Lawsuit/bad outcome fears

[uhmocksuhsillen]

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So just started practicing independently in an inpatient setting and I'm really struggling. I'm second guessing and over thinking everything. Every discharge, every med order, I'm worried I'm forgetting to order the appropriate lab. I have this irrational fear of being sued and/or losing my license. How do you all deal with this and rationally conceptualize the liability?

 

[Merovinge]

The same way you should be talking to your patients when addressing their irrational anxieties/fears, by looking at the actual facts of the situation. You will quickly find it is virtually impossible to lose your license in cases except for wanton wrongdoing (and even then it is tough). Malpractice judgements very rarely exceed your insurance limits, and even if they did early in your career it would be relatively easy to bankruptcy them and start fresh (credit doesn't much matter if you make 300k/year and cash flow your life). This is a bit like worrying about a mass shooter event, yes it does clearly happen, but the actual odds of it happening to you approach zero. There would be no time in this world for anything if you worries about every <0.01% event that could occur.

 

[Sushirolls]

1) Time, the more you do it the better it gets. Make notes of your second guessing and hit the texts during/after work. Eventually that'll stop or become more rare. Even several years out I still have things that pop up, or I totally space on and need to look up.
2) Look at the facts, odds are low of any lawsuits, and if ARNPs are out there practicing with ~400 clinical hours of training, independently and barely getting sued, you will do well. You also have the gift of those hairs rising on the back of your neck to know what you might be missing and know what could go wrong - they don't. See point one above, time will help with this.
3) Radical acceptance. Statistically we are likely to be sued once over a 30 year career. Accept it will happen. Pay attention to the insurance Liability CME when they pop up and what you can to mitigate. Accept it. Recently had a good friend not so sympathetically summarize my rant about these liability concerns, "Dude, that's why you get paid the big bucks." In theory we get paid 'big bucks'
4) Practice with each patient, what would you want for your own family member? I've found this has helped, and I sleep easier at night.

 

[MedMan80]

Anyone can sue anyone, so almost expect it in a way..but that in no way means you did anything wrong or are going to have a payout against you. Working rural psych you should see some of the stuff i see daily. As long as you practice within standards of care you are ok. Most psychs that lose their licenses are due to prescribing wayyyy too many pain meds or doing clearly inappropriate things with patients.

 

[uhmocksuhsillen]

Anyone can sue anyone, so almost expect it in a way..but that in no way means you did anything wrong or are going to have a payout against you. Working rural psych you should see some of the stuff i see daily. As long as you practice within standards of care you are ok. Most psychs that lose their licenses are due to prescribing wayyyy too many pain meds or doing clearly inappropriate things with patients.

I guess I don't really know what standard of care means. It feels like this vague term that is hard to define in psychiatry at times.

 

[J ROD]

I tend to think of it this way. If you are paralyzed by fear and indecision you are more likely to make a mistake. Practice within what you were trained to do and let the chips fall where they may. Be fearless and a boss. That’s why you have the insurance. Enjoy

 

[calvnandhobbs68]

1) It is extremely likely you get sued for malpractice SOMETIME at SOME POINT in your career. If you look at statistics, even for psychiatry which is one of the lowest sued specialities, the chance of it occurring some time during your career is high. Basically accept it as an inevitability while also realizing that you're in one of the specialities with the lowest lawsuit and payout rates.

2) Being sued does not mean that you get dragged through some giant malpractice trial. Actually pretty rarely in psychiatry as it's often very hard to prove the bad outcome (suicide in most instances) was directly caused by your negligence because there are so many psychosocial factors. So either it often ends up getting tossed out or the malpractice company decides to cut their losses to avoid spending money on it and settles.

3) Agree with @MedMan80, this is 'murica which means anyone can sue anybody for basically anything. You can get sued if a houseguest trips and falls over your rug. Doesn't mean it goes anywhere. So yeah, it's just a fact of life it could happen.

 

[uhmocksuhsillen]

It's more the medical side of things I worry about. Like a slightly elevated white count I didn't work up properly, etc.

