Is 24/7 availability really the standard of care?

[Mastac741]

Hey, I'm a psych resident and planning to start an outpatient child practice when I graduate. I've been doing research on every aspect of setting up a practice, especially in regards to liability. I've come across some disturbing articles, especially from Dr. Robert Simon who apparently is some big whig forensic psych:

"Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time. "

"In solo practice, the psychiatrist or covering clinician must be accessible 24 hours a day, 7 days a week, by cell phone, pager...Twenty-four hour coverage for patient emergencies is an established... standard of care." ("Suicidal Patients' Access To Their Psychiatrists")

This is pretty disturbing to me. I like the idea that when I'm out of the office, I'm out of the office. I'm okay with leave a message and I'll get back to you within 24 hours. Some people are saying that "Standard of care" is within an hour or less. Now, come on, It's 2:00AM in the morning and a patient calls me because they're feeling suicidal? I mean I would tell them to go to the ER or I would have to call the crisis line MYSELF to get them to the ER for evaluation. Why can't the message, "If this is an emergency, call 911, go to the nearest emergency, or call the crisis line" work? I mean if I have an asthma attack, or a heart attack, or a gunshot wound, my internal medicine doctor is definitely not going to answer the phone to tell me to go to the emergency room. This is why we have emergency rooms, for .... Emergencies.

I'd like to know if anyone really has been sued for not being available if a suicidal patient killed them self? Could I negate this "standard of care" by telling my patients (even before I establish a doctor-patient relationship) that I will not be available even for emergencies after 10:00PM and that I will get back to them within 24 hours?

Penny for your thoughts ...

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[atsai3]

Hey, I'm a psych resident and planning to start an outpatient child practice when I graduate. I've been doing research on every aspect of setting up a practice, especially in regards to liability. I've come across some disturbing articles, especially from Dr. Robert Simon who apparently is some big whig forensic psych:

"Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time. "

"In solo practice, the psychiatrist or covering clinician must be accessible 24 hours a day, 7 days a week, by cell phone, pager...Twenty-four hour coverage for patient emergencies is an established... standard of care." ("Suicidal Patients' Access To Their Psychiatrists")

This is pretty disturbing to me. I like the idea that when I'm out of the office, I'm out of the office. I'm okay with leave a message and I'll get back to you within 24 hours. Some people are saying that "Standard of care" is within an hour or less. Now, come on, It's 2:00AM in the morning and a patient calls me because they're feeling suicidal? I mean I would tell them to go to the ER or I would have to call the crisis line MYSELF to get them to the ER for evaluation. Why can't the message, "If this is an emergency, call 911, go to the nearest emergency, or call the crisis line" work? I mean if I have an asthma attack, or a heart attack, or a gunshot wound, my internal medicine doctor is definitely not going to answer the phone to tell me to go to the emergency room. This is why we have emergency rooms, for .... Emergencies.

I'd like to know if anyone really has been sued for not being available if a suicidal patient killed them self? Could I negate this "standard of care" by telling my patients (even before I establish a doctor-patient relationship) that I will not be available even for emergencies after 10:00PM and that I will get back to them within 24 hours?

Penny for your thoughts ...

Isn't that one of the primary reasons why physicians have migrated towards larger group models and why the small-town solo practitioner is a dying species? It's hard being on call 24-7.

Plus, the emergency room is not the inevitable outcome of a 2am page. There may be situations in which a patient would be willing to accept a next-day appointment. The outpatient psychiatrist would be able to save the system a lot of money that way.

 

[dl2dp2]

You are overthinking this. If you have a large insurance based psychopharm outpatient practice, you can hire an emergency triage service and rotate calls with other providers. If you have a non-insurance small boutique office, you can charge PER MINUTE.

My psychotherapy supervisor advocates this as a way to clamp down on unnecessary midnight calls from patients. He charges $12 a minute for emergency phone calls. Just spell it out in your initial treatment contract. You'll still hate the 2AM calls from the borderline, but at least you'll be laughing when you get to bill for that service.

Unless you have a certain specialized practice (i.e. DBT), emergency phone calls in this line of work are not NEARLY as problematic compared to being a specialist in a group setting (i.e. on-call for the cath lab.) First of all you can always call 911 and send the police over, and you almost never have to show up directly. Secondly, if you are doing things right these events are not very often. This is why despite all that solo practice in psychiatry is still extraordinarily common. If you do do something psychotherapy heavy for chronically high risk patients like DBT, then you include that in your rate.

