Declining outpatient referrals

[nexus73]

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In outpatient psychiatry, as a solo doc, or in a small group, with minimal staff, no therapists, no case management, do you limit the types of patients you will accept for initial consultation?

I'm guessing there are certain diagnoses or symptoms that you would not accept...like severe psychotic illness, maybe substance use disorders, severe borderline personality disorder, behavior problems related to autism or low IQ? Just because these patients may need more in depth services with therapy and case management, and may be beyond what a small clinic can adequately provide. In cases like this, where you decline to see a patient, do you let the referring doctor know why, or make recommendations like they need to be in a community mental health agency, or some other specialty clinic?

What diagnoses or other factors would lead you to decline to accept a referral?

Or do you see every referral, and if not appropriate for your clinic, send back to the PCP with recs on appropriate treatment setting, etc?

 

[Indodo]

In outpatient psychiatry, as a solo doc, or in a small group, with minimal staff, no therapists, no case management, do you limit the types of patients you will accept for initial consultation?

I'm guessing there are certain diagnoses or symptoms that you would not accept...like severe psychotic illness, maybe substance use disorders, severe borderline personality disorder, behavior problems related to autism or low IQ? Just because these patients may need more in depth services with therapy and case management, and may be beyond what a small clinic can adequately provide. In cases like this, where you decline to see a patient, do you let the referring doctor know why, or make recommendations like they need to be in a community mental health agency, or some other specialty clinic?

What diagnoses or other factors would lead you to decline to accept a referral?

Or do you see every referral, and if not appropriate for your clinic, send back to the PCP with recs on community mental health, etc?

It kind of depends on where you are. If there are other places, larger groups and community outpatient behavioral health centers that can provide those services then its up to you.
If you are in short supply, you should see the pt with schizophrenia over the naval gazer. Just my 2 cents.
I don't think legally you are obligated to take anyone.
If you are asking because this would irritate your referral base...just think what you would do as the referring doctor.

 

[nexus73]

It kind of depends on where you are. If there are other places, larger groups and community outpatient behavioral health centers that can provide those services then its up to you.
If you are in short supply, you should see the pt with schizophrenia over the naval gazer. Just my 2 cents.
I don't think legally you are obligated to take anyone.
If you are asking because this would irritate your referral base...just think what you would do as the referring doctor.

I think wanting to be helpful and not piss off the PCPs is one of the main reasons for my question. The other concern is not wanting to take on patients I can't adequately care for.

 

[PikminOC]

It kind of depends on where you are. If there are other places, larger groups and community outpatient behavioral health centers that can provide those services then its up to you.
If you are in short supply, you should see the pt with schizophrenia over the naval gazer. Just my 2 cents.
I don't think legally you are obligated to take anyone.
If you are asking because this would irritate your referral base...just think what you would do as the referring doctor.

Navel gazer?

 

[PikminOC]

Eating disorders

 

[futuredo32]

Eating disorders people with a history of violence. I am a petite girl renting an office in a building with all females. No court ordered patients . I usually say "We can meet and decide after a few visits and decide if it is a good fit so we can be sure you are getting the best care possible."

 

[randomdoc1]

I decline new patients who are on things like 6mg of clonazepam and 100mg oxycodone daily. Unless they are truly fully invested in breaking that benzo. Which most are not >.>

 

[nexus73]

Are there any patients you won't see because you don't have the resources or availability to treat them appropriately? For example, if someone needs a lot of case management help, and you're the only one available, you're doing the case management. You can't just refuse to address their needs...once you take on a patient you've basically agreed to provide them necessary care, even if that means extra phone calls, multiple visits per week, etc. Then that time can't be spent with other patients who also need your help.

 

[randomdoc1]

Are there any patients you won't see because you don't have the resources or availability to treat them appropriately? For example, if someone needs a lot of case management help, and you're the only one available, you're doing the case management. You can't just refuse to address their needs...once you take on a patient you've basically agreed to provide them necessary care, even if that means extra phone calls, multiple visits per week, etc. Then that time can't be spent with other patients who also need your help.

If I am finding it difficult to accommodate all their needs, I transfer them to a provider who can better meet them.

 

[whopper]

A major problem here is you can't diagnose the person until you see them. After you've seen them you now have a doctor-patient relationship. I've gotten a few patients who were inappropriate for my office but we only found out after the fact.

E.g. one hospital had a severe alcoholic and discharged him without a psych consult. He was still withdrawing when he came to my office. What happened was they told him to set up a psych appt, we just happened to have an opening the same day, and then just dropped him off in front of my office and then pulled a Pontius Pilate on all of us.

