Interesting ethical/legal hypothetical

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DD214_DOC

DD214_DOC

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So here's an interesting debacle. Let's say there is a primary care doctor (FP/Peds/IM) who has patients on his panel with serious diagnoses such as bipolar disorder. Some are medicated and doing well, a few are not medicated and possibly hypomanic, manic, or depressed.

Said primary care doctor refuses to both refill psychiatric medications for those who are stable and doing well, and also refuses to do anything for the ones not doing so well and are not medicated at all. This doctor cites the reason as, "I'm not comfortable treating that" and instead simply refers the patient to a psychiatrist.

However, this is where it becomes interesting. Unfortunately for the primary care doctor, there currently are no psychiatrists available to accept the referral. The few that do exist in the community are not accepting new patients because they are already so overwhelmed with demand.

The patients, although showing signs of deteriorating, do not yet meet the threshold for involuntary hospitalization and have refused voluntary hospitalization. They are willing to start medications, but the primary care doctor is unwilling to prescribe them because he is, "uncomfortable" doing so.

Given these circumstances, what possible ethical and legal issues exist? I have my own thoughts but I'm more interested in hearing what others think.
 
Interesting. No one can force a physician to do something that he or she isn't trained to do. However, one might surmise that a primary care doctor should have at least a basic understanding of psychiatry and has had at least some exposure to that in their training, at least FM/Peds, not sure about IM.

If their patient would have an adverse outcome, such as killing themselves by accident while manic because they thought they could jump off a building and fly, who would the patient's family sue? The PCP, not the psychiatrist, since the patient has never seen the psychiatrist. One could argue that it was the duty of the PCP to prevent harm to the patient in the preceding weeks/months while they were hypomanic by starting a mood stabilizer and/or an atypical antipsychotic.
 
Primary care really should not be treating legitimate cases of bipolar disorder or psychosis. They're not trained to do so and they're rightly not comfortable with it.

This is a systems problem that isn't going to be solved by this one doc who should not feel forced to practice outside of his area of expertise.

Situations like this require a systems based solution. At the very least, perhaps figure out a way to get this primary care doc some psychiatric advice and back up.



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It's clearly not standard of care for a PCP to initiate antipsychotic treatment in these patients. Now, they do have a duty to the patient if they are deteriorating, and simply saying "see a psychiatrist" might not be fulfilling that duty.
 
If they don't know how and don't feel they are professionally capable, it's irrelevant if there is no psych around. They are responsible to make referral, not change physician geographic disbursement.

It's like saying the doc should be responsible for performing a surgery they don't know how to do because no one else is around...they simply aren't
 
Shikima said:
Yes they do. But to qualify further, it's only 4 weeks in 3 years.
Click to expand...
we have some of the top FM residency programs in the country here and none of them have a mandatory psychiatry rotation for FM residents. They do have balint groups, and "Behavioral medicine" with a psychologist but no psychiatry. We've only recently had psychiatry integrated care elective for FM residents (but it's not required). There are no ACGME requirements for FM residents to do a psychiatry rotation. They are only required to have "behavioral health" integrated into their training per ACGME and the only reference in the FM ACGME milestones to mental health is to their own.
 
I agree it's a system issue. It's tough because even if the PCP does everything they can, lawsuits happen because of bad outcomes. Is there not a county mental health clinic available to see these patients?
 
You pose the question as relating to patients "on his panel"--which to me means that the doctor has a physician-patient relationship, and therefore responsibility for the patient's wellbeing. If "not comfortable" prescribing, if he is still recognizing a need for treatment that warrants a referral and not doing anything, I think he is still being negligent, even if it is not his fault that there is no accepting psychiatrist to be found. His appropriate responsibility, I would think, is at least to pick up the phone and ask for advice. That's what I would do if faced with a medical situation that I wasn't "comfortable with".
 
In the hypothetical, who was previously treating prescribing for the patients who were already taking medication for mental illness?

If it was another doctor who left practice, it's my understanding they have some limited responsibility for continuity of care, such as helping the person find a new doctor. In practice, this doesn't always happen, but wouldn't that be a factor in who has responsibility?

EDIT: If the other way of reading this is the case (that the PCP initiated treatment and then decided he wasn't comfortable), then that just seems odd and reckless. I don't know how you could justify being comfortable with it at one point, see a patient improve, and then become uncomfortable with it and willing to see a patient decompensate over your newfound discomfort.
 
It was a while ago, but I reviewed the RRC requirements for FM during an internal review and psych was there then. Now what counts for psych was termed "behavioral medicine", and this wasn't further defined very much so there is a lot of latitude.
 
What I find fascinating is that 80% of psychtropics are prescribed by PCPs in this country. Yet the minute someone doesn't want to take on the job they play the "I"m not comfortable" card.

Yet, I'm willing to bet, if you look at the prescribing record that there are plenty of Rx's for Benzo's and Opiates.
 
