How to Screen Patients Without Establishing Doctor-Patient Relationship?

[AD04]

How do you screen patients without establishing doctor-patient relationship?

And is it common practice to screen people before taking them as patients?

Thanks.

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[FlowRate]

In private practice, advertise your initial visit(s) as consultations, explain to the patient on the phone or during the first visit that it's a consultation and what that entails. Give them your consultative advice at the end, whether that's treatment recommendations (doctor-patient) or referrals to other doctors who you think might help.

 

[PistolPete]

A private practice psychiatrist I've talked to recommends doing a decent screening by phone prior to the visit. His argument that once you see a patient in-person, that a doctor-patient relationship has already been established.

 

[Jules A]

A private practice psychiatrist I've talked to recommends doing a decent screening by phone prior to the visit. His argument that once you see a patient in-person, that a doctor-patient relationship has already been established.

Prossibly different for all cash practices but to the best of my knowledge even when completing and billing for an initial evaluation you are under no obligation to prescribe medication or continue inappropriate medications.

 

[hamstergang]

Prossibly different for all cash practices but to the best of my knowledge even when completing and billing for an initial evaluation you are under no obligation to prescribe medication or continue inappropriate medications.

Of course that's true. But even if you don't prescribe, that doesn't mean you haven't established a doctor-patient relationship.

 

[Armadillos]

Maybe I poorly understand the legal implications, but I’ve heard many folks talk about this. Why is it a big issue to not have someone become your patient? My understanding is (atleast in my state) you can discharge any patient at any time and only need to provide appropriate referrals and be available to provide care for them for 30 days after you discharge. None of that puts you under any obligation to prescribe things you disagree with or do anything different than you would do if a random non-patient called you and said they were suicidal.

Unless I’m misunderstanding?

 

[TexasPhysician]

Maybe I poorly understand the legal implications, but I’ve heard many folks talk about this. Why is it a big issue to not have someone become your patient? My understanding is (atleast in my state) you can discharge any patient at any time and only need to provide appropriate referrals and be available to provide care for them for 30 days after you discharge. None of that puts you under any obligation to prescribe things you disagree with or do anything different than you would do if a random non-patient called you and said they were suicidal.

Unless I’m misunderstanding?

Example:
A depressed borderline patient sees you for an evaluation. You determine that you are not the ideal practitioner for this person for whatever reason and provide referrals, no medications. Said person commits suicide after calling your office at 3am to warn you. Their family could allege that their was a doctor/patient relationship and the person even clearly believed there to be a doctor/patient relationship that prompted the cry for help. Despite the alleged relationship, no antidepressants were provided, nor did inpatient admission occur. The lack of prescribing a relatively safe SSRI without sound reasoning could be construed as substandard care.

Anyone trying to avoid a doctor/patient relationship should consult an attorney. Paperwork should probably explain in multiple areas that there is no doctor/patient relationship and that your services are for diagnostic purposes only. This will likely confuse many potential patients as you would need people that “become patients” to sign further paperwork describing the new relationship.

 

[thoffen]

There is a doctor patient relationship with a consultation, but that doesn't mean you can't limit your duty to the patient. If you provide a misdiagnosis that was negligent and causes harm you are liable even if you were never expected to treat them. But I do think you can make clear the boundaries of your relationship and reasonable expectations of contact. Even still, if a patient calls you in imminent crisis you still have a duty to protect them. But if it is clear from the outset that you have a voicemail which you check at 12pm M-F and they are expected to call the crisis line for emergencies, I don't see any problem with you being liable if they called your voicemail at 11pm Friday and kill themselves Monday morning unless they can demonstrate you did check that message and ignored it.

 

[TexasPhysician]

There is a doctor patient relationship with a consultation, but that doesn't mean you can't limit your duty to the patient. If you provide a misdiagnosis that was negligent and causes harm you are liable even if you were never expected to treat them. But I do think you can make clear the boundaries of your relationship and reasonable expectations of contact. Even still, if a patient calls you in imminent crisis you still have a duty to protect them. But if it is clear from the outset that you have a voicemail which you check at 12pm M-F and they are expected to call the crisis line for emergencies, I don't see any problem with you being liable if they called your voicemail at 11pm Friday and kill themselves Monday morning unless they can demonstrate you did check that message and ignored it.