I would encourage you to talk to the attendings who are doing private work about this. I felt relieved after doing so.

I'd like to know if anyone really has been sued for not being available if a suicidal patient killed them self? Could I negate this "standard of care" by telling my patients (even before I establish a doctor-patient relationship) that I will not be available even for emergencies after 10:00PM and that I will get back to them within 24 hours?

 

[atsai3]

Also, you can always make sure to screen out chronically suicidal patients. Many of the private practice psychiatrists I know specify that the first encounter is simply a consultation. After the initial consultation, they may or may not take on the patient ("I'm sorry, I just don't have the ability to provide you with the level of care you need").

 

[IAmAUser]

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[Mastac741]

I appreciate the comments and suggestions. I'm wondering how much this emergency triage service is. Sounds like the majority of psychiatrists don't offer 24/7 accessibility which makes me wonder why this is considered standard of practice

 

[sunlioness]

When I had my solo practice, I was available 24/7 unless I had arranged for someone else to cover me. I didn't get a lot of calls after hours, but it still sucked. I don't believe the "call 911" message is standard of care.

 

[strangeglove]

Most medical specialties have 24 hour access to a doctor by phone. Usually, this is through an answering service. However, they are not in any way clinically trained, nor would I want someone other than myself assessing a potentially suicidal patient over the phone. While many psychiatrists in private practice make themselves (or a covering psychiatrist) available at all times, in practice patients don't really call that frequently, especially at night. It's much less onerous than being an internist in call. Every now and then you get a suicidal patient at 2 am, but then you send those patients to the ED and then make yourself available by phone to the MD there.

 

[digitlnoize]

So if I run out of an important med and die, is the pharmacy liable for not being open to refill my rx at 2am?

I know I'm playing Devil's Advocate here, but one does have to wonder why Dr. X's LLC is more liable than Pharmacy X's LLC...for example.

 

[Leo Aquarius]

After 5pm my family physician stops taking calls, which roll over to a call center. What's wrong with this?

 

[Socrates25]

I dont know what the specific requirements for psychiatry are, but in peds I can tell you that 24/7 coverage is NOT the expected "standard" of care.

In fact I know many many PCPs who arent available at all after hours. They simply have a phone message which says "call 911" and all of their patients go to the ER after hours. If they need to be admitted, the ER admits them directly or utilizes a hospitalist team to admit them. But the PCP never gets involved.

You can argue thats unethical or whatever, but its not malpractice. Patients might not like it very much though if you just dump evertying to the ER, but technically you should be able to get away with it.

Choosing to be on call 24-7 is a choice, not a requirement. I imagine that there are lots of group practices that require you to be on some kind of call schedule, but thats not because the group will get sued for malpractice if they dont do it -- its a customer service issue and that's all it is.

 

[aphenomenon]

Also, you can always make sure to screen out chronically suicidal patients. Many of the private practice psychiatrists I know specify that the first encounter is simply a consultation. After the initial consultation, they may or may not take on the patient ("I'm sorry, I just don't have the ability to provide you with the level of care you need").

Is this really okay? Something always seems unethical about telling patients who need the most help that you're not willing to provide it because it's an inconvenience or difficult to manage. For example, internists refusing to treat infectious disease until substance abuse is stopped etc.

Or am I missing something? (honest question)

 

[aphenomenon]

since no psychiatric interventions with the possible exceptions of lithium and clozapine, meds that are rarely prescribed, reduce the risk of suicide

Including psychosocial interventions?

 

[twright]

Is this really okay? Something always seems unethical about telling patients who need the most help that you're not willing to provide it because it's an inconvenience or difficult to manage. For example, internists refusing to treat infectious disease until substance abuse is stopped etc.

Or am I missing something? (honest question)

I wasn't advocating this behavior on ethical grounds. I think it is a dereliction of duty. But that doesn't stop many psychiatrists from engaging in this behavior.

 

[splik]

no there are no psychosocial treatments shown to reduce risk of completed suicide. as mentioned above there are treatments which appear to reduce suicide attempts but have not been shown to reduce risk of suicide. These are different things and should not (as much of literature unfortunately does) be conflated. part of the problem is that incident suicides are rare in the context of RCTs so it is difficult to study, but nevertheless it would be quite correct to say none of these treatment reduce the risk of suicide.