As an example recently had a 20 something female w stabbing chest pain. No pmh. No other concerning signs or sx. Odds of a MI so incredibly low. But I'm sitting there wondering should I order ekg and stat trop for every psychotic person who says their chest hurts?

 

[Sushirolls]

In those examples, what would you want for your own family member?

 

[Merovinge]

It's more the medical side of things I worry about. Like a slightly elevated white count I didn't work up properly, etc.

As an example recently had a 20 something female w stabbing chest pain. No pmh. No other concerning signs or sx. Odds of a MI so incredibly low. But I'm sitting there wondering should I order ekg and stat trop for every psychotic person who says their chest hurts?

Consult medicine? Every psychiatric unit should have easy access to IM/FM hospitalists.

 

[calvnandhobbs68]

Consult medicine? Every psychiatric unit should have easy access to IM/FM hospitalists.

lol tell that to the inpatient adult psych unit we rotated on in residency...and that was actually attached to a community hospital.

There are a pretty decent amount of freestanding psych hospitals that have basically no access to a medicine consult.

 

[Merovinge]

lol tell that to the inpatient adult psych unit we rotated on in residency...and that was actually attached to a community hospital.

There are a pretty decent amount of freestanding psych hospitals that have basically no access to a medicine consult.

It's a bit different in residency, although even then it's important to have access but certainly the expectation is to complete more of the workup as primary. In community/PP setting there should be someone on call at all times and easily accessible. I cannot imagine taking a psych IP job where I am also responsible for chest pain workups, there's already more than enough to worry about from a psychiatric management standpoint. Even UHS staffs all their standalone psych hospitals with a IM/FM team...

 

[shoomer]

Piggybacking off of this, do less litigious states make a significant difference in a psychiatrist's chance of getting sued? Meaning is it reasonable to want to work in a less litigious state due to this concern?

 

[Sushirolls]

It weighs in the calculus, yes. My state transitioned from being routine, to having a case few years back that thrust Psychiatry liability potentially to the worst nationally. This is one of the many things, in addition to fleeing failed Blue State liberal policies, has prompted my spouse to get a job elsewhere. Now I'm deciding on relocating my private practice versus taking an employed job.

 

[Stagg737]

It's more the medical side of things I worry about. Like a slightly elevated white count I didn't work up properly, etc.

As an example recently had a 20 something female w stabbing chest pain. No pmh. No other concerning signs or sx. Odds of a MI so incredibly low. But I'm sitting there wondering should I order ekg and stat trop for every psychotic person who says their chest hurts?

If you’re truly worried about an MI, then consult IM or send them to an ER for clearance. Idk why you wouldn’t just order an EKG on a psychotic patient with chest pain, especially since you’ll likely be prescribing an antipsychotic.

 

[Merovinge]

Piggybacking off of this, do less litigious states make a significant difference in a psychiatrist's chance of getting sued? Meaning is it reasonable to want to work in a less litigious state due to this concern?

There are certainly going to be different rates of lawsuits/patient seen in different states based on how pro-lawyer they are. However, we are already in one of the lowest risk specialties for malpractice so if I was making a ranking list to choose a location to live this is actually on the list but last or near last in that consideration. Wisconsin, for example, makes it impossible to be sued for any of your personal finances as they use a state wide fund to pay any claims. Working for the VA makes it nearly impossible to be sued as well. Those things mean something, but statistically, not a whole lot.

 

[jbomba]

We've been told in our program that even if you do something that results in a malpractice case against you AND you lose the case and are found at fault, unless you did something that was malicious and/or illegal you generally can rest assured you're not going to lose your license. Thoughts on this?

 

[forchinet121]

It's more the medical side of things I worry about. Like a slightly elevated white count I didn't work up properly, etc.

As an example recently had a 20 something female w stabbing chest pain. No pmh. No other concerning signs or sx. Odds of a MI so incredibly low. But I'm sitting there wondering should I order ekg and stat trop for every psychotic person who says their chest hurts?

Consult medicine on everyone with any hint of issues..that’s what we do and it’s great

 

[lockian]

Ok, so getting sued is usually not that scary. Even if you “lose” there is an insurance payout and it rarely exceeds coverage limits. License loss does not occur unless something really egregious occurs, such as reckless prescribing or patient abuse.

