Treading on MD territory when writing reports?

Logic Prevails · Jun 14, 2006

I had assessed an individual recently who was a longstanding alcoholic and was presenting with memory concerns. In my report, one of the recommendations I made was for them to consider taking a vitamin B1/B12 and that they may want to discuss this with their family doctor.

I gave this person a short explanation of how individuals struggling with alcoholism have a vitamin deficiency that may lead to wernicke-korsakoffs psychosis and how taking vitamins may lesssen some of the damage they were doing.

Although I thought I was okay by making this recommendation, my supervisor made me to take the whole thing out... saying that "we are not doctors" and "we have no business making these sort of recommendations."

What do people think about this? Was I being to forthright with my recommendation? Should I just have said "you might discuss your diet with your family doctor?"

Logic Prevails · Jun 14, 2006

Just to be clear, I am NOT asking for client advice, I am asking whether we should make recommendations that borderline MD territory.

clinpsychgirl · Jun 14, 2006

Brad3117 said:
Just to be clear, I am NOT asking for client advice, I am asking whether we should make recommendations that borderline MD territory.

My thoughts are this: If possible, I think the best approach is to liase with the client's primary care provider and alert them of the symptoms if its very concerning and then let the pcp take it from there. I don't know if I would do that in the situation you presented. I might just tell the client to talk to their pcp about it.

On the other hand, I have done some recent work on empirically supported psychopharmacologic treatments for various mental health disorders in children; thus, I would assume my knowledge in this area is something to be shared in a more collaborative way with my client's primary care providers.

I would think it would only be beneficial to the treatment of the client's mental health disorder. And I think that most pcps would be happy to collaborate in this way. And, if I thought the pcp was disregarding the empirically-based guidlines, I would take a stand. And I think it would be a disservice to the client if I didn't.

But again, this is very specific to the treatment of psychiatric disorders, where I think we have a personal responsibility to liase with pcps on such matters and to be up-to-date on the supported psychopharm treatments to assure that our clients are receiving the best overall standard of care.

Personally, I would not feel comfortable going beyond that line- so, if I thought something more "medical" was going on, I'd might advise the client to speak with their pcp or if I was really concerned, I'd attempt to let the physician know of the symptoms myself, but i wouldn't make a recommendation per say- just my thoughts.

50960 · Jun 14, 2006

That is just dumb to ask you to take it out. If the info is based on sound principles and within your scope and training then you should make such recommendations. What does your supervisor think an MD would want when they read a psych eval??

Psyclops · Jun 14, 2006

I think this is a pretty good example of a tough call. Let me give you another way to look at it CPG. Vitamins, although "a substance" certainly do not require a physician or prescription for purchase or administration. Daily countless people decide that they should start, or "titrate" their current vitamin intake. Psychologists just happen to be aware of what a B vitamin deficency, caused by a arguably psycholgical disorder, might result in. Hence I think it would be in their bounds of expertise to suggest it. The same goes for caloric intake in my opinion.

Psyclops · Jun 14, 2006

I had been working on my response for awhile, so I hadn't seen yours psisci, but basically I think you put it well, scope of training sums it up.

PsychEval · Jun 14, 2006

Until you have your own license, you could put the following under the recommendations:

Consult with dietitian to determine if B1/B12 would be beneficial considering long standing alcohol use.

PublicHealth · Jun 14, 2006

clinpsychgirl said:
My thoughts are this: If possible, I think the best approach is to liase with the client's primary care provider and alert them of the symptoms if its very concerning and then let the pcp take it from there. I don't know if I would do that in the situation you presented. I might just tell the client to talk to their pcp about it.

On the other hand, I have done some recent work on empirically supported psychopharmacologic treatments for various mental health disorders in children; thus, I would assume my knowledge in this area is something to be shared in a more collaborative way with my client's primary care providers.

I would think it would only be beneficial to the treatment of the client's mental health disorder. And I think that most pcps would be happy to collaborate in this way. And, if I thought the pcp was disregarding the empirically-based guidlines, I would take a stand. And I think it would be a disservice to the client if I didn't.