 

[sunlioness]

Is this really okay? Something always seems unethical about telling patients who need the most help that you're not willing to provide it because it's an inconvenience or difficult to manage. For example, internists refusing to treat infectious disease until substance abuse is stopped etc.

Or am I missing something? (honest question)

If you don't have the resources (whatever those resources may be) to provide the patient with the care they need, then I think it's unethical to say you do. It unfortunately gets kinda hairy in that in this climate, many places don't have the resources/level of care that people need. And for those that do have it, the wait list for services can be intense. Recently, I wanted to refer a patient to what in my former state we called "Community Treatment Team", only to find in my current state that this level of care doesn't really exist. It's very frustrating, to say the least.

 

[splik]

it is difficult to study by your assumption that reduction in suicide attempts leads to reduction in suicides is not borne out by the evidence. For every suicide there are many many attempts, most of which are never even reported or present to hospital. Whilst it might make sense to presume that reducing suicide attempts would reduce suicide, unfortunately this is not the case. That is not to discount the important of reducing suicide attempts and suicidal ideation of course, their reduction are worthy outcomes measures themselves, but the relationship between suicide attempt and completed suicide is a complex one, one that had much more to do with means than motives, and for this reason alone psychiatric interventions have largely failed to reduce the risk of suicide. If anything there is evidence that the current structure of our mental health services increases the risk of suicide if it does anything at all. (I am currently writing a book chapter on this topic and have reviewed literally thousands of papers - if there is something I have missed that suggests a psychiatric intervention that reduces suicide risk other than clozapine and lithium I would be grateful to be pointed in the right direction)

 

[whopper]

The standard of care is considered geographical. That is, in the middle of nowhere the standard will be lower vs. places where there's plenty of good psychiatrists.

That said, if the APA, for example, or other noteworthy people in the field declare a new standard, one could argue effectively in court that this is a national standard, not really a local one. For example, there are plenty of texts to support that Lithium labs MUST BE DONE before the person starts Lithium so even if a doctor was the only guy in the state prescribing it, I'd find it unlikely he could escape a malpractice suit where the other criteria of malpractice was met.

As for Dr. Simon, the guy is a Guttmacher award winner and writer of some pretty hefty accomplishments in the field. If he said it, it'd have high weight as the standard no matter where you are.

I agree with the above comments made by the others on the forum and I've said this in the past, working private practice can be a pain in the ass, especially if you have a troublesome and high-maintenance patient. There's a reason why some doctors choose to make $180K/year in an institution and not do private practice for $250+/year, because they can go home and leave the work at work. I personally would not do PP ever again unless I was with a team of other mental health professionals where we could divvy up this responsibility so I wouldn't be on duty 24/7, or I'd follow the above guidelines-charge big time for it or triage it out.

When I did PP, a psychologist in the practice handled the 24 hours calls for me and filtered them out, only bothering me if he felt I really needed to talk to the person. The guy knew enough to know what was important and could wait till the business hours and what needed to be given to me ASAP. With him on duty it literally only had me being bothered about once every 2-3 months. The guy was also intentionally blunt with several callers telling them they were not calling appropriately. I also terminated a handful of patients out of a few hundred because those people literally called daily, multiple times a day for frivolous reasons and had some serious Axis II pathologies.

If you make a PP, you need to figure these things out. My own personal practice style was to the degree where if I felt the call was important, I never held it against the patient. E.g. the patient had a very serious side effect to a medication and was very scared and didn't know if they should go to the hospital. If a patient called frivolously, I was alright if it happened once. I would draw a line and tell them they couldn't do this anymore. If they broke this line, I'd either terminate them, refer them to a therapist that could handle the more high maintenance aspects of this patient, or consider other alternatives. I did have a handful of patients that were very serious cases, and were financially needy so I decided to take in their calls and just deal with it because hey, that's why I went into this job to begin with--to help people. I'm not going to allow every single person to walk all over me, but if there's a case where I feel I can do some good, the person is trying their best, and I'm doing alright myself, I might as well allow a few select cases that are outside the norm to get very good individualized care they won't be able to get anywhere else.

 

[dl2dp2]

Is this really okay? Something always seems unethical about telling patients who need the most help that you're not willing to provide it because it's an inconvenience or difficult to manage. For example, internists refusing to treat infectious disease until substance abuse is stopped etc.