This has helped me, though one thing I always wonder about is… what if you get sued twice in a short amount of time? I read somewhere that med mal insurance can drop you and then you essentially can’t practice. This is more a question for others in the thread than the OP.

 

[uhmocksuhsillen]

Consult medicine on everyone with any hint of issues..that’s what we do and it’s great

From a legal perspective does that alleviate me of liability?

 

[lockian]

From a legal perspective does that alleviate me of liability?

I would say it definitely reduces it. You are not expected to be able to handle everything, but knowing when to refer or consult when you are not comfortable is part of appropriate clinical practice.

To your point above about standard of care, it is a fairly wide set of goal posts. It’s basically a question of “does this constitute a reasonable course of action based on what we know as a field?” It is hard to define, but you know it when you *don't* see it, and even then there may be facts of the case that justify the medical decision making.

 

[forchinet121]

From a legal perspective does that alleviate me of liability?

Of course it does..does the internist have liability if your patient kills himself? No..so you don’t have liability for medical issues if they are on board that’s why everyone consults everyone these days

 

[jbomba]

What's the liability with declining voluntary walk ins? These are often done while on call at night, so I'm not writing a note justifying why I'm declining someone from admission.

 

[Bartelby]

From a legal perspective does that alleviate me of liability?

Not completely, but it is an excellent shield. For example, if someone appears to be dying on the floor of your psych ward and the consultant brushes off your call then a court might make the case that a reasonably prudent psychiatrist would have still recognized that there is a problem. In general, though, if you consult an expert and they get it wrong, it is likely they will be the ones who are deemed liable (after all, a reasonably prudent psychiatrist would consult someone else when in over their heads right?).

 

[Bartelby]

What's the liability with declining voluntary walk ins? These are often done while on call at night, so I'm not writing a note justifying why I'm declining someone from admission.

I presume this means refusing admission to someone who comes to the ER seeking admission voluntarily? I think there is significant room for liability there. Even if they presented willingly, they might pose an imminent risk to themself or others because of decompensated mental illness. I may be misunderstanding you, but if you simply refuse to admit them without leaving any documentation demonstrating that you exercised reasonably prudent medical decision making I think plaintiff's lawyers would be very happy to see that!

 

[Bartelby]

Something that helps me sleep easier is thinking back to some of the worst psychiatrists I have worked with. They seem to be doing okay, which tells me the bar can be pretty low. As others have pointed out, others with far less training also practice psychiatry and seem to do okay. And as has been stated, you are very unlikely to lose your license and exceedingly unlikely to lose your personal assets because of a lawsuit.

In general, carry good liability insurance and practice good psychiatry. The risks of something catastrophic happening to you in terms of liability are low. You could also get in a fatal or permanently disabling crash driving, but given the odds of each scenario if you do not spend a lot of time obsessing about that you probably should not spend a lot of time obsessing about a lawsuit ending your career.

 

[forchinet121]

I presume this means refusing admission to someone who comes to the ER seeking admission voluntarily? I think there is significant room for liability there. Even if they presented willingly, they might pose an imminent risk to themself or others because of decompensated mental illness. I may be misunderstanding you, but if you simply refuse to admit them without leaving any documentation demonstrating that you exercised reasonably prudent medical decision making I think plaintiff's lawyers would be very happy to see that!

This is standard practice though the ED doc calls the on call psychiatrist who is on home call, they never write a note only the ED doc does

 

[lockian]

Something that helps me sleep easier is thinking back to some of the worst psychiatrists I have worked with. They seem to be doing okay, which tells me the bar can be pretty low. As others have pointed out, others with far less training also practice psychiatry and seem to do okay. And as has been stated, you are very unlikely to lose your license and exceedingly unlikely to lose your personal assets because of a lawsuit.

In general, carry good liability insurance and practice good psychiatry. The risks of something catastrophic happening to you in terms of liability are low. You could also get in a fatal or permanently disabling crash driving, but given the odds of each scenario if you do not spend a lot of time obsessing about that you probably should not spend a lot of time obsessing about a lawsuit ending your career.

