Right to decline referral

[Attending1985]

I am employed by a healthcare system with an outpatient mental health clinic. We have no associated inpatient unit or IOP. We have offer no wraparound services. I have a consult scheduled in two weeks with a patient with extremely severe BPD. She has numerous suicide attempts over the years with some recent. The private psychiatric hospital and the cmhc will no longer see her due to some behavior. I was also told she has taken legal action against a mental healthcare provider in the past. I told my manager it is not appropriate for me to see her and I was told we don’t have the right to refuse care but if I see her for the consult and feel she’s not appropriate I can refer her elsewhere. This is ridiculous because where am I supposed to refer her? No one else will accept her. I was under the impression you can refuse care if you don’t have the proper resources. Please help me out with this.

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[calvnandhobbs68]

I am employed by a healthcare system with an outpatient mental health clinic. We have no associated inpatient unit or IOP. We have offer no wraparound services. I have a consult scheduled in two weeks with a patient with extremely severe BPD. She has numerous suicide attempts over the years with some recent. The private psychiatric hospital and the cmhc will no longer see her due to some behavior. I was also told she has taken legal action against a mental healthcare provider in the past. I told my manager it is not appropriate for me to see her and I was told we don’t have the right to refuse care but if I see her for the consult and feel she’s not appropriate I can refer her elsewhere. This is ridiculous because where am I supposed to refer her? No one else will accept her. I was under the impression you can refuse care if you don’t have the proper resources. Please help me out with this.

I’d probably talk to your malpractice insurance company about this particular situation for the specifics but unless you have a doctor patient relationship, you generally don’t have an legal obligation to a potential patient.

However that might be different than what your clinics policy is and it then becomes a question of if you’re willing to blow up your job/leave over this issue.

Legal obligations and institutional policies can be quite a bit different.

 

[splik]

Well unless there is something in your contract about this, you may want to consider being very firm about declining. In this case, it sounds like it could actually be harmful to see this patient. If the pt is expecting ongoing care and you see her and say you cant provide ongoing care she is likely to feel rejected and abandoned and could decompensate, become suicidal, or act in punitive ways towards you. If the patient knows beforehand that it will only be a one time consultation without any ongoing care and accepts that, then that is a different thing altogether. Are there other psychiatrists in your clinic? I can't imagine anyone else would think it is appropriate either.

also who triages referrals? There needs to be clear exclusion criteria for patients if you cannot provide them with the services or level of care they need.

 

[robellis]

I am employed by a healthcare system with an outpatient mental health clinic. We have no associated inpatient unit or IOP. We have offer no wraparound services. I have a consult scheduled in two weeks with a patient with extremely severe BPD. She has numerous suicide attempts over the years with some recent. The private psychiatric hospital and the cmhc will no longer see her due to some behavior. I was also told she has taken legal action against a mental healthcare provider in the past. I told my manager it is not appropriate for me to see her and I was told we don’t have the right to refuse care but if I see her for the consult and feel she’s not appropriate I can refer her elsewhere. This is ridiculous because where am I supposed to refer her? No one else will accept her. I was under the impression you can refuse care if you don’t have the proper resources. Please help me out with this.

Don’t see the patient it’s not that hard, just tell them you refuse to see her period if they want her seen someone else can see her

 

[TexasPhysician]

Outpatient facilities can refuse care to anyone they wish for any reason (other than for federally protected classes). I’d be quite strict about this. It is your medical license. You decide what you do with it.

 

[wolfvgang22]

also who triages referrals? There needs to be clear exclusion criteria for patients if you cannot provide them with the services or level of care they need.

A very good question! Clearly not OP. I bet triage consists of 2 minutes spent by a non-psychiatrist merely verifying the source of payment.

 

[Attending1985]

A very good question! Clearly not OP. I bet triage consists of 2 minutes spent by a non-psychiatrist merely verifying the source of payment.

Our department nurse does. Clearly not working. Gonna go to my manager on Monday to let her know I’m not seeing this patient and discuss referral criteria. Thanks everyone.

 

[robellis]

Our department nurse does. Clearly not working. Gonna go to my manager on Monday to let her know I’m not seeing this patient and discuss referral criteria. Thanks everyone.