But again, this is very specific to the treatment of psychiatric disorders, where I think we have a personal responsibility to liase with pcps on such matters and to be up-to-date on the supported psychopharm treatments to assure that our clients are receiving the best overall standard of care.

Personally, I would not feel comfortable going beyond that line- so, if I thought something more "medical" was going on, I'd might advise the client to speak with their pcp or if I was really concerned, I'd attempt to let the physician know of the symptoms myself, but i wouldn't make a recommendation per say- just my thoughts.

I would not get too excited about EBM in psychiatry:

http://www.ncbi.nlm.nih.gov/entrez/...uids=16677777&query_hl=17&itool=pubmed_docsum

Dr.JT · Jun 14, 2006

PsychEval said:
Until you have your own license, you could put the following under the recommendations:

Consult with dietitian to determine if B1/B12 would be beneficial considering long standing alcohol use.

Where did the referral come from? If it was from an MD, I would just report the results of the cognitive eval, since this would be the reason for the referral (i.e., memory problem). In this case your recommendation would run the risk of insulting the MD (you are implying she/he did not think of this).

If it wasn't an MD, I think PE's recommendation is appropriate along with recommending a full medical workup. Going beyond this, IMHO, is questionable.

PsychEval · Jun 14, 2006

I hear what your saying, but I also dont think it is appropriate to withhold information which you know to be helpful for a patient because you are concerned about insulting a M.D. or any referral source for that matter.

Dr.JT · Jun 14, 2006

PsychEval said:
I hear what your saying, but I also dont think it is appropriate to withhold information which you know to be helpful for a patient because you are concerned about insulting a M.D. or any referral source for that matter.

The assumption is the MD would (or should) know to look at these issues. A review of the records would confirm this.

JatPenn · Jun 14, 2006

Dr.JT said:
Where did the referral come from? If it was from an MD, I would just report the results of the cognitive eval, since this would be the reason for the referral (i.e., memory problem). In this case your recommendation would run the risk of insulting the MD (you are implying she/he did not think of this).

If it wasn't an MD, I think PE's recommendation is appropriate along with recommending a full medical workup. Going beyond this, IMHO, is questionable.

Heaven forbid :scared:

PsychEval · Jun 14, 2006

Much of the research on integrated care suggests that procedures or recommendations get missed because someone on the treatment team is assuming someone else will take care of it. As brilliant as our physician colleagues are, they cant be expected to know everything about every condition. It takes a team.

PsychEval · Jun 14, 2006

JatPenn said:

Heaven forbid

Click to expand...

My thoughts as well. Too funny, as they say, navigating narcissistic landmines.

clinpsychgirl · Jun 14, 2006

PublicHealth said:
I would not get too excited about EBM in psychiatry:

http://www.ncbi.nlm.nih.gov/entrez/...uids=16677777&query_hl=17&itool=pubmed_docsum

Public health, I recognize that negative outcomes in RTCs aren't fully reported (whos going to publish a study with no results); that there is high comorbidity in youth with psychiatric disorders; etc...

but in pcp settings (i'm not talking psychiatry here); physicans may not always have a solid background in mental health to know how to effectively evaluate/manage youth and many would appreciate and make ready use of the treatment guidlines.

I'm not saying the system is without its flaws; however, being on the dissemination end of this movement is exciting and I think we are making some great strides. I won't go into massive amounts of detail here- but if you are interested- feel free to pm me.

clinpsychgirl · Jun 14, 2006

Psyclops said:
I think this is a pretty good example of a tough call. Let me give you another way to look at it CPG. Vitamins, although "a substance" certainly do not require a physician or prescription for purchase or administration. Daily countless people decide that they should start, or "titrate" their current vitamin intake. Psychologists just happen to be aware of what a B vitamin deficency, caused by a arguably psycholgical disorder, might result in. Hence I think it would be in their bounds of expertise to suggest it. The same goes for caloric intake in my opinion.