Or am I missing something? (honest question)

Yes. This is called scope of practice. Outpatient psychodynamic psychiatrists are not really practicing the kind of psychiatry that is necessary for chronically suicidal unstable patients. It is absolutely ok to evaluate the patient and say I cannot treat you because one two three and here are a list of numbers of people to call.

Consider this, if you are a dermatologist, and the patient comes to the office with lung cancer, would you not send the patient somewhere else?

Something else that may be a bit more ethically problematic is that often psychiatrists reject patients based on their ability to pay, even if these patients fall within their practice scope. However, while this may be unethical in some systems of ethics, it is most certainly standard of practice. This is similar to internal medicine doctors who refuse to take patients based on insurance status. It's just that in psychiatry self-pay is much more frequent.

 

[whopper]

Giving in too much with several patients simply enables them and if that occurs you're actually doing more harm than good in your attempts to help these patients.

A problem I've noticed with pay in private practice is if you try to help those that seem more needy with such things as letting them go with a free office visit, several of them will take advantage of you. You will likely never be in a position to truly know their real net monetary worth and ability to pay unless you do things outside the scope of care such as demand their tax records and personal credit rating. I've had patients tell me they can't pay for their visit and beg me to refill their meds (without seeing them) while literally their husband is in the background yelling at them to hurry up so they can go on their cruise to the Carribean or their daughter's wedding in Mexico where they will be staying in a very expensive hotel.

No I'm not making that up.

I also recall a case where a guy making decent money accused me of being a scam-artist because I wouldn't refill his meds without an office visit after I hadn't seen him for 6 months. The longest I let a patient go without a visit is 6 months, and those are only if the patient is stable, is on a medication regimen that is working and doesn't need any high maintenance, and doesn't want their meds changed.

--> To which my receptionist replied, "If you would like a doctor to refill your medications indefinitely without ever seeing you again, you can look for another one on your own. Our doctor here will not do that."

I have on occasion done things such as spend a few hours on one patient because the case was truly a difficult one for no extra charge, doing things such as lit-searches etc. I've also at times let a few patients go here and there, but be careful about this, and definitely do not enable a patient or allow them to exploit you.

 

[sunlioness]

And then there's the crap that still haunts you years later. Like today, I had the pleasure of finding in my mailbox a letter from some agency in the state wherein I used to reside stating that they were going to refer me to the licensing board for possible disciplinary action for failing to purchase tail coverage for the insurance policy I had when I was solo. I did, in fact, purchase such a policy. I remember it well. It cost over $9,000. But in case I did hallucinate that, I actually have proof in writing of having done so. So it should work out okay, but it's a ton of aggravation I'd just rather not be having to deal with right now. Especially since they gave me 20 days to respond and sent the letter to my old address (even though I did update my address with the state licensing board). I know what I'm doing over lunch tomorrow.

 

[Mastac741]

And then there's the crap that still haunts you years later. Like today, I had the pleasure of finding in my mailbox a letter from some agency in the state wherein I used to reside stating that they were going to refer me to the licensing board for possible disciplinary action for failing to purchase tail coverage for the insurance policy I had when I was solo. I did, in fact, purchase such a policy. I remember it well. It cost over $9,000. But in case I did hallucinate that, I actually have proof in writing of having done so. So it should work out okay, but it's a ton of aggravation I'd just rather not be having to deal with right now. Especially since they gave me 20 days to respond and sent the letter to my old address (even though I did update my address with the state licensing board). I know what I'm doing over lunch tomorrow.

Are you legally required to purchase malpractice insurance? I thought it was optional but foolish if you didn't.

 

[whopper]

Again depends on the state.

 

[sunlioness]

Are you legally required to purchase malpractice insurance? I thought it was optional but foolish if you didn't.

I actually didn't know I was required to purchase the tail. I purchased it because it's foolish not to. And right there is another downside of private/solo practice. There are tons of regs you have to be adhering to and that change all the time. No matter how much time you devote to learning them, there's a good chance you're going to miss one that could bite you. Therefore, it behooves you to hire a lawyer or somebody who's up on these things to make sure you're adhering to everything. This isn't cheap. (And even when you Do It Right, you still need to devote time every now and then to proving that fact.)