After I evaluated the case I told him to go back to the hospital. He was still actively withdrawing and since they admitted him in the first place, dropped him off, and didn't even give me his records from his hospital stay I told him I didn't know if his electrolytes were still off. Of course questions were asked such as "why would they discharge me if I wasn't stable?" I told him I couldn't give him an answer cause I didn't even know if he was stable cause I never got any records. Of course we asked the hospital to fax us the records and they didn't. Their medical records office was closed (it was an evening appt). It turned out the hospital didn't even have a psychiatrist on duty, hence why they did such a lame job dropping him off.

Needless to say everyone involved was very upset. The hospital didn't want to take him back, I was pissed, and so was the patient.

This type of thing can easily happen to you the first year of private practice. You'll be so open to seeing new patients cause you're not filled up and because you'll have a lot of open spots people can quickly come in. This never would've happened had the person had to wait several days for an initial appt.

To avoid these things try to have a delay between meeting a brand new patient. E.g. if the person is very severe they likely cannot wait at least 2-4 weeks for a new appt. Further don't accept a new patient over the phone unless it's the person who is going to be the patient. On a few occasions I'd get a new patient's parent, the patient doesn't show up and then the patient argues he shouldn't pay the no show fee cause he never set up the appt. Also don't allow your receptionist to allow a new patient from a hospital unless they clear it with you. Some hospitals are notorious for dumping patients they know aren't stable.

 

[futuredo32]

A major problem here is you can't diagnose the person until you see them. After you've seen them you now have a doctor-patient relationship. I've gotten a few patients who were inappropriate for my office but we only found out after the fact.


To avoid these things try to have a delay between meeting a brand new patient. E.g. if the person is very severe they likely cannot wait at least 2-4 weeks for a new appt. Further don't accept a new patient over the phone unless it's the person who is going to be the patient. On a few occasions I'd get a new patient's parent, the patient doesn't show up and then the patient argues he shouldn't pay the no show fee cause he never set up the appt. Also don't allow your receptionist to allow a new patient from a hospital unless they clear it with you. Some hospitals are notorious for dumping patients they know aren't stable.

How do you get paid for new patient no shows? How do you know their insurance info address etc prior to the first appointment? Do you collect all of that prior to the first appointment?

 

[whopper]

Collection agencies can only make patients pay fees owed only if they show up to your office in the first place and you saw them. They cannot collect for no shows (at least that's what my billing office tells me). So the only way you can enforce someone who never had 1 appt ever is to tell them they can never ever schedule a new appt unless they pay the no show fee.

You won't know their insurance info address unless you intentionally collect that with making the first appt. Most doctors don't cause it's not worth the effort.

 

[dl2dp2]

A major problem here is you can't diagnose the person until you see them. After you've seen them you now have a doctor-patient relationship. I've gotten a few patients who were inappropriate for my office but we only found out after the fact

Collection agencies can only make patients pay fees owed only if they show up to your office in the first place and you saw them. They cannot collect for no shows (at least that's what my billing office tells me). So the only way you can enforce someone who never had 1 appt ever is to tell them they can never ever schedule a new appt unless they pay the no show fee.

Whopper is spot on on both as usual.

I generally don't see patients who are "super urgent", since that means they need to go to the ER. However, outside of that, it's impossible to know ahead of the time whether someone's "appropriate" for me until I did a comprehensive evaluation. Which means, I accept all evaluation requests as long as I have room and the patient can pay. Unless it's for something that's clearly inappropriate (i.e. child, peripartum consult).

The evaluation itself costs $X. I don't do phone screenings except for pure logistic things (i.e. how much, how to pay, where/when, purpose of visit, disclaimers, etc). If after the evaluation the patient is clearly inappropriate you refer out. Prior to writing a script you do the referral. After writing the script the patient may still become inappropriate, but you can close your chart for any number of legit reasons, including clinical need for a higher level of care.

 

[whopper]

I've told my receptionist do not take patients directly from hospitals. One of the local hospitals is trying to get us to take their outpatient psych patients despite that they have their own psych department. Patients from that hospital have typically been disasters and because of the hospital. E.g. they make the patients use their pharmacy. If the patients are on workman's comp, the workman's comp typically won't pay for the meds despite that they told the patient and I they are supposed to do so. The pharmacist at that hospital is an a-hole and is very rude to the patients and to us. I've brought this up to them several times and they never fixed it.

