How to not give medical advice

[roubs]

Sometimes I see clients with a cache of prescribed medication from an old psychiatrist with no appt to see a new psychiatrist for 3-5 months. I tell all clients that I don't and can't give advice on medication which usually doesn't stop them from asking about it every other session.

Lets say a client has decided to go off 200mg/day of an antidepressant that they had started at 25mg/day. 3 months go by, they've dropped out of seeing their psychiatrist because they can't afford appointments/no insurance, then they come in to see me and announce that they are going to restart their medication at 200mg because they feel more depressed and don't want to wait the 3-5 months to see someone new. At this point whats the best thing to do? We don't have a psychiatrist I can consult with, they come in 2 days a month.

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[michaelrack]

what do you mean by "old psychiatrist"?? Did the old psychiatrist work in the same clinic with you previously. Did the "old psychiatrist" stop practicing?????

 

[heyjack70]

Encourage the patient to not make changes to their medication regimen without seeing a physician first (family doctor, psychiatrist). Document that you told them this.

 

[Bartelby]

...seeing a physician first (family doctor, psychiatrist).

Good point. If they have a family doc or internist who they see for other medical problems he or she could advise on medications while the patient waits for the intake interview with the new psychiatrist. Obviously that's not ideal (ideal would be the patient never dropping his old psychiatrist in the first place) but better than letting the patient play doctor with leftover meds.

 

[roubs]

what do you mean by "old psychiatrist"?? Did the old psychiatrist work in the same clinic with you previously. Did the "old psychiatrist" stop practicing?????

No, the patient was seeing a psychiatrist at an outside private clinic that they could no longer afford.

Encourage the patient to not make changes to their medication regimen without seeing a physician first (family doctor, psychiatrist).

Agree. Many clients I see can't afford payment for an outside office visit and have no insurance, but it's much easier to get a regular medical appt from city services than a psychiatric visit. Maybe if the PCPs get annoyed they will push to hire more psychiatrists :/

 

[michaelrack]

No, the patient was seeing a psychiatrist at an outside private clinic that they could no longer afford.


:/

The patient should be instructed to call that psychiatrist. That psychiatrist still has a responsibility to the patient (especially since the patient still has a prescription from the psychiatrist). OF course, the psychiatrist has the right to charge the patient and even sue the patient for unpaid fees, but he can not abandon/discharge the patient without helping to arrange for follow up care from a qualified physician (a follow up appt in 3-5 months would not be sufficient for most pts, the old psychiatrist would need to continue providing tx in the meantime).

 

[whopper]

The patient could also see their primary care doctor. When a medication has already been found that works, often times this is enough information for the PCP to take over.

IMHO, psychologists, with appropriate training could give medication recommendations in cooperation with an M.D. Of course, whether or not you choose to do that, that's up to you. You certainly don't want to handle meds all by yourself.

but he can not abandon/discharge the patient without helping to arrange for follow up care from a qualified physician (a follow up appt in 3-5 months would not be sufficient for most pts, the old psychiatrist would need to continue providing tx in the meantime).

Depends on the state. In some states, all you need do is tell the patient the relationship is terminated, give them a month supply of medication, and they're off on their way. Of course, the patient might not be able to find another doctor within a month, but per the law in several states, then it's their problem, not the doctor's problem. (I'm not saying that's right, I'm saying that's the allowable standard).

Another problem, and this is one my patients have been experiencing is several of them, against the office's recommendation, play with medications on their own, and then they develop a problem. They then try to have me treat it over the phone that 1) is often times inappropriate. Treatment is not considered the standard of care when it's only over the phone 2) I can't bill for it because insurance companies don't reimburse for phone interview (as far as I know, if I'm wrong someone let me know) and 3) it's unfair to me and my other patients because sometimes these patients want a lot of time....that I don't have to give them because they're calling me on the fly without scheduling an appointment. If I got patients scheduled to see, then I'm encroaching on their time.

I have no problem answering questions my patient has over the phone, but there's line between answering a simple question, and a patient literally trying to wring out as much out of me as they can so they can save money by getting out of a visit.

 

[nitemagi]

A question I would ask to preempt this is - just how much medication do you have? You'll need to see someone eventually to get a refill. Also point out that it probably didn't feel good to stop the medication all at once, so how would starting it all at once be a good idea.

Otherwise I'd agree with others- there's an ongoing treatment obligation from the original provider, which we're presuming hasn't been met (the provider could have already given a lot of time for the pt. to find a new provider). A family doc is an ok alternative, but often won't know the subtleties of ssri titration, though is still better than the pressure you're feeling as a psychology student.

 

[ratched]

How could the "old psychiatrist" be seen as abandoning the pt? They had a treatment relationship which included private compensation, and the pt was then no longer able to hold up his end of the relationship, so the pt terminated care with the psychiatrist. The pt can then contact the psychiatrist and ask all the clinical questions he/she wants, but the psychiatrist does not legally have to provide any help at that point whatsoever.