I’m curious, what defines a bad psychiatrist for you?

 

[jbomba]

I presume this means refusing admission to someone who comes to the ER seeking admission voluntarily? I think there is significant room for liability there. Even if they presented willingly, they might pose an imminent risk to themself or others because of decompensated mental illness. I may be misunderstanding you, but if you simply refuse to admit them without leaving any documentation demonstrating that you exercised reasonably prudent medical decision making I think plaintiff's lawyers would be very happy to see that!

This is more so to do with taking call for a hospital overnight. This particular private psych hospital accepts walk ins. The admissions nurse calls to wake me up. She tells me about the patient and based on what she's told me, I need to make a decision. On occasion they do not seem to meet criteria for admission. Maybe they aren't psychotically decompensated and/or are denying SI/HI. Maybe they are well known to malinger for a bed. Whatever the reason, we feel they don't warrant admission and I decline them. In this instance, any idea what my liability is having never seen this patient in person?

 

[michaelrack]

Malpractice judgements very rarely exceed your insurance limits, and even if they did early in your career it would be relatively easy to bankruptcy them and start fresh (credit doesn't much matter if you make 300k/year and cash flow your life).

A bankruptcy filed after a judgement against you does not typically wipe out the judgement. On the other hand, if you meet qualifications for chapter 7 bankruptcy for some reason, and file before there is a judgement against you, that liability can be wiped out. A typical doctor who has a malpractice judgment against him typically will not be able to use bankruptcy to escape paying it. (I spent over $45,000 in bankruptcy court for non-malpractice related reasons)

 

[michaelrack]

What's the liability with declining voluntary walk ins? These are often done while on call at night, so I'm not writing a note justifying why I'm declining someone from admission.

I currently work at several facilities (run by Acadia and UHS) that have walk in's. People walk in for a variety of reasons- some are seeking counseling/IOP. Others come in seeking "detox from meth"- obviously don't admit for that alone. For child/adolescent, sometimes parents bring kids in for the oddest reasons, or for "clearance" to return to school- Parents might bring in a kid 10 days after being suspended for making terroristic threats at school; in which case an outpatient referral (sometimes internally) might be done instead of inpatient admission.
People walk in at all hours of the day and night for assessments, often in response to facility marketing/advertising that emphasizes both the facility's IP and outpatient/PHP programs.


when declining admissions, you have to rely on what the assessor writes.

 

[lockian]

Something that helps me sleep easier is thinking back to some of the worst psychiatrists I have worked with. They seem to be doing okay, which tells me the bar can be pretty low. As others have pointed out, others with far less training also practice psychiatry and seem to do okay. And as has been stated, you are very unlikely to lose your license and exceedingly unlikely to lose your personal assets because of a lawsuit.

In general, carry good liability insurance and practice good psychiatry. The risks of something catastrophic happening to you in terms of liability are low. You could also get in a fatal or permanently disabling crash driving, but given the odds of each scenario if you do not spend a lot of time obsessing about that you probably should not spend a lot of time obsessing about a lawsuit ending your career.

For my part, it actually quite annoys me that there are other psychiatrists and psychiatric “providers” who are frankly bad and seem just fine practicing for years, and here you and I are, reasonably good and responsible, losing sleep over whether we did the right thing or missed some detail that turns out to be critical.

 

[michaelrack]

It's a bit different in residency, although even then it's important to have access but certainly the expectation is to complete more of the workup as primary. In community/PP setting there should be someone on call at all times and easily accessible. I cannot imagine taking a psych IP job where I am also responsible for chest pain workups, there's already more than enough to worry about from a psychiatric management standpoint. Even UHS staffs all their standalone psych hospitals with a IM/FM team...

The IM/FM team isn't always available 24/7. Sometimes the psych on call is responsible for medical issues at night- typically expected to be able to give prn Blood pressure meds but send out anything too complicated to the ER.