So after I told my receptionist to stop taking the patients from that hospital. Then the administration, that is completely oblivious to the problems going on in their own hospital calls our practice and tells us they have no knowledge of what I mentioned, and then continues to beg us to take their patients.

So guess we we did? That's a no brainer. We continued to stop taking their patients. If they're not willing to fix their own house and not let us fix it either, I'm not wasting my time with them.

 

[nexus73]

Whopper is spot on on both as usual.

I generally don't see patients who are "super urgent", since that means they need to go to the ER. However, outside of that, it's impossible to know ahead of the time whether someone's "appropriate" for me until I did a comprehensive evaluation. Which means, I accept all evaluation requests as long as I have room and the patient can pay. Unless it's for something that's clearly inappropriate (i.e. child, peripartum consult).

The evaluation itself costs $X. I don't do phone screenings except for pure logistic things (i.e. how much, how to pay, where/when, purpose of visit, disclaimers, etc). If after the evaluation the patient is clearly inappropriate you refer out. Prior to writing a script you do the referral. After writing the script the patient may still become inappropriate, but you can close your chart for any number of legit reasons, including clinical need for a higher level of care.

Do you refer the patient on to someone else from your clinic, or recommend where the pcp should refer them?

 

[dl2dp2]

Do you refer the patient on to someone else, or recommend the pcp refer them to someone else?

Around where I am, PCPs don't have a clue who's a good or a bad psychiatric referral, especially if the case is declined by me, which would be someone who's quite ill. In general, if after an intake I think the patient is not a good fit, I would refer the patient to a day program or something more intensive and serve as a consult if necessary. I also have a list of generic academic facilities that are reliable where I send patients.

 

[nexus73]

Around where I am, PCPs don't have a clue who's a good or a bad psychiatric referral, especially if the case is declined by me, which would be someone who's quite ill. In general, if after an intake I think the patient is not a good fit, I would refer the patient to a day program or something more intensive and serve as a consult if necessary. I also have a list of generic academic facilities that are reliable where I send patients.

The only reason to pre-emptively refer is if I have enough clinical information to say confidently this person is very likely to need higher level service. In that case, why have the person wait a few weeks to see me, then I recommend another clinic, then they wait another few weeks, maybe longer, to get into the other clinic. In the meantime I've used space in my clinic for a patient I won't continue to see, space that could have been used for someone else, and I've taken on the liability of a higher risk patient I don't have the resources to treat.

 

[dl2dp2]

The only reason to pre-emptively refer is if I have enough clinical information to say confidently this person is very likely to need higher level service. In that case, why have the person wait a few weeks to see me, then I recommend another clinic, then they wait another few weeks, maybe longer, to get into the other clinic. In the meantime I've used space in my clinic for a patient I won't continue to see, space that could have been used for someone else, and I've taken on the liability of a higher risk patient I don't have the resources to treat.

All you say would be correct. But in real life this doesn't happen very often: only if the patient says I'm suicidal with a plan on the phone, or says I'm actively in alcohol withdrawal. You refer to ER. Or if you are getting a hospital discharge where it's clear the outpatient plan is not appropriately set up.

On the other hand, in order to get enough clinical information to say confidently that a person needs a higher level of care and determine what that care level would be, it often takes a full evaluation. For example, in substance abuse, the ASAM placement criteria is fairly detailed and has lots of pieces. In public psychiatry it would the same: does the patient have enough negative symptom to require a specialized program? Is it a prodromal case? Does the patient need a state hospital admission? How do you know what to refer to until you have a comprehensive treatment plan designed? The space issue is a non-issue. In private practice, you often need to do an evaluation first before "accepting" the patient into your practice. This is considered standard of care. You would bill every time someone shows up, regardless of whether they would stay.

Think of this another way: if you are any other medical specialist, would you do such screening? No. It's nonsensical. People show up to your outpatient practice for a chief complaint or a referral from PCP, and they might end up with cancer, or lupus, or MS, and might need to be 1) hospitalized 2) get procedures, but this doesn't mean that they get "screened" out from the get go because routine outpatient follow-up is determined, after a work up, to be clinically inappropriate. "Screening people out" is a weird archaic psychoanalytic remnant that's really no longer relevant in modern psychiatric practice.

 

[PikminOC]

I think it is different in psychiatry esp as we don't have alot of staff, etc. It can get dangerous.