Ethically, perhaps, the psychiatrist ought to help out; but I don't believe that any Board would find enough fault with the psychiatrist's behavior to penalize or even reprimand the psychiatrist in any way.

If my reasoning is off somehow, please let me know. Fundamentally, if a pt terminates the pt-doctor relationship, then the doctor did not abandon anyone and has no further obligations (including finding referrals) except providing medical records if requested.

As far as the initial poster is concerned, I would be very clear with the pt that offering medication advice is outside the scope of your practice (as others have already suggested), but that your general sense is that abrupt discontinuation and resumption of psychotropic medications at high doses tends to be a bad idea. And that your formal recommendation is that the pt should ask a treating PCP/internist/psychiatrist exactly how to go about restarting the medication.

 

[F0nzie]

I was told by another resident who heard from a medical malpractice attorney that many psychiatrists have been sued for "breach of duty" by not providing a terminated patient an appropriate referral to another mental health provider. Apparently psychiatrists have been sued for abandonment even if they have provided up to 2 referrals and patient was not able to establish care in either clinic. However, according to this attorney, so far nobody has been sued for providing 3 referrals following termination of care. I have also heard about the "1 month rx rule", but I am not sure how to find out if it's law in my state. I'm thinking if I ever need to terminate a patient or the patient self-terminates for whatever reason that I'll provide 3 referrals (the magic number 3) and and at least 1 month supply of medication.

 

[MissAmanda]

How could the "old psychiatrist" be seen as abandoning the pt? They had a treatment relationship which included private compensation, and the pt was then no longer able to hold up his end of the relationship, so the pt terminated care with the psychiatrist. The pt can then contact the psychiatrist and ask all the clinical questions he/she wants, but the psychiatrist does not legally have to provide any help at that point whatsoever.

Ethically, perhaps, the psychiatrist ought to help out; but I don't believe that any Board would find enough fault with the psychiatrist's behavior to penalize or even reprimand the psychiatrist in any way.

If my reasoning is off somehow, please let me know. Fundamentally, if a pt terminates the pt-doctor relationship, then the doctor did not abandon anyone and has no further obligations (including finding referrals) except providing medical records if requested.

As far as the initial poster is concerned, I would be very clear with the pt that offering medication advice is outside the scope of your practice (as others have already suggested), but that your general sense is that abrupt discontinuation and resumption of psychotropic medications at high doses tends to be a bad idea. And that your formal recommendation is that the pt should ask a treating PCP/internist/psychiatrist exactly how to go about restarting the medication.

I am also interested in knowing more about what constitutes abandonment. For example, what would you do in the following cases:

1. A patient has lost his job and can no longer afford to come to see you, or any clinic for that matter. He wants to continue seeing you as his psychiatrist. Are you required to see him?
2. A patient is continuously disruptive and violent in your office; you no longer want to treat him as your patient. What can you do if he wants to continue being your patient, but will not control his actions in your office?
3. A patient continuously misses appointments and fails to schedule appointments at reasonable intervals. Say you give him three referrals, and medication for a month. He calls your office and says he's called the referrals but he tells you they are too far, too expensive, not friendly, etc, are you still required to see him?

When are you liable? When are you abandoning? When can you be sued?

 

[michaelrack]

Depends on the state. In some states, all you need do is tell the patient the relationship is terminated, give them a month supply of medication, and they're off on their way. Of course, the patient might not be able to find another doctor within a month, but per the law in several states, then it's their problem, not the doctor's problem. (I'm not saying that's right, I'm saying that's the allowable standard).

.

that's true in general, although sometimes more is required for "unstable" patients. In addition, the OP states "Sometimes I see clients with a cache of prescribed medication".
I would hate to be halled in front of a jury for malpractice (in the event of an adverse outcome) and have to defend myself if I refused to see an unstable psych patient who I had recently given a "cache of prescribed medication"

But I agree that you are in general right for meeting the minimal requirements of most state medical boards.

 

[nitemagi]

1. A patient has lost his job and can no longer afford to come to see you, or any clinic for that matter. He wants to continue seeing you as his psychiatrist. Are you required to see him? ?

Yes. You need to continue to provide care and give them several referral sources where they can receive care (such as community clinics), along with notice (say 1-2 months). You may need to see them in that interim.

2. A patient is continuously disruptive and violent in your office; you no longer want to treat him as your patient. What can you do if he wants to continue being your patient, but will not control his actions in your office?

Others can correct me if I'm wrong, but this is a legitimate case for terminating a patient. Imminent or ongoing risk of harm to provider, particularly if it's more in the sociopathic spectrum/behavioral is an ok term for termination of care.

3. A patient continuously misses appointments and fails to schedule appointments at reasonable intervals. Say you give him three referrals, and medication for a month. He calls your office and says he's called the referrals but he tells you they are too far, too expensive, not friendly, etc, are you still required to see him?

When are you liable? When are you abandoning? When can you be sued?

I'm not up to speed on the case law, but this last case gets into a bit more of a gray area. If you've given reasonable #'s of referrals and meds, then I'd say your hands are clean. If they shoot down all the referrals for poor reasons, that's on them.