 

[michaelrack]

Agree that malpractice related issues won't lead to license loss- the psychiatrists I know of with license problems, it's due to either excessive prescription or careless prescription of controlled substances, or for inappropriate sexual activity, including whipping patients during therapy:

Memphis doctor accused of using whips and riding crops on patients

A psychiatrist in Memphis is accused of striking at least 10 patients with whips and/or riding crops.

www.wkrn.com

edit: the link is from 2018, but she apparently has relapsed and gotten into more trouble with the medical board; as I have treated one of her former patients in the last year. I don't know anything personally about her, other than what I have read in the newspaper.

 

[Bartelby]

I’m curious, what defines a bad psychiatrist for you?

A few examples I have personally observed:

-Discharging patients who seemed incredibly dangerous (seeming far out of line with other psychiatrists' judgment)
-Starting medications in almost bizarre ways, such as an initial Zyprexa 30 mg in an elderly patient (not currently on antipsychotics)
-Falling asleep repeatedly while conducting patient interviews, as a persistent pattern
-Appearing to persistently struggle with basic tasks such as correctly writing orders in the EMR, leading to repeated mistakes with the potential to cause harm
-Telling patients odd and obviously falsifiable information, such as telling a patient who overdosed on a small supply of an SSRI that "when people overdose 95% of the time they die! You are incredibly lucky to have survived."
-Being on call but simply disappearing / failing to answer the phone or pager

In general, when I think of a bad psychiatrist I don't really think of personal style or whether they tend to be less cautious then I would. I tend to think of problems that would be pretty obvious to a layperson who had some basic background information. Interestingly, laypeople are also ultimately the jurors who determine what is and is not standard of care.

 

[Bartelby]

This is more so to do with taking call for a hospital overnight. This particular private psych hospital accepts walk ins. The admissions nurse calls to wake me up. She tells me about the patient and based on what she's told me, I need to make a decision. On occasion they do not seem to meet criteria for admission. Maybe they aren't psychotically decompensated and/or are denying SI/HI. Maybe they are well known to malinger for a bed. Whatever the reason, we feel they don't warrant admission and I decline them. In this instance, any idea what my liability is having never seen this patient in person?

The honest answer is that I don't know. You would want to clarify whether local courts hold practitioners to a local or national standard. If this setup is standard practice in your area, then by a local standard it should not be considered malpractice (unless you engage in it in a way that others would not).

I think a few questions are also relevant:
-Is a licensed practitioner (not a nurse) seeing this patient and writing a note?
-How much information goes into the admission nurse's note?
-When issues such as an identified risk for harm to self or others come up, what is the mechanism for dealing with it? Does, for example, an ER physician evaluate? Do you then have a very low / conservative bar and just admit? As you might imagine, admitting someone who really didn't need it has a lower risk of liability than sending someone out who did need admission.
-Is anyone screening for acute medical issues?

When I supervise residents, I don't see the patient but there is a well-written note that spells out the clinical reasoning and I can addend to further clarify anything that is not clear. In this case, if the admissions nurse is only jotting a few basics about the person's presentation and you are not writing anything, where is the medical decision making demonstrated, and are you demonstrating that all of the information that should have been gathered was gathered? If that patient walks out that night and completes suicide or homicide, my understanding is that you are the one who signed off that they were safe for discharge. Will the record be able to support your determination? You can speak to your thought process in a deposition, but that will be your word about some case you heard about briefly over the phone (by that point likely years ago). I personally would feel much more comfortable putting my thoughts into writing before I learn there has been any kind of bad outcome.

I think sending people you don't know well out of the ER is one of the higher-risk settings for subsequent serious bad outcomes, so if it were me I would be a little uncomfortable having the liability for the decision fall on me based just on a nurse's triage assessment (and no assessment or documentation of my own). But then again, I may just be too cautious. I don't worry a lot about risk management issues, but part of that is (I think) that I only agree to work in systems where I feel very comfortable with the setup with regard to risk. I can discharge a high-risk patient and sleep like a log as long as I know I did an appropriate assessment and documented it.

 

[calvnandhobbs68]

Agree that malpractice related issues won't lead to license loss- the psychiatrists I know of with license problems, it's due to either excessive prescription or careless prescription of controlled substances, or for inappropriate sexual activity, including whipping patients during therapy:

Memphis doctor accused of using whips and riding crops on patients

A psychiatrist in Memphis is accused of striking at least 10 patients with whips and/or riding crops.

www.wkrn.com

edit: the link is from 2018, but she apparently has relapsed and gotten into more trouble with the medical board; as I have treated one of her former patients in the last year. I don't know anything personally about her, other than what I have read in the newspaper.