 

[Trismegistus4]

Think of this another way: if you are any other medical specialist, would you do such screening? No. It's nonsensical. People show up to your outpatient practice for a chief complaint or a referral from PCP, and they might end up with cancer, or lupus, or MS, and might need to be 1) hospitalized 2) get procedures, but this doesn't mean that they get "screened" out from the get go because routine outpatient follow-up is determined, after a work up, to be clinically inappropriate. "Screening people out" is a weird archaic psychoanalytic remnant that's really no longer relevant in modern psychiatric practice.

I disagree. I do not want to treat ADHD or prescribe stimulants or daily benzos, and I think it's perfectly legitimate to screen out people who are looking for those things. It's more trouble than it's worth to make them wait for their initial appointment only to be told "I don't do that," and deal with the ones who keep coming back and hounding you for whatever it is they want.

 

[ryerica22]

Eating disorders people with a history of violence. I am a petite girl renting an office in a building with all females. No court ordered patients . I usually say "We can meet and decide after a few visits and decide if it is a good fit so we can be sure you are getting the best care possible."

You mean Eating Disorders and people with a history of violence, right? I don't typically think of Anorexics as Violent.

 

[Liquid8]

You can decline referrals for a number of reasons, most commonly being that you don’t have sufficient interest or expertise in a particular area. One of our Old Age psychiatrists (who has been around for a very long time) still gets referrals for younger adults which he declines and passes on. However, when he first started he did see these patients as he was building up his practice.

A lot of our general adult psychiatrists refuse to see ADHD or eating disorders. A lot also will not see borderline personality disorder, but that tends to be more of a preference rather than a hard and fast rule as a “bipolar” referral can often turn out to be BPD instead. If you’re firm on this, one could make the diagnosis and discharge to an alternative provider, but I don’t think this happens too often. Typically we will manage any drug or medication related issues, and suggest suitable external DBT options if we’re not going to engage in therapy ourselves. One thing to also keep in mind is that the acuity of borderlines is private is often less than what you might previously have been expecting. Compared to what I used to see in ED and acute public wards, often they are better supported, have less self-harm/suicidal behaviours and are more functional.

A patient may also not be suitable if you don’t think you can assist them or they need more care than you could provide. The very complex patient with multiple comorbidities may fit that category, and may not be suitable for a solo practitioner even in a shared care model. The difficulty here is often you don’t know until you see the patient – that just means you have to organise the additional supports or refer them elsewhere if you think it is required.

If you don’t sight referrals, you may end up getting into difficulty situations that can be hard to extract oneself from or having to deal with time-wasters. Not too long ago, we had a referral for a new patient wanting to see a psychiatrist for a letter to support them getting a government pension when he was going to be in Thailand for a 6 month “drug rehab resort.” Naturally an urgent appointment was demanded because he was flying out soon, and it had to be bulk billed which means no out of pocket expenses to the patient! Our reception staff will usually offer a new referral to 5-6 psychiatrists, but even they knew that no-one would touch this one or was so desperate for work that they needed to pick this kind of case up.

 

[aim-agm]

Why the preference not to see eating disorders?

 

[whopper]

Why the preference not to see eating disorders?

I cannot answer for another person but can say that the majority of eating disorders and their sx aren't treatable with meds. The majority of them are psychotherapy-only cases unless the ED is severe requiring hospitalization.

The only solid data with eating disorders and meds are SSRIs reduce purging (and some binging) behavior. Topiramate helps with binging in some studies but it never got an indication. Although Vyvanse got an indication for treating binge-eating many psychiatrists aren't comfortable with this treatment because ED patients typically have cluster B traits, stimulants are controlled substances with addiction potential, and it's a while it will treat the sx it doesn't treat any fundamental physiology that will lead to health benefits other than sx improvement.. (In comparison most antidepressants, for example cause physiological changes more fundamental than simply just treating the sx such as change in the regulation of neurotransmitters, increased brain-derived neurotrophic factor, decreased pathological cytokine release, all of which are healthy benefits more fundamental than simply improving sx, and they aren't addictive. Also several long-term studies show antidepressants for the most part are safe and can yield disease preventing benefits).

I'm blanking on her name, she's Paul Keck's wife, and one of the top authorities on eating disorders. She gave a presentation and showed the dozens of studies of various meds on various eating disorders. The overwhelming majority when you looked at them as a whole showed no direction with using psychotropics for most eating disorders. While some of them showed some benefits, simply look at a few more and you'll see the same med in another studying when repeated didn't show benefits or even adverse effects and almost all of them had very small sample sizes. E.g. less than 20 in many of them.