Good, remember you are the doctor, the captain of the ship, the leader of the team, the one whos gonna get blamed and sued, so it’s ultimately always your decision, don’t ever give in to the pressure of the admin, their job is to pressure you and your job as the leader is to resist the pressure and make the best decision for you and the patient

 

[Attending1985]

Good, remember you are the doctor, the captain of the ship, the leader of the team, the one whos gonna get blamed and sued, so it’s ultimately always your decision, don’t ever give in to the pressure of the admin, their job is to pressure you and your job as the leader is to resist the pressure and make the best decision for you and the patient

Thanks for that. I switched locations and am the only md so I don’t have anyone there to back me up. I’m hoping they’re respectful of my decision but I’m prepared to stand my ground. Our clinical leader is a psyd I’m not crazy about and I’m anticipating some pushback from her.

 

[robellis]

Thanks for that. I switched locations and am the only md so I don’t have anyone there to back me up. I’m hoping they’re respectful of my decision but I’m prepared to stand my ground. Our clinical leader is a psyd I’m not crazy about and I’m anticipating some pushback from her.

Psyd is a joke compared to an MD, if she has a problem with it you can walk down the street and get 11 job offers, you’re the boss of your schedule period. Good luck

 

[NickNaylor]

Agree that this is likely an institutional policy rather than anything legally based. As others have said, I would be firm and tell your clinic manager that you will not see the patient and that they need the schedule the patient with someone else if they want the patient seen. If they refuse to reschedule the patient, don't see her if she shows up at her scheduled appointment. Focus on your concerns about your facility not being able to offer the services that you feel are able to safely manage the patient - that's a harder argument to get upset about as, presumably, everyone would be interested in providing safe care (at least facially).

I've done this a few times in our TRD/interventional clinic because it's clear from available documentation that the patient seeing me isn't appropriate. Fortunately we have supportive clinic staff, and if there's any push-back I'll just ask them to call the patient to clarify what they are hoping to achieve with the visit. Most times they've just rescheduled the patient with a general outpatient provider (often the patient is trying to establish care, which is not an appropriate use for our clinic).

 

[Mad Jack]

Thanks for that. I switched locations and am the only md so I don’t have anyone there to back me up. I’m hoping they’re respectful of my decision but I’m prepared to stand my ground. Our clinical leader is a psyd I’m not crazy about and I’m anticipating some pushback from her.

Yeah, just let her know it's not just a no but a hard no and that if they have a problem with it they can hire another doctor. If you're not firm now about safety of referrals, you're going to be putting up with this for the rest of your time there. Level of care should be carefully assessed for all patients to ensure that they can be safely cared for by a practice, and agreeing to see a patient once without performing this assessment creates great liability for the practice and yourself that I would find unacceptable.

 

[PikminOC]

Good, remember you are the doctor, the captain of the ship, the leader of the team, the one whos gonna get blamed and sued, so it’s ultimately always your decision, don’t ever give in to the pressure of the admin, their job is to pressure you and your job as the leader is to resist the pressure and make the best decision for you and the patient

Bwahaha. No one cares.

 

[liquidshadow22]

So what other psychiatrist would be appropriate to see this pt in the outpatients setting?

If you document well, youll protect yourself from a lawsuit. This pt just sounds like a major pain in the ass you don't want to deal with.

 

[splik]

So what other psychiatrist would be appropriate to see this pt in the outpatients setting?

If you document well, youll protect yourself from a lawsuit. This pt just sounds like a major pain in the ass you don't want to deal with.

I disagree. It's not the psychiatrist issue so much, but what other services this patient needs that the op is not able to provide. a patient like this most likely needs a case manager, and ideally a therapist. Ideally they will be able to access a structured DBT program, or another treatment for DBT (e.g. MBT, transference focused psychotherapy, etc)

 

[liquidshadow22]

I disagree. It's not the psychiatrist issue so much, but what other services this patient needs that the op is not able to provide. a patient like this most likely needs a case manager, and ideally a therapist. Ideally they will be able to access a structured DBT program, or another treatment for DBT (e.g. MBT, transference focused psychotherapy, etc)

Yes makes sense but that is assuming there are other clinics with openings nearby the patient would have access to? I presume the OPs office has therapists since they have a PsyD on staff.