The legal world doesn’t exactly follow logic. You can sue for anything. Our jury “peers” are not medically educated. Our documentation and intake paperwork in simple terms can deter attorneys.

 

[MedMan80]

I've seen private attendings do screenings by phone, of course this isn't a perfect system and some patient's that you're looking to screen out can be missed...that being said, I've seen exam questions that do say that even that can construe a DP relationship

 

[Candidate2017]

A private practice psychiatrist I've talked to recommends doing a decent screening by phone prior to the visit. His argument that once you see a patient in-person, that a doctor-patient relationship has already been established.

There is no phone vs in person distinction. You are asking long, invasive questions about their medical history during a screening. To the patient, you are a doctor, functioning as a doctor. Their doctor. No judge or jury will buy your excuse you were not their doctor, absent a clear written policy signed by the “patient”. Rightly so. It is incumbent on you as the learned physician to lay out terms to the person seeking help from you. If you don't enforce boundaries, the legal system will.

 

[thoffen]

The legal world doesn’t exactly follow logic. You can sue for anything. Our jury “peers” are not medically educated. Our documentation and intake paperwork in simple terms can deter attorneys.

Well certainly the documentation has to clearly express the boundaries of your treatment relationship. Perhaps putting in there that there is no treatment relationship at all is prudent but it is still false. I think my example is technically correct in following the law, but I agree that things don't necessarily work that way in practice.

Still, I absolutely think that one should be careful and consult assistance in constructing the paperwork and office policies around this. As you know, if it isn't documented, it didn't happen.

 

[PistolPete]

There is no phone vs in person distinction. You are asking long, invasive questions about their medical history during a screening. To the patient, you are a doctor, functioning as a doctor. Their doctor. No judge or jury will buy your excuse you were not their doctor, absent a clear written policy signed by the “patient”. Rightly so. It is incumbent on you as the learned physician to lay out terms to the person seeking help from you. If you don't enforce boundaries, the legal system will.

I disagree. But of course I'm not a lawyer. I think one could very reasonably argue that a 10 minute phone conversation where the patient or patient's parent outlines the problems that they hope to have addressed and you stating whether or not you feel you could be a provider that would fit their needs vs refer to someone better suited (such as an addictionologist, eating d/o specialist etc) would NOT be construed as establishing a doctor-patient relationship. This would be much harder to argue after a 60 or 90 minute in-person (or even telepsychiatry) evaluation.

 

[Jules A]

The cases this thread reminds me of usually involve benzos and or stimulants. In those instances I discuss, document my recommendations and add that the patient has declined to remain under my care.

 

[smalltownpsych]

Obtaining treatment records before meeting with patient is one good way to screen without establishing a relationship. First contact is usually with my office staff who gets some basic info and if I have concerns about appropriateness of referral or fit then I request additional records. My understanding is that once I meet with a patient then a treatment relationship is established and I could be liable for substandard care regardless of what I call the first contact.

 

[PistolPete]

Obtaining treatment records before meeting with patient is one good way to screen without establishing a relationship. First contact is usually with my office staff who gets some basic info and if I have concerns about appropriateness of referral or fit then I request additional records. My understanding is that once I meet with a patient then a treatment relationship is established and I could be liable for substandard care regardless of what I call the first contact.

That's interesting, I hadn't thought about obtaining records prior to meeting the patient. Although in a small solo practice this may not be very feasible to do on every new patient.

 

[smalltownpsych]

That's interesting, I hadn't thought about obtaining records prior to meeting the patient. Although in a small solo practice this may not be very feasible to do on every new patient.

In a small practice, maybe just place the burden on the patient. Our PMHNP does it here and also requires a tox screen and she can afford to be selective because she is always completely booked primarily due to lack of competition in this small town. I know that when I was at a private pay residential treatment, we had requirements for complete psychological evaluation before accepting patients. I am headed back to that environment (private pay residential) and can say that having effective screening for appropriateness will be a welcome relief. I could probably list about ten other things about that world that are going to be huge pluses for me. Only two and a half more months of this outpatient grind.