So before someone responds back saying there's dozens of studies, yeah there are, and most of them aren't good studies with contradicting results when you look at the other ones likely cause of the small sample sizes. E.g. there's a study showing Ondansetron can reduce binge eating and purging but it only had 29 patients.

Further, while private companies don't have to release their own research data, I'm 99% convinced many of them did do some thorough studying on eating disorders and psychotropic meds such as SSRIs cause this is an untapped goldmine in terms of pharmaceutical treatment. Imagine, having an already existing med so you don't have to research a new one, treating a disorder nothing else treats, and it adding a new indication? I'm sure they've tried...and failed but won't release the failure data.

 

[whopper]

Adding to the OT, simply accepting private insurance literally cuts down most of the problematic first time meetings.

For someone to have private insurance it almost all the time means they are working full-time, are the children of someone working full-time or the person is otherwise financially stable.

That cuts down most problematic admissions right there. People with a GAF of below 40 almost can never afford private insurance. Will you still get headache patients? Yes. but it's to the degree that things such as pre-screening are not time/cost-effective, not to mention will already establish a doctor patient relationship anyways.

 

[MedMan80]

Adding to the OT, simply accepting private insurance literally cuts down most of the problematic first time meetings.

For someone to have private insurance it almost all the time means they are working full-time, are the children of someone working full-time or the person is otherwise financially stable.

That cuts down most problematic admissions right there. People with a GAF of below 40 almost can never afford private insurance. Will you still get headache patients? Yes. but it's to the degree that things such as pre-screening are not time/cost-effective, not to mention will already establish a doctor patient relationship anyways.

And accepting cash only even further cuts down on the problem patients even more

 

[whopper]

Frustrating ER patients-about 1/2 of them.
Frustrating private insurance patients, or cash-only: About 5-10% of them. As you continue your practice you can terminate them if they are acting inappropriately so with time you will cut them down. As I said above, during your first year you'll get many. 5-10% might not sound like a lot but it is when you got about 1 person a day ticking you off and you don't have collateral sources like a social worker to deal with them.

Frustrating Buprenorphine patients: About 1/2 even with private insurance or cash only. Again this is at first. You'll weed out many over time.

 

[dl2dp2]

I think it is different in psychiatry esp as we don't have alot of staff, etc. It can get dangerous.

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.

I disagree. I do not want to treat ADHD or prescribe stimulants or daily benzos, and I think it's perfectly legitimate to screen out people who are looking for those things. It's more trouble than it's worth to make them wait for their initial appointment only to be told "I don't do that," and deal with the ones who keep coming back and hounding you for whatever it is they want.

I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

 

[clausewitz2]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.



I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

You know I know we have butted heads before about the ethics of treatment and some inpatient payment models but right. The f*ck. On.

 

[Trismegistus4]

I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

The adult ADHD thing has been discussed extensively on these forums numerous times. My line has been that this is something that didn't exist at all when I was in residency, and I was blindsided by when starting a job in the worried well outpatient world. I suppose you might say that just shows I went to a crappy residency program, but based on what I've gleaned from prior discussions, it's a perfectly reasonable and evidence-consistent opinion that adults do not need stimulants in order to function. If adult ADHD is now 20% of general psychiatry, that in and of itself is evidence that psychiatry is fake medicine--is ADHD a new virus, like HIV? If not, how can something that didn't exist 50 years ago now constitute 20% of the practice? On the contrary, I would much prefer to see suicidal patients and prescribe lithium, antipsychotics, and MAOIs, than spend one more day dealing with the damn worried well and their fake, first world problems of supposedly being unable to function without Adderal or Xanax.

Sent from my SM-G920V using Tapatalk

 

[dl2dp2]

The adult ADHD thing has been discussed extensively on these forums numerous times...

This is not what I'm talking about. I'm talking about bona fide childhood onset ADHD that persists into adulthood. In general psychiatry, this is about 10-20% of the cohort. In addiction, this is about 50-60% of the clinic cohort. This is well studied epidemiologically. This prevalence (low single digits) has not changed significantly in the last few decades and are consistent across different countries.

Adults who randomly present with new onset "ADHD" and use stimulants to enhance performance is a different cohort.

Also, stimulants are completely different from benzos. Long acting stimulants don't give you seizures when you stop them, for one.

