dr. B”
Pharmacologic advances and altered reimbursement patterns have drastically changed how psychiatrists understand and manage mental problems. Not long ago, insight-oriented psychotherapy was the primary treatment—and often the only one—psychiatrists provided for outpatients. Nowadays, most visits to psychiatrists involve little or no in-depth psychotherapy,1 and many patients receive “joint treatment”—a psychiatrist performs the diagnostic and medical assessment and prescribes medications where appropriate, and a nonphysician provides other treatment services.
Psychiatrists need to be clear about their responsibilities for patients whom they “share” with other mental health professionals. In this article, we’ll discuss:
- forces that promote split treatment
- types of split-treatment relationships
- how to limit liability risk when you split treatment with an nonphysician mental health practitioner.
Dollars and cents reasons
Since the 1980s, psychiatrists have spent less time with their patients, provided less psychotherapy, and prescribed medications more frequently.2 An estimated 70% of outpatient visits to psychiatrists involve no psychotherapy.1
Market conditions are a major factor in these changes. Cost-containment policies and reduced private insurance payments for psychotherapy visits have incentivized psychiatrists to collaborate with less-well-paid psychotherapists. Combining medication and psychotherapy may be the best and most cost-effective treatment for mentally ill patients, but psychiatrists get paid more for three 15-minute “med checks” than for one 45-minute psychotherapy session.3-5
Although managed care payment patterns may be “perversely influencing” psychiatry (as one psychiatrist puts it)6 other factors contributing to the decline of psychotherapy include:
- new medications with fewer side effects
- aggressive pharmaceutical company promotions of psychotropics
- greater public acceptance of mental illness and its treatment
- an increasingly cohort of psychiatrists trained by teachers and mentors who emphasized biologic therapies.1
DO YOU HAVE A QUESTION ABOUT POSSIBLE LIABILITY?
- Submit your malpractice-related questions to Dr. Mossman at douglas.mossman@qhc.com.
- Include your name, address, and practice location. If your question is chosen for publication, your name can be withheld by request.
Forms of split treatment
Psychiatrists engage in several types of professional relationships that split the care provided to mentally ill patients (Table 1),7 and Dr. B has asked us to focus on one type of split-care relationship: a physician and psychotherapist treat the same patient, ideally collaborating to provide good clinical care.
Split, collaborative care is common throughout medicine. Most of us see medical specialists who treat different illnesses, but each doctor is responsible for the care he or she provides. An allergist knows what orthopedic surgery is, but we don’t expect our allergist to provide follow-up after arthroscopic surgery—and neither does our orthopedist.
The same considerations apply when a psychiatrist’s patient sees an independent nonphysician therapist. The psychiatrist provides the same care that a patient receiving only pharmacotherapy would need. The psychiatrist should not expect the collaborating therapist to monitor the patient’s pharmacotherapy—for example, by checking lab tests or asking about medication side effects—although the therapist is welcome to tell the psychiatrist about pharmacotherapy matters or encourage the patient to do so.
Table 1
Types of split-care relationships
| Type | Characteristics |
|---|---|
| Consultative | Develops when one licensed practitioner asks for the opinion of another |
| Informal (‘curbside’) | One practitioner describes clinical characteristics to another; patient’s identity is unknown to consultant |
| Formal | Consultant documents findings after reviewing record and/or examining patient; consultant knows patient’s identity |
| Supervisory | Mandated relationship between 2 professionals in which supervisee should follow supervisor’s recommendations |
| Collaborative | Credentialed professionals share ongoing responsibility for care and complementary aspects of a patient’s treatment |
| Same agency | Practitioners have distinct treatment roles (eg, therapist and prescriber) in several patients’ care and may have regular contact with each other; shared medical record |
| Independent | Practitioners lack regular contact; scope of treatment duties is established for the individual shared patient |
| Source: Reference 7 | |
Limiting liability
Psychiatrists who share patients with independent nonphysicians can take several steps to promote better care and limit potential liability.
Delegation. Do not delegate essential aspects of medical care. For example, tell young patients starting antidepressants (and minors’ legal guardians) about the risk of increased suicidal ideation, and provide close monitoring. Although it is acceptable for a patient to tell his or her therapist about worsening suicidal thoughts, instruct the patient to inform you as well.