Shikima said:
What I find fascinating is that 80% of psychtropics are prescribed by PCPs in this country. Yet the minute someone doesn't want to take on the job they play the "I"m not comfortable" card.

Yet, I'm willing to bet, if you look at the prescribing record that there are plenty of Rx's for Benzo's and Opiates.
Click to expand...
bet they have no problems prescribing antipsychotics for sleep and other things they're not actually required for too.
 
I see plenty of FM docs prescribing amitriptyline for "sleep", Celexa for depression, Wellbutrin for depression/smoking cessation, Cymbalta for fibromyalgia, etc. They usually don't touch mood stabilizers (unless the patient has a seizure d/o) or anti-psychotics.

I agree that someone should not be forced to do something that's outside their area of expertise. But if you're a PCP and you have a truly bipolar patient, you still need to monitor for manic episodes, and if one is occurring, even if you're not comfortable managing that via pharmacology, you still need to get that patient hospitalized. Rather than just release them to the community and wait for an opening with a psychiatrist. In my book that's malpractice.
 
What about the converse situation (where medically ill patients come into a psychiatrists office and refuse to or can't see a PCP)?
(or their insurance doesn't cover it)?

What about a patient in pain that comes into your office that asks you for opiates because they can't get a pain mgt physician who accepts their insurance? Is it malpractice to refuse to assess and treat their pain?
 
keifernny2 said:
What about the converse situation (where medically ill patients come into a psychiatrists office and refuse to or can't see a PCP)?
(or their insurance doesn't cover it)?

What about a patient in pain that comes into your office that asks you for opiates because they can't get a pain mgt physician who accepts their insurance? Is it malpractice to refuse to assess and treat their pain?
Click to expand...

The converse is not the same situation, because I'm not the patient's PRIMARY care provider who is responsible for their overall health.
 
PistolPete said:
The converse is not the same situation, because I'm not the patient's PRIMARY care provider who is responsible for their overall health.
Click to expand...

While we think of pcp's being responsible for a patients overall health, I would be pretty surprised if they were held to any different standard from a medico legal standpoint than any other physician.

Also if they can't treat something properly then obviously they should refer to someone else even if it is hypothetically hours drive away and the patient decides not to go. I don't see why they would have any more responsibility to attempt to treat bipolar than they would a rare cancer. It's up to the patient to decide if it's worth the effort to drive to the nearest academic hospital for treatment of X rare malignancy, nobody expects the pcp to attempt to address that just because he is responsible for the health of the patient as a whole.
 
A PCP should be no more required to prescribe an antipsychotic than they should be required to prescribe chemo or take out someone's appendix.

I think insisting they should devalues our own training.

Plus I think we as a field need to be supporting our colleagues in primary care. They are often overworked, underpaid, and stretched very thin. It seems like they're all too often given responsibility for things they don't have any real power over. But without them, everything goes to crap very quickly.


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The IM and FM docs at our hospital pick up the phone when dealing with this type of situation. What do you all think about the person they have to call being a midlevel and then the midlevel telling them which medication and dosage to provide without examining patient themselves?
 
smalltownpsych said:
The IM and FM docs at our hospital pick up the phone when dealing with this type of situation. What do you all think about the person they have to call being a midlevel and then the midlevel telling them which medication and dosage to provide without examining patient themselves?
Click to expand...

It's times like this we've forgotten about collegiality and curb-side consults.
 
smalltownpsych said:
The IM and FM docs at our hospital pick up the phone when dealing with this type of situation. What do you all think about the person they have to call being a midlevel and then the midlevel telling them which medication and dosage to provide without examining patient themselves?
Click to expand...

I think it sucks, quite bluntly.


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Shikima said:
It's times like this we've forgotten about collegiality and curb-side consults.
Click to expand...

No, this is a systems problem and and has nothing to do with curbside consults and collegiality.

Calling a colleague for direction when you're stuck is something different. Because that colleague can always say, "wow. That sounds really complicated. Put in a formal consult or have him make an appointment with me. Thanks for the referral."

If you're routinely depending on unpaid phone conversations to guide you through something over your head . . . That's not cool. There is a marked difference between saying, "hey I have a patient here with some mild depression. We've tried lexapro 10mg for a month or so, but it doesn't appear to be helping. Do you have advice for the next step?" And "hey, I have this patient who just told me that his landlord is controlling him through the WiFi in his apartment building. He also believes his upstairs neighbors are deliberately having sex above him and filling the vents with chemicals. He keeps calling the police about it and they're tired of hearing from him. He's about to get evicted. He is not suicidal or homicidal and won't go to the hospital because he's not 'crazy'. What do I do?"

Big difference.

And if your entire day as a psychiatrist is dealing with curbsides like #2 because there just aren't any psychiatrists with openings to send these folks to . . . You're going to start to want to get paid or tell people, "I'm sorry I can't help you."