But the point being, without a full evaluation (and in this case, a 360 eval with parental collateral, a full structured interview like DIVA), how do you know who REALLY has ADHD and who doesn't? And if you can't know, how is it right to "screen them out" if they say on the phone they have ADHD? This makes no sense. How would you know if someone is an "addict" or doing "performance enhancement" if you don't do a full eval? I guess you just don't want to deal with this type of patients, which is fair, except this is now a huge portion outpatient of psychiatric practice.

From a clinical perspective, a lot of these people who come in with an upper and a downer have a (severe) personality disorder, and my job these days often consist of trying to carefully streamline people's crazy regimen. If you think that it's "fake" and "first world problems", I think you did go to a crappy residency. Frankly too many people like that out there are refused by people like you, and then they get seen by pill pushers. This is what gives the field a bad name.

 

[clausewitz2]

This is not what I'm talking about. I'm talking about bona fide childhood onset ADHD that persists into adulthood. In general psychiatry, this is about 10-20% of the cohort. In addiction, this is about 50-60% of the clinic cohort. This is well studied epidemiologically. This prevalence (low single digits) has not changed significantly in the last few decades and are consistent across different countries.

Adults who randomly present with new onset "ADHD" and use stimulants to enhance performance is a different cohort.

Also, stimulants are completely different from benzos. Long acting stimulants don't give you seizures when you stop them, for one.

But the point being, without a full evaluation (and in this case, a 360 eval with parental collateral, a full structured interview like DIVA), how do you know who REALLY has ADHD and who doesn't? And if you can't know, how is it right to "screen them out" if they say on the phone they have ADHD? This makes no sense. How would you know if someone is an "addict" or doing "performance enhancement" if you don't do a full eval? I guess you just don't want to deal with this type of patients, which is fair, except this is now a huge portion outpatient of psychiatric practice.

From a clinical perspective, a lot of these people who come in with an upper and a downer have a (severe) personality disorder, and my job these days often consist of trying to carefully streamline people's crazy regimen. If you think that it's "fake" and "first world problems", I think you did go to a crappy residency. Frankly too many people like that out there are refused by people like you, and then they get seen by pill pushers. This is what gives the field a bad name.

I mean it makes perfect sense if you aren't comfortable saying "no" when appropriate and place a high value on avoiding these situations entirely.

 

[PikminOC]

Psychiatrist Stabbed After Denying Pot Prescription: Authorities
Psychiatrist Stabbed After Denying Pot Prescription: Authorities
A Crystal Lake man now faces attempted murder and armed violence charges, authorities said.
By Amie Rowland, Patch Staff | Aug 16, 2018 11:47 am ET | Updated Aug 17,
..
There has been a handful of times I have been uncomfortable with patients

 

[PikminOC]

I mean it makes perfect sense if you aren't comfortable saying "no" when appropriate and place a high value on avoiding these situations entirely.

I am very comfortable saying no. Some patients are just not ok with it

 

[Stagg737]

Psychiatrist Stabbed After Denying Pot Prescription: Authorities
Psychiatrist Stabbed After Denying Pot Prescription: Authorities
A Crystal Lake man now faces attempted murder and armed violence charges, authorities said.
By Amie Rowland, Patch Staff | Aug 16, 2018 11:47 am ET | Updated Aug 17,
..
There has been a handful of times I have been uncomfortable with patients

There was also the doc from Wichita who was stabbed to death by one of his patients about a year ago:

Police: Kansas psychiatrist stabbed to death by his patient

Granted these cases certainly aren't the norm, but I've met quite a few psychiatrists who were attacked by their patients in the outpt setting. Heck, I was almost assaulted by an outpatient when I was a med student because I told them I didn't think my attending would prescribe them Xanax (new patient, not on benzos who was very obviously drug-seeking).

 

[WisNeuro]

While jobs in mental health (variable with setting) are probably more dangerous than some fields, the vast majority of people are still much more likely to be killed on the ride to and from work, than they are during their work day. It's always good to know your risks, and to minimize them, but to make it sound like some fatalistic thing, is kind of laughable.

 

[VA Hopeful Dr]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.



I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

Seems needlessly harsh. I don't know any doctor that does everything in their field. I know lots of family doctors who don't see kids under 16. Are they not real doctors anymore?

What about OB/GYNs who stop doing deliveries? Are they no longer real doctors?

The cardiologist in our group doesn't do caths any more. Is he no longer a real doctor?

You get the idea.

 

[whopper]

The cardiologist in our group doesn't do caths any more. Is he no longer a real doctor?

This is a complex argument. IMHO if one doesn't do a specific type of treatment that is within the standard of care you are possibly negligent, but just as medicine is highly complex, this isn't black and white.