Is it better to see the patient or have them perhaps wait months without care to get into another clinic?

 

[heyjack70]

Yes makes sense but that is assuming there are other clinics with openings nearby the patient would have access to? I presume the OPs office has therapists since they have a PsyD on staff.

Is it better to see the patient or have them perhaps wait months without care to get into another clinic?

That's an interesting question. From an ethical/professional standpoint (in an ideal world), if this is the only psychiatrist available within a reasonable amount of time, they should take on the patient and do their best. From a liability standpoint however, I'm not aware of any legal protections for psychiatrists taking on SPMI (including severe BPD) and not having the appropriate resources for them. So if this patient ends up needing twice weekly therapy, which the psychiatrist can't provide, and calls the clinic multiple times a week in crisis, beyond what the psychiatrist can accommodate, and the patient ends up committing suicide, the psychiatrist would be unlikely to get relief claiming they were just doing their best from an ethical standpoint in a setting of limited resources. On the contrary, if this person remains stuck with a PCP and there is a similar bad outcome, I would assume a lower expectation and a harder lawsuit to win against the PCP. The PCP would have an easier time claiming they were doing there best and they tried to refer out but no resources were available.

Which is why our medical malpractice environment is garbage.

 

[Mass Effect]

So what other psychiatrist would be appropriate to see this pt in the outpatients setting?

If you document well, youll protect yourself from a lawsuit. This pt just sounds like a major pain in the ass you don't want to deal with.

It's not that the patient is a pain in the ass the OP doesn't want to deal with. It's that the OP doesn't have the support structure in place to adequately treat this patient and taking her on would likely be bad for the patient as well as the OP. The patient won't get the care she needs and the OP will be in over his/her head trying to compensate for that and do the job of an entire team. That said, I'm not convinced a one time consult is the worst thing ever, as long as the patient knows ahead of time. Many psychiatrists see patients one time with no committment and then refer out if they can't treat and it may be a way for the OP to not piss off management.

 

[Mad Jack]

Yes makes sense but that is assuming there are other clinics with openings nearby the patient would have access to? I presume the OPs office has therapists since they have a PsyD on staff.

Is it better to see the patient or have them perhaps wait months without care to get into another clinic?

Taking on a patient that you know you do not have the resources to provide safe care for is, in the legal sense, irresponsible and opens you up to high liability. Our legal system doesn't place a high value on ethics.

 

[vistaril]

you guys are overthinking this.....it's likely nobody in the area has these fabulous 'resources' academia types love
to crow about. Take her, don't take her, whatever.....but let's not act like this is some rare patient. Severe borderlines are seen all the time in psych
pracctices. Yes they probably don't make up a large percentage of the total patients, but if you were to remove every group that
represents a challenging population, that would make up a good chunk of the overall patients.

 

[Attending1985]

Want to add that this patient is not merely difficult or demanding with repeat self harm. This patient makes repeated serious life threatening suicide attempts. I have knowledge of this patient from my training. It’s not just a matter of avoiding a stressful patient encounter it’s a matter of her dying.

 

[wolfvgang22]

I find in my practice these particular types of patients either agree to follow a treatment plan, or quickly fire me as their doctor because they are unwilling to make changes and resent my encouragement. So I usually don't have to terminate care, the patient does. If a patient is particularly obnoxious it seems to happen more often. I do not tolerate abuse of myself or the therapeutic relationship, anymore.
I follow the standard of care, and usually do more, but sometimes a patient is still in a precontemplative stage of change and not ready to accept any recommendations. I document well and move on. It is the patient who has an illness, not me.
That's the way she goes.

I will say I have several patients who have been banned by other clinics or doctors, and with kindness and firm limits it has worked out very well. A lot of that is due to the patient learning what the boundaries are by getting banned already elsewhere.

 

[vistaril]

Want to add that this patient is not merely difficult or demanding with repeat self harm. This patient makes repeated serious life threatening suicide attempts. I have knowledge of this patient from my training. It’s not just a matter of avoiding a stressful patient encounter it’s a matter of her dying.