This is a good point. My overly conversative answer is a good indicator that I probably stare at a computer all day as apposed to interacting with real human beings

Dr.JT · Jun 14, 2006

PsychEval said:
Much of the research on integrated care suggests that procedures or recommendations get missed because someone on the treatment team is assuming someone else will take care of it. As brilliant as our physician colleagues are, they cant be expected to know everything about every condition. It takes a team.

This is a good point PE, but in this situation anyone remotely competent would check for Thiamine deficiency. Furthermore, in this case it would not be an issue since a patient with Wernicke-Korsakoff would be reported memory problems. They would be obviously impaired. also, I agree with addressing these issues and I never hesitate to, but sometimes a phone call, rather than passively questioning someone's thoroughness in your report, builds better professional relationships as well as more referrals.

Psyclops · Jun 14, 2006

clinpsychgirl said:
This is a good point. My overly conversative answer is a good indicator that I probably stare at a computer all day as apposed to interacting with real human beings

Not necessarily a bad suggestion, I was playing devil's advocate. If psychologists got sued more often they might have a more clear answer in this case. And if you dealt with people more often as you put it, you may even be more conservative.

I second PE's my thoughts exactly to JPs post.

PsychEval · Jun 14, 2006

Dr.JT said:
This is a good point PE, but in this situation anyone remotely competent would check for Thiamine deficiency. Furthermore, in this case it would not be an issue since a patient with Wernicke-Korsakoff would be reported memory problems. They would be obviously impaired. also, I agree with addressing these issues and I never hesitate to, but sometimes a phone call, rather than passively questioning someone's thoroughness in your report, builds better professional relationships as well as more referrals.[/QUOTE]

Agree

Logic Prevails · Jun 14, 2006

WOW! - lots of quick feedback. Some good stuff here.

I will elaborate a bit by saying that the referral came from an addictions counsellor and there had been no physician involved for contact.

I feel the most comfort saying what PsycEval said:
"Consult with dietitian to determine if B1/B12 would be beneficial considering long standing alcohol use."

...which is pretty much what I had in the report before I was asked to take it out.

Dr.JT · Jun 14, 2006

Brad3117 said:
WOW! - lots of quick feedback. Some good stuff here.

I will elaborate a bit by saying that the referral came from an addictions counsellor and there had been no physician involved for contact.

I feel the most comfort saying what PsycEval said:
"Consult with dietitian to determine if B1/B12 would be beneficial considering long standing alcohol use."

...which is pretty much what I had in the report before I was asked to take it out.

I would also recommended a neurological eval if there are actual memory problems. WK is probably an unlikely culprit in this case.

Neuro-Dr · Jun 15, 2006

Here is my two cents...

If your supervisor said take it out, there is no more discussion because it is their license and they can interpret ethics the way they want.

However, your question more generally is whether recommending B1/B12 is within your purview as a psychologist. Perhaps, the burden would be on you to demonstrate competency to understand the effects, interactions and mechanisms of action involved in your recommendation.

I have seen a psychologist sued (although not successfully) for recommending Vitamin E and Ginko Biloba in dementia cases.

The issue of whether something is ok just because it is not a pharmaceutical is problematic. You are in a position of power and an attorny will argue that the patient is not expected to know whether your advice is sound or just an opinion that any layperson can offer.

I routinely recommend consideration of prescription meds by classes (not specific or doses). However, I will add things like - if a child is already a little moody and has ADHD, it may be prudent to try a methlyphenidate drug over something like adderall because of wash out problems. If your testing aids in the determination of benefits or side effects, it is up to you to report it.

The question you pose is whether your evaluation specifically lead to that conclusion and I think it did not. Does that mean you couldn't say to consider possible reversible forms of dementia, I think you must. By not doing so, you could lead to a recommendation of something like Aricept, which may be helpful for the symptoms, but not the cause.

We could argue over the language to use, but I think you judgement in terms of how you make decisions (including asking for feedback on the forum) is sound.

Treading on MD territory when writing reports?

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