 

[michaelrack]

. You will likely never be in a position to truly know their real net monetary worth and ability to pay unless you do things outside the scope of care such as demand their tax records and personal credit rating.
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I wouldn't consider this unethical (although a credit rating is probably not necessary). I think it is wise to offer a limited amount of charity/reduced cost care and have strict criteria for this care.

 

[IAmAUser]

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[Mastac741]

When I had my solo practice, I was available 24/7 unless I had arranged for someone else to cover me. I didn't get a lot of calls after hours, but it still sucked. I don't believe the "call 911" message is standard of care.

I've enjoyed the debate and other legal issues that have arisen. I'm still on the fence about this, but I think that even though Dr. Simon is a big whig and supposedly set the "standard of care" in which he does not adhere, I think if you were sued for not being available, you could argue to the jury that it really isn't a reasonable standard of care for an outpatient psychiatrist to adhere to -- for hospitals, yes -- for private practitioners, no. I don't know of any other specialty that requires such access to a physician, and I don't see why we should be any different than our colleagues. Again, patient with a heart attack is going to be treated by an on-call doctor at the local ER. A patient who is suicidal should be treated by an on-call doctor (psychiatrist) at the local ER.

I bet you could make a good case stating that of the psychiatrists in your area, how many really have 24/7 access. If it's small, then it's really not "standard of care."

I think i'll try to sit down with a mental health defense lawyer before I setup my practice. I'd like to know if a psychiatrist was ever really sued for lack of availability or if this is all just academic. I don't plan on letting fear rule my life. Of psychiatrists sued, 7 of 8 cases are ruled in the psychiatrists favor.

Also, maybe I can try to look up ways to make your patients like you better without having to sacrifice too much time. Patients who like their doctor, don't sue them.

 

[whopper]

I think it is wise to offer a limited amount of charity/reduced cost care and have strict criteria for this care.

Agree. I've had a few fulfilling cases where I did a lot of work for free for a patient and I'm thinking of one right where I spent on the order of perhaps a total of 20 hours without billing for that person because her case was significantly difficult and I believed my work was doing some good and she truly needed the help but could not afford all my services otherwise.

At one point in her case, an inpatient psychiatrist, a psychologist, myself all had a meeting where we just told each other we didn't know WTF was going on with her but we were determined to trudge through this case because she was in serious dire straits we knew she wouldn't get better with just the standard of care. We had to surpass it. The psychologist in this case did an MMPI for peanuts.

If we were in this completely for the money we'd be in the wrong field, and it's not the real reason why I chose to be a psychiatrist. I'd actually do a heck of a lot more work for reduced rates or free if I was able to tell with complete certainty that the patient wasn't exploiting me. I certainly wasn't going to let the lady going to the Carribean get prescriptions without a visit telling me she couldn't afford it.

 

[whopper]

I bet you could make a good case stating that of the psychiatrists in your area, how many really have 24/7 access. If it's small, then it's really not "standard of care.

True, but where I'm at, everyone has 24/7. Further if you're one of the only ones in the area, if professional organizations like the APA or notables in the field state it's the national standard-you're going to be in a tough position to argue otherwise.

If one really did not want to do the 24/7 thing, I'd recommend they get a lawyer and figure out if such a practice is reasonable in terms of ethics but also liability in your locality before you invest yourself into a private practice.

I've said this before of private practice. If you watch those restaurant makeover shows like Ramsay's Kitchen Nightmares or Restaurant Impossible, all those failing restaurants were the result of people not knowing WTF they were doing before they entered the business. Same goes with private practice. You need to know what you're doing before you invest your time into it. As a doctor you'll likely not fail into bankruptcy with PP, but you could be losing large amounts of profits to the degree where PP might not have been worth it to begin with, and it would've been just easier to be a hospital doctor.

 

[IAmAUser]

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[dl2dp2]

not to beat a dead horse, but this kind of statement is why I feel compelled to continue on the point

You are correct in saying that "suicide attempt" may not be a good proxy outcome measure for completed suicide. However, most suicidalologists consider suicide attempt to be a negative outcome to track in its own right.

In terms of pulling back to the original discussion, few therapies actually have a consistent record for preventing either suicide attempt or completion. Lithium and clozaril have some longitudinal support, but double blind studies specific for high risk patients are equivocal. DBT has good evidence for preventing hospitalization and reducing impulsive self-injury, but not for suicide completion. 24/7 doctor's follow-up definitely does NOT have an evidence basis.