It not the responsibility of any individual to correct a systems problem. And to call it an issue of collegiality is to exploit a doctor's good nature and genuine desire to help. It's not cool.


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And it's better for peds/IM/FP who aren't comfortable to not prescribe. There have been numerous cases of them being sued when something happens.
 
Yeah. Basically it's saying, "we're going to push you into a corner and make you treat something you have no experience or training in treating. But if you mess up, you're in big time trouble for practicing outside your scope and causing harm."

It's a double bind. And it's not okay.


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smalltownpsych said:
The IM and FM docs at our hospital pick up the phone when dealing with this type of situation. What do you all think about the person they have to call being a midlevel and then the midlevel telling them which medication and dosage to provide without examining patient themselves?
Click to expand...
This is a hospital with much more protection than us out in pp. And the docs get paid a salary. So they get paid for taking time to call for curbsides.

The midlevel question is another whole ball of wax.
 
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There is a difference between a curbisde consult and providing care over the telephone (which is akin in this situation to collaborative care). A curbside consultant doesn't document, shouldn't be identified by name, does not provide specific advice or recommendations and you don't bill for it. Otherwise it's a formal consultation. Here are some examples of cases of curbsides I have done:

PCP: "patient is on zoloft and pain have started the patient on amitriptyline. is this okay? I am worried about serotonin syndrome"
Me: "although there is a small risk of serotonin syndrome with combining multiple serotonergic medications, the risk is small. the main risk of this combination is that zoloft may inhibit CYP2D6 and increase amitriptyline levels."

PCP: "I have a patient with psychosis and epilepsy who I am treating with Xanax. I am trying to get him seen jointly by neurology and psychiatry. Is it okay for me to continue giving him Xanax in the meantime."
Me: "I cannot give you specific advice for your patient, but in general it is better to use a longer acting benzodiazepine like clonazepam or diazepam if you have to use the at all."

In these situations, the advice given is general and not specific to the patient, and thus does not form a doctor-patient relationship. Thus there should be no liability. Of course things can get murky and in the worst cases, a judge may say it's up to a jury to decide whether there a doctor-patient relationship formed. But if you don't do anything such as examine, interpret data, diagnose, or treat than it is hard to argue that a doctor-patient relationship was created.

As for liability for treating patients you haven't seen - psychiatrists and NPs working in collaborative care models do this all the time. They never see the patients and are reliant on the care manager. The liability question is an interesting one and to my knowledge hasn't been tested yet though here is the APA's last resource document on this.
 
sunlioness said:
Yeah. Basically it's saying, "we're going to push you into a corner and make you treat something you have no experience or training in treating. But if you mess up, you're in big time trouble for practicing outside your scope and causing harm."

It's a double bind. And it's not okay.
Click to expand...

At the heart of it the two basic rules seem to conflict:

1 - You cannot be forced to practice below your own standard of care, and
2 - If you do not provide treatment or an appropriate referral to your unstable patient then you have abandoned them.

So the PCP is on the hook for providing sub-par care if they manage schizophrenia, bipolar, etc without appropriate training. If they offer up the name of a psychiatrist three hours away who is probably taking patients, knowing that their patient will not make it, and wash their hands of the issue it might be argued that they have committed abandonment. I also agree with the above posters that, while it would be great if they had an integrated care psychiatrist who could guide them by phone, the magical wish for such availability will not make it appear.

I really don't know what is the answer for this or similar situations (of course improving the system is the right answer from a big picture vantage point, but we're talking the right decision for the person stuck in this spot right now). My gut feeling from a liability standpoint is that they should make the referral to a psychiatrist even if that person is extremely far away if they truly do not know how to manage the situation. My gut feeling from a "right thing to do clinically" standpoint is that they should make their best effort to diagnose and treat the patient unassisted since that is probably better than the de facto abandonment that would otherwise occur. A compromise might be to make the referral, document the patient's refusal to show for said referral, and then document that given the inability to find optimal treatment after weighing risks and benefits the PCP chose to treat on their own (with appropriate informed consent from the patient or from a surrogate decision maker if the patient has impaired capacity). Really it's a no win situation though.
 
I would also add that if two PCPs in similar areas confer with each other on these cases it would help from a liability standpoint (and would not be as one-sided as asking a psychiatrist to remotely manage your panel for free). It would show that the PCP put thought into the situation, and agreement by the other PCP would suggest that the plan that was created met the local standard of care for practitioners of that level.
 
Fortunately, I'm in a different role where I'm developing relationships and the PCPs feel they can count on me to help them in a jam.

During residency, what a burden and a bother. The workload was already enough and putting in 50-60 hours a week between call and all of the other nonsense. There was no chance to develop collegiate relationships which had a direct impact upon the bottom line.

I have a lot of examples where I've been able to help PCPs create a plan of care which was helpful and safe that took 2 minutes of my time and I didn't bill for the services because in return, I know I can count on them if an issue arises for their patient.
 
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