 

[birchswing]

I have a weird question that is something I've thought of before not because it applies to be but more because it's just a bit mind-bending. So I know that doctors can pick and choose patients, believing they have strengths in certain areas or aren't comfortable treating some conditions or performing some procedures. And I also know that a disease is not synonymous with a disability. However, a disability status is sometimes informed by the the presence of an illness that affects functions of daily living. And generally businesses can't discriminate on the basis of disability. So what happens then if a patient has an illness that you don't wantn to treat but that illness is basically synonymous with a government-recognized disability in that it is the cause of impairment of daily living activities? Can you say that you won't treat a patient because of a certain disease and separate it out from the disability? Or are the two so enmeshed that denying on the basis of a disease which is the basis for the status of disability would be illegal? I'm not asking this to prove a point or to argue for a position. I ask because I really don't know. Like say for example, you're a psychiatrist who really doesn't like treating PTSD--you're just not comfortable with it. But a person has disability status due to PTSD affecting activities of daily life. And you say you won't treat that person. Is the onus on you to prove you're incapable treat that problem once it rises to the level of a recognized disability? From my understanding, you don't need a reason if it's just that you don't like certain types of diseases--but the catch I've always wondered about is when the disease is part of a disability. If you are technically capable of treating the disease causing the disability is refusing to provide it like refusing to provide a wheelchair ramp? I don't know. Just asking.

 

[smalltownpsych]

I have a weird question that is something I've thought of before not because it applies to be but more because it's just a bit mind-bending. So I know that doctors can pick and choose patients, believing they have strengths in certain areas or aren't comfortable treating some conditions or performing some procedures. And I also know that a disease is not synonymous with a disability. However, a disability status is sometimes informed by the the presence of an illness that affects functions of daily living. And generally businesses can't discriminate on the basis of disability. So what happens then if a patient has an illness that you don't wantn to treat but that illness is basically synonymous with a government-recognized disability in that it is the cause of impairment of daily living activities? Can you say that you won't treat a patient because of a certain disease and separate it out from the disability? Or are the two so enmeshed that denying on the basis of a disease which is the basis for the status of disability would be illegal? I'm not asking this to prove a point or to argue for a position. I ask because I really don't know. Like say for example, you're a psychiatrist who really doesn't like treating PTSD--you're just not comfortable with it. But a person has disability status due to PTSD affecting activities of daily life. And you say you won't treat that person. Is the onus on you to prove you're incapable treat that problem once it rises to the level of a recognized disability? From my understanding, you don't need a reason if it's just that you don't like certain types of diseases--but the catch I've always wondered about is when the disease is part of a disability. If you are technically capable of treating the disease causing the disability is refusing to provide it like refusing to provide a wheelchair ramp? I don't know. Just asking.

Great question. It is my responsibility to refer patient to someone who can provide the best care if I cannot. In a rural practice, I do end up treating many cases that I am not very good at and this has been one of my frustrations. One can only expand their competence so much but we are obligated to treat patients or refer. The challenge is when there is limited referral sources and then I cannot refuse to treat.

 

[FlowRate]

This article seems to have good guidance.

 

[Candidate2017]

I disagree. But of course I'm not a lawyer. I think one could very reasonably argue that a 10 minute phone conversation where the patient or patient's parent outlines the problems that they hope to have addressed and you stating whether or not you feel you could be a provider that would fit their needs vs refer to someone better suited (such as an addictionologist, eating d/o specialist etc) would NOT be construed as establishing a doctor-patient relationship. This would be much harder to argue after a 60 or 90 minute in-person (or even telepsychiatry) evaluation.

Anything can be argued by anyone. Your argument is stronger if there is clear, signed documentation showing the extent of the relationship. You can be held liable for a 2 minute curbside consult with a fellow physician without ever agreeing to take on the patient or speaking to the patient, and you are only increasing your risk with actual patient contact via phone.

Clear boundaries, clear guidelines. No matter how irrational doctors think the legal system is, there is a method to the madness.