Nevertheless, you absolutely can get sued for things that don't have an evidence basis. This kind of thing is really problematic for people in PP who have a huge psychopharm caseload because they often have sicker patients. But from what I've learned some people really enjoy it, esp. if you have a smaller mostly cash patient population. The other thing is the fiduciary duty issue, which is that there might be a gray line between what is and isn't going to get you sued, and if you get sued it might just be a luck of a draw thing, and has nothing to do with if you followed the guidelines. The question is are you comfortable with having a patient in your practice like that without providing 24/7.

In any case, all these things notwithstanding, people do thrive in solo/small group practices in psychiatry, especially on the coastal areas and in rich suburbs, and especially for high end subspecialty practices. This is where you have extremely wealthy psychiatrists. But as whooper said, you COULD be the next Mario Batali, but let's hope you don't end up on the next Bravo reality show called "psych PP 911"

 

[freaker]

I wonder how this works for someone like myself looking to get into a more rural area. I have a love of flyfishing. Anyone have any idea which primetime fishing holes have good cellphone coverage? Am I really supposed to limit my life to technology-limited lifestyle and cling breathelessly to the phone because a patient might choose to have an emergency if I go hiking for flyfishing? I can't just on a whim cut out and enjoy life because a patient MIGHT have a catostrophe?

This seems a bit absurd. There are vast swaths of the mountain west that have NO cellphone reception. If I'm driving in my car through one of these areas and miss a call, I'm responsible for that?

Again, it seems illogical and unnecessarily onerous.

I guess that an answer service or message that I will be available within a few hours and that if care is needed more urgently to call 911 makes sense. I have no problems answering calls at 2AM, provided they are rare emergencies. I do, however, have a problem, with being tied to a telephone or pager and remaining within the technical limitations of these devices.

Go sue Verizon for their horrible reception over vast areas in our country. When you look at states like Nevada, Idaho, and Oregon, over 40% of their territories have no cellphone coverage.

 

[strangeglove]

Here's a relevant article:

http://www.psychiatrictimes.com/display/article/10168/1147576

 

[twright]

I wonder how this works for someone like myself looking to get into a more rural area. I have a love of flyfishing. Anyone have any idea which primetime fishing holes have good cellphone coverage? Am I really supposed to limit my life to technology-limited lifestyle and cling breathelessly to the phone because a patient might choose to have an emergency if I go hiking for flyfishing? I can't just on a whim cut out and enjoy life because a patient MIGHT have a catostrophe?

This seems a bit absurd. There are vast swaths of the mountain west that have NO cellphone reception. If I'm driving in my car through one of these areas and miss a call, I'm responsible for that?

Again, it seems illogical and unnecessarily onerous.

I guess that an answer service or message that I will be available within a few hours and that if care is needed more urgently to call 911 makes sense. I have no problems answering calls at 2AM, provided they are rare emergencies. I do, however, have a problem, with being tied to a telephone or pager and remaining within the technical limitations of these devices.

Go sue Verizon for their horrible reception over vast areas in our country. When you look at states like Nevada, Idaho, and Oregon, over 40% of their territories have no cellphone coverage.

You are not expected to pick up the phone every time a patient calls you during the middle of the work day-- after all, you may be in the middle of another patient appointment, you may be attending to administrative paperwork, etc. However, it would be reasonable for the patient to expect that he can leave a message, that you would check your voice mail at some point during the day, that you would discover that he is having a psychiatric emergency, and that you would return his call later that day.

Similarly, you are not expected to be tied to a pager 24-7 (at least that is my understanding of how things work in my area). But a patient should have a reasonable expectation that if she calls in the middle of the night, someone should be calling her back later that night. Because most people aren't working at 1am, for overnight coverage this typically involves being on call, using a call service, or being tied to a pager.

 

[aphenomenon]

How is drinking implicated in such availability? Have there been cases? As in, after that wine or whiskey or what have you...at what point to you have an obligation to not answer the call (or otherwise triage)? Is it after having anything to drink? Is it a knowing your competence thing? Etc. Any legal precedents?

 

[IAmAUser]

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[Chimed]

Thanks for the article. I don't think I could disagree with it more strongly though. Psychiatrists are human beings. We sleep, go hiking, get drunk, take vacations, etc.