The LAW does specifically state if that you must offer the patient treatment options and you cannot limit the patient to the only types of treatment you like to give.

E.g. one patient was told to walk as his form of antidepressant treatment. He underwent this treatment for years with little success, even to the point of wearing out shoes within just days cause he walked so much cause he was so desperate to treat his depression.

After undergoing years with no improvement he finally decided to see another doctor who put him on an antidepressant and he got better within weeks. He sued his first psychiatrist for never offering this treatment which was then within the standard of care, and won, with the court finding it ridiculous that the first psychiatrist never offered him this option to begin with especially since it was within the standard and the walking wasn't working.

(Anyone know which case this is? It's an AAPL landmark case).

 

[VA Hopeful Dr]

This is a complex argument. IMHO if one doesn't do a specific type of treatment that is within the standard of care you are possibly negligent, but just as medicine is highly complex, this isn't black and white.

The LAW does specifically state if that you must offer the patient treatment options and you cannot limit the patient to the only types of treatment you like to give.

E.g. one patient was told to walk as his form of antidepressant treatment. He underwent this treatment for years with little success, even to the point of wearing out shoes within just days cause he walked so much cause he was so desperate to treat his depression.

After undergoing years with no improvement he finally decided to see another doctor who put him on an antidepressant and he got better within weeks. He sued his first psychiatrist for never offering this treatment which was then within the standard of care, and won, with the court finding it ridiculous that the first psychiatrist never offered him this option to begin with especially since it was within the standard and the walking wasn't working.

(Anyone know which case this is? It's an AAPL landmark case).

Its possible we are talking about different scenarios here.

So long as you refer to someone else who does whatever it is that you don't do, its not negligence. Obviously if a cardiologist tells the STEMI patient to go home and take an aspirin that's a problem. But that's rarely the case with physicians who limit their practices. If our cardiologist thinks someone needs a cath, he sends to one of the people in town who still does them.

Delivering babies is well within my scope as an FP. I don't do it. So long as I refer pregnant women to someone who does deliver babies, there is no negligence.

There is a semi-retired ophthalmologist in town who doesn't operate anymore. If his patients need surgery, he refers them to someone who does still operate. No negligence.

Your case is someone who treats a specific condition but does so without using the appropriate tools. That's a problem. If in that example the doctor said "I don't treat depression, go see Dr. Whopper who does" this wouldn't be a landmark case. It'd be a Tuesday.

 

[clausewitz2]

Seems needlessly harsh. I don't know any doctor that does everything in their field. I know lots of family doctors who don't see kids under 16. Are they not real doctors anymore?

What about OB/GYNs who stop doing deliveries? Are they no longer real doctors?

The cardiologist in our group doesn't do caths any more. Is he no longer a real doctor?

You get the idea.

Yeah but we're talking about knowing how to use like 40 drugs tops and then saying "y'know actually I'm only going to deal with people who need 20 of them."

If our diagnostic entities were real things that had clearly defined etiologies and a range of testing, medications and procedures that we had to be proficient with in order to meet a basic standard of care, that would be one thing.

This is not the case here.

 

[VA Hopeful Dr]

Yeah but we're talking about knowing how to use like 40 drugs tops and then saying "y'know actually I'm only going to deal with people who need 20 of them."

If our diagnostic entities were real things that had clearly defined etiologies and a range of testing, medications and procedures that we had to be proficient with in order to meet a basic standard of care, that would be one thing.

This is not the case here.

I'm not sure I get what you're trying to say here. I'm not trying to be snarky or anything, I'm legitimately confused.

 

[clausewitz2]

I'm not sure I get what you're trying to say here. I'm not trying to be snarky or anything, I'm legitimately confused.

"Depression" and "schizophrenia" are not real things in the same sense that "vaginal delivery" and "MI" are real things. The later have a series of interventions, tests, and exams associated with them that you need to be would on I order to be providing adequate care. If you are declining to deal with these things simply because you find them boring or unrewarding, then as a family doc I assume you are dealing with entities like "CHF" and "T2DM". You are avoiding particular disease entities either because you cannot keep adequately current on everything or you feel you can provide better care focusing on a subset of entities.

While @Trismegistus4 clarified that he did not mean this, @sluox was throwing shade on psychiatrists who refused to treat people with genuine mental illness. Our catalog of interventions is quite small, and to the extent you systematically cut out larger and larger swathes of them you make yourself closer and closer to a (usually under-trained) therapist.