Patients are going to die....it happens. I lost a couple in the last year. The fact that she is at such high risk to die of suicide probably speaks to the fact that she *needs* your help and is a reason to take her, not pass her on to these fictitious other providers with tons of resources that don't likely exist with them/for her either....

I'm sorry but "I can't see you because you need a practice with a DBT group or a highly regarded DBT practitioner" is bs....if you pass on the patient she likely isn't going to magically drop in a setting with these things.

 

[TexasPhysician]

Patients are going to die....it happens. I lost a couple in the last year. The fact that she is at such high risk to die of suicide probably speaks to the fact that she *needs* your help and is a reason to take her, not pass her on to these fictitious other providers with tons of resources that don't likely exist with them/for her either....

I'm sorry but "I can't see you because you need a practice with a DBT group or a highly regarded DBT practitioner" is bs....if you pass on the patient she likely isn't going to magically drop in a setting with these things.

OP has knowledge of the patient from peers and already has a significant distaste. In my mind, it’s like trying to give a patient Zoloft when all of their friends had a bad reaction. It’s predetermined to cause frustration/failure, and the counter transference is detrimental. While the “perfect” clinical situation may not exist, this is the worst beginning possible. It would be nice to provide some possible better referrals, but at this point, I wouldn’t recommend taking the patient. Just pointing out an opposing viewpoint. I can see your side as well. We can’t just neglect difficult cases, but we need to go into the relationship feeling as if we can make a difference.

 

[vistaril]

OP has knowledge of the patient from peers and already has a significant distaste. In my mind, it’s like trying to give a

patient Zoloft when all of their friends had a bad reaction. It’s predetermined to cause frustration/failure, and the counter transference is detrimental. While the “perfect” clinical situation may not exist, this is the worst beginning possible. It would be nice to provide some possible better referrals, but at this point, I wouldn’t recommend taking the patient. Just pointing out an opposing viewpoint. I can see your side as well. We can’t just neglect difficult cases, but we need to go into the relationship feeling as if we can make a difference.

thats fine and I don't have any issue with this. My point is let's drop all this "oh they need x,y,z" nonsense to give the person the care they deserve need lol.....if the patient had access to that stuff, they'd likely already be there. It's fine to not take the patient as I said, but the OP shouldn't throw out a lot of BS to make himself feel better about it.

 

[Attending1985]

thats fine and I don't have any issue with this. My point is let's drop all this "oh they need x,y,z" nonsense to give the person the care they deserve need lol.....if the patient had access to that stuff, they'd likely already be there. It's fine to not take the patient as I said, but the OP shouldn't throw out a lot of BS to make himself feel better about it.

I can’t get into specifics here but the fact that this patients needs a clinic with ability to directly admit to their inpatient unit from clinic is not bs in the least and just common sense. There’s a place in town with associated inpatient unit, iop and DBT. Problem is not available resources it’s patients preference to not get care at places with these resources.

 

[vistaril]

I can’t get into specifics here but the fact that this patients needs a clinic with ability to directly admit to their inpatient unit from clinic is not bs in the least and just common sense.

Why is it so hard for you to admit patients? Just call the ED and let them know they are coming.....so what if they need to process through ED first before
getting on the unit. Surely some of your outpts have needed to be admitted before, so that doesn't make a lot of sense

 

[PikminOC]

Op, what's the update?

 

[Attending1985]

Why is it so hard for you to admit patients? Just call the ED and let them know they are coming.....so what if they need to process through ED first before
getting on the unit. Surely some of your outpts have needed to be admitted before, so that doesn't make a lot of sense

There are 2 inpatient units in town. One she’s banned from and the other is associated with the other hospital system who naturally gives preference to their own patients and wont likely take her. As you know inpatient beds aren’t easy to come by which means she’s gonna boarded in the ED for days or worse. Not good care.

 

[Attending1985]

Op, what's the update?

Risk management is now being pulled in but my wishes are being respected. Will be interesting to see what risk says.

 

[PikminOC]

Risk management is now being pulled in but my wishes are being respected. Will be interesting to see what risk says.

They always say everything is fine. No risk