Of course urgent calls should be returned when reasonably possible, but if it is not possible at 2am then it is just not possible. I don't believe that arranging "coverage" is any better than providing a suicide hotline or advice to go to a psychiatric emergency room. Why is it better for your patient to talk to someone covering, who they do not know / have never met and will likely be annoyed at being woken up, then for your patient to talk to a trained crisis counselor or emergency psychiatrist?

For those saying this is their local standard of care, my answer is... really? When was the last time you tried to contact a patient's psychiatrist after hours or on a weekend in an emergency setting? If you try this frequently, are you really telling me you get the person on the phone 100% of the time? As someone who takes weekly call in the ER, that's frankly hard for me to believe. As I said before, in my ER / location, it's more like 20% of the time, if that.

It is always interesting that "Standard of Care" recommendations are written by academic psychiatrists who do not practice in the community. I freely admit that I'm a product of academic psychiatry and will likely stay in the environment. But I think we need to be careful with telling community psychiatrists how they should practice and then raising our eyebrows in a self-righteous manner when they don't (or are just not able) to follow that advice because of the realities of the real world. It really can be the classic "Ivory Tower" snobbery.

 

[strangeglove]

It is always interesting that "Standard of Care" recommendations are written by academic psychiatrists who do not practice in the community. I freely admit that I'm a product of academic psychiatry and will likely stay in the environment. But I think we need to be careful with telling community psychiatrists how they should practice and then raising our eyebrows in a self-righteous manner when they don't (or are just not able) to follow that advice because of the realities of the real world. It really can be the classic "Ivory Tower" snobbery.

As it turns out, this article is also consistent with APA ethical guidelines, which are meant to bring psychiatry in line with other medical specialties. If you are having diarrhea and fever, you are supposed to call your internist's office and either he or the doctor "on call" that day is supposed to return your call within a reasonable time frame. It is then his/her job to determine whether you can simply "take two aspirin and call me in the morning" or go to the ED. That's how it's been since doctors had telephones. And we are doctors, after all. Call is onerous, but it is one of the reasons why we get paid more than nurses. And if you need to go fly fishing and will be out of range for several hours, then you might want to arrange coverage for that time. Same goes for nights you want to get drunk/high.

 

[twright]

I agree-- I don't think I would go so far as to say that some of these guidelines are just "ivory tower snobbery". Practicing psychiatry carries with it some minimal standards. If you can't practice within the range of these minimal standards then there are some other practice options to consider.

 

[strangeglove]

For those saying this is their local standard of care, my answer is... really? When was the last time you tried to contact a patient's psychiatrist after hours or on a weekend in an emergency setting? If you try this frequently, are you really telling me you get the person on the phone 100% of the time? As someone who takes weekly call in the ER, that's frankly hard for me to believe. As I said before, in my ER / location, it's more like 20% of the time, if that.

You are correct. This is because substandard care is the standard of care. Nevertheless, would you want to be a psychiatrist who can't be found when his/her patient is in the emergency room and a conversation with you could avert an admission? And if you are interested in succeeding in any kind of cash-only private practice, you'd better plan on being available when your patients call, or having someone cover you.

 

[Chimed]

I agree-- I don't think I would go so far as to say that some of these guidelines are just "ivory tower snobbery". Practicing psychiatry carries with it some minimal standards. If you can't practice within the range of these minimal standards then there are some other practice options to consider.

I meant to say that I can understand where the ivory tower snobbery perception comes from. And in cases the perception is often justified. Patient's need to and have the right to quality care, which includes being able to have emergencies addressed after hours (which can include calling 911 or going to the ER). But I stand by my statement that we need to be careful of how we impose standard of care recommendations as we sit in academic settings. Examples of this are even more prominent in child psych. The guidelines for child psychiatrists to be calling school teachers, having the child receive therapy before medications, having meetings with several members of the family, etc, are ridicules for the average psychiatrist who doesn't have the time or access to resources. Sure, I can do those things as a fellow in a major academic center with plenty of resources, and do those things. But to expect community psychiatrists to be able to follow some of these things is just not realistic.