Sure, there still psychiatrists who do only therapy, and I am sure many of them do good work, but that is not medicine.

If all you do is prescribe SSSRIs or Latuda to high-functioning neurotics, what is the point of you having medical training when we could swap out an NP with no noticeable difference? Are you really still a doctor then?

The above example is only mildly hyperbolic. We have all seen folks in the community who roll like this.

 

[VA Hopeful Dr]

"Depression" and "schizophrenia" are not real things in the same sense that "vaginal delivery" and "MI" are real things. The later have a series of interventions, tests, and exams associated with them that you need to be would on I order to be providing adequate care. If you are declining to deal with these things simply because you find them boring or unrewarding, then as a family doc I assume you are dealing with entities like "CHF" and "T2DM". You are avoiding particular disease entities either because you cannot keep adequately current on everything or you feel you can provide better care focusing on a subset of entities.

While @Trismegistus4 clarified that he did not mean this, @sluox was throwing shade on psychiatrists who refused to treat people with genuine mental illness. Our catalog of interventions is quite small, and to the extent you systematically cut out larger and larger swathes of them you make yourself closer and closer to a (usually under-trained) therapist.

Sure, there still psychiatrists who do only therapy, and I am sure many of them do good work, but that is not medicine.

If all you do is prescribe SSSRIs or Latuda to high-functioning neurotics, what is the point of you having medical training when we could swap out an NP with no noticeable difference? Are you really still a doctor then?

The above example is only mildly hyperbolic. We have all seen folks in the community who roll like this.

Ah, OK that makes sense. Thanks for clearing that up for me.

 

[PikminOC]

Our liabilty is much higher than nurses, who are held to a nursing standard. Practice in what you are comfortable with.

 

[whopper]

So long as you refer to someone else who does whatever it is that you don't do, its not negligence.

Totally agree with you there. It's unrealistic for an FP doctor to do everything within the scope of FP.
There's also issues with liability, do you have hospital admitting privileges, etc.

Bottom line, per that landmark case, if you don't offer a certain type of therapy that's within the standard of care, definitely bring this up as an option and tell the patients they have other options on the table that are outside your practice.

 

[clausewitz2]

Our liabilty is much higher than nurses, who are held to a nursing standard. Practice in what you are comfortable with.

While not at all the point, this is wildly variable from state to state. Some states with independent practice authority for NPs certainly do make them liable for medical malpractice torts.

Liability aside, if your practice pattern resembles a mid-level's, why did you waste so many years of your life in training?

 

[nexus73]

Adding to the OT, simply accepting private insurance literally cuts down most of the problematic first time meetings.

For someone to have private insurance it almost all the time means they are working full-time, are the children of someone working full-time or the person is otherwise financially stable.

That cuts down most problematic admissions right there. People with a GAF of below 40 almost can never afford private insurance. Will you still get headache patients? Yes. but it's to the degree that things such as pre-screening are not time/cost-effective, not to mention will already establish a doctor patient relationship anyways.

I think this is a great point. I work for a health care system that takes all insurance, so there is not a built in filter (like only accepting private insurance). Because of this I think it's part of my job to not accept patients who are obviously in need of more intensive outpatient treatment, like clinics that have ready access to therapists and case management on site.

 

[whopper]

Yeah well this is a reason why I don't think they should've gotten rid of the GAF.

In situations like this it clearly explains something very succinctly. Also from personal experience if you took the GAF seriously the numbers were accurate. What happened most of the time IMHO was that clinicians weren't referencing the chart when making the number and allowing the insurance directive to mandate the number. E.g. "do we want to keep her inpatient longer? If so make GAF 15 even if it's really a 45.

 

[PikminOC]

While not at all the point, this is wildly variable from state to state. Some states with independent practice authority for NPs certainly do make them liable for medical malpractice torts.

Liability aside, if your practice pattern resembles a mid-level's, why did you waste so many years of your life in training?

They are held to a nursing standard for malpractice. They are not held to a physician's standards. It is much less of a standard so easier not to be sued. I am not talking about the amount of malpractice insurance they hold.

 

[clausewitz2]

They are held to a nursing standard for malpractice. They are not held to a physician's standards. It is much less of a standard so easier not to be sued. I am not talking about the amount of malpractice insurance they hold.

I am not talking about malpractice insurance either, I am talking about the legal standard they are held to if sued. In some states you are correct, but in some states they are most certainly held to the same liability standards as we are. Essentially any blanket statement made about this across all states is false.