 

[IAmAUser]

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[IAmAUser]

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[strangeglove]

maybe kernberg says it better than I am trying to:

"the essential point in discussing suicidality is that, while discussion of these feelings is welcome in the context of the therapy, issues of suicidal intent or actions are not within the realm of a psychotherapy treatment, but must be dealt with in the emergency services segment of the health care system. This position is sometimes criticized as a shirking of responsibility by the therapist. However, it can be argued that it is irresponsible for the therapist to pretend to provide a level of security and protection that is not realistically possible. In our experience, therapists create problems more often by offering themselves as available for emergency intervention and then not having the necessary resources than by making clear what the limits of their involvement are and when a patient must have access to a different level of intervention."

I can't get the google books link to work, but it's from pp 91-92 of "A Primer on Transference-focused Psychotherapy for the Borderline Patient"

I don't think it's Kernberg's intent that
psychiatrists should ignore their
suicidal patients. They are still supposed to call patients back when they leave messages about imminent suicidal plans. However, rather than talk them down, they tell their patients to go to the ED or they call 911. Kernberg is specifically criticizing the DBT model where the therapist is available 24/7 to "coach" the patient to use coping skills.

Suicidality is not the only reason we need to be available to our patients. We are in the business of prescribing medications - medications with side effects, that can be consumed in overdose (sometimes unintentionally) and that are occasionally lost or stolen, causing worsening of the patient's condition. It's part of medicine that our patients have someone knowledgeable to call if they are having medical problems. It's not the fun part, but it is our job.

 

[Socrates25]

As it turns out, this article is also consistent with APA ethical guidelines, which are meant to bring psychiatry in line with other medical specialties. If you are having diarrhea and fever, you are supposed to call your internist's office and either he or the doctor "on call" that day is supposed to return your call within a reasonable time frame. It is then his/her job to determine whether you can simply "take two aspirin and call me in the morning" or go to the ED. That's how it's been since doctors had telephones. And we are doctors, after all. Call is onerous, but it is one of the reasons why we get paid more than nurses. And if you need to go fly fishing and will be out of range for several hours, then you might want to arrange coverage for that time. Same goes for nights you want to get drunk/high.

If it's the 'standard of care' to have a pediatrician or an internist available 24/7 by phone (either the PCP or a partner covering him) then I'd estimate at least 50% of internists and pediatricians are guilty of breaking the standard. If you try to call them at night, many times you wont even get an answering service, you just get a phone ringing over and over again.

If psychiatry wants to hold itself up to a higher standard, then thats all well and good. God knows those patients need help. But lets be clear -- in the every day working world of other specialties, particularly primary care, it is VERY COMMON to find practices that dont provide 24/7 coverage and instead divert everyone to the ER.

 

[IAmAUser]

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[IAmAUser]

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[strangeglove]

Here's a practical way to solve the problem in private practice: get 2 Google voice numbers: The
First number is for new patients. It is linked to your office landline, but goes straight to a voicemail box which instructs callers on leaving messages to make an appointment Second number is for established patients only. You instruct your patients in person on what this phone number is for; that you will return calls about routine matters within one business day; that you will return calls about urgent matters within 1-2 hours; that if the matter is so urgent that it cannot wait this long, then it is an emergency and they need to go to the ED after leaving you a message. Your outgoing message should also say the same thing. This second number rings your cellphone, coming up as "private practice." When you pick it up, a robotic voice from Google says "Call from Joe Smith (it recognizes the name because Joe Smith is in your Google and phone contact lists). To accept, press 1; to send to voicemail, press 2; to interrupt the message at any time, press *". This allows you to glance at your phone when it rings and either 1) pick it up right away; 2) listen to see if their is something urgent going on and pick up if their is; 3) ignore the call and check your text messages or email a couple of minutes to hours later to see what was transcribed by Google voice and listen to the message. At night, be prepared to get the rare phone call from an existing patient in crisis. If you want to talk them down because that is what you like/know how to do, then by all means do so. Otherwise, tell them to go to the ED.

 

[nancysinatra]

Suicide's not the only possibly emergency in psychiatry. What if a patient has a lamotrigine rash that's getting worse and worse over a weekend? The patient might vaguely remember something their psychiatrist said about this or that side effect and call them in the middle of the night rather than just go to the ER.

Also, if the standard of care is determined locally, couldn't the local doctors in an area get together and conspire to be lazy and not provide any after hours coverage at all? Would that fly legally?

 

[TreeOfSouls]

A consideration with the Google Voice idea is that Google does track/record/analyze all of its services, including phone calls (and text messages on Google phones). It may be at odds with HIPAA.