Yeah OP if anything can make you feel better…you can apparently whip your patients and only get a 60 day license suspension and then get put on a 3 year “probation” where you just have to go to psychotherapy every month.

Doctor accused of whipping patients has license suspended after violating probation orders

MEMPHIS, Tenn. – A Germantown psychiatrist who was accused of whipping patients has had her license suspended after violating the orders of her probationary period. The Tennessee Board of Medical E…

wreg.com

 

[JKinSC]

Yeah OP if anything can make you feel better…you can apparently whip your patients and only get a 60 day license suspension and then get put on a 3 year “probation” where you just have to go to psychotherapy every month.

Doctor accused of whipping patients has license suspended after violating probation orders

MEMPHIS, Tenn. – A Germantown psychiatrist who was accused of whipping patients has had her license suspended after violating the orders of her probationary period. The Tennessee Board of Medical E…

wreg.com

What in the actual...

 

[HemeOncHopeful19]

I guess I don't really know what standard of care means. It feels like this vague term that is hard to define in psychiatry at times.

That’s because it is a made-up term invented by lawyers that is intentionally vague such that an argument can always be made that you somehow violated it despite it not appearing in any medical textbook (other than perhaps a textbook on malpractice).

 

[Stagg737]

I’m curious, what defines a bad psychiatrist for you?

Examples were already given, but I've seen more than one patient on med lists that would probably kill much larger animals (horses, maybe even elephants). I've written about this example previously.

Early morning stat consult from FM resident for "med recs" for an encephalopathic patient seen by a local addiction psychiatrist. Patient was prescribed a ridiculous regimen (something like this, can't remember exactly): 3 antipsychotics, 2 benzos, 2 stimulants, multiples SS/NRIs, trazodone, mirtazapine, buspar, gabapentin, and of course lamotrigine. They were also taking an opiate, tramadol, and either zanaflex or flexeril. The patient had apparently been taking these meds for years per chart review. If people can prescribe a list like that for years and still be practicing as an addiction psychiatrist without action, I'd say the bar for what defines a "bad psychiatrist" is pretty low...

 

[comp1]

I mean the only way I can judge another psychiatrist is on their documentation. So if there's minimal documentation or it doesn't match what actually happened, they might be bad. In terms of the weird stuff described above, the more out there what you're doing is, ie benzos and opiates, three antipsychotics, the more documentation you need to support it.

 

[FlowRate]

and of course lamotrigine.

Random aside but why "of course" LTG? Do you see a lot of inappropriate LTG prescribing in your area?

If anything, it's way under-utilized around here with lots of outside referrals I get having patients on oxcarbazepine instead.

 

[Stagg737]

Random aside but why "of course" LTG? Do you see a lot of inappropriate LTG prescribing in your area?

If anything, it's way under-utilized around here with lots of outside referrals I get having patients on oxcarbazepine instead.

Yea, just kind of gets thrown at patients a lot here at non-therapeutic dosing, especially by mid-levels. Not uncommon for me to encounter people on doses of 50mg or less or doses over 300mg without a seizure history.

 

[meow1985]

I don't think I have a great answer and I also struggle with the fact that you can do literally nothing wrong and someone can still sue you. I was sued as a PGY4 for something that happened as an intern. I was named alongside my attending. The case was quickly dropped due to being fairly frivolous. In some cases, there is no weeding out process for frivolous med mal lawsuits, which was the case in the state where I did residency. In other states there needs to be an expert on the plaintiff's side who is willing to say "yes, there is a case here" for the proceedings to go ahead. The state I live in now falls into the latter category, which helps some. You may want to check your state's rules.

Still, that frivolous case is something that is going to follow my attending and I around. Any time there was paperwork to be filled out for a license, credentialing, med mal insurance, even a new job, I had to put it down. I'm still traumatized from the experience, and I keep worrying it will happen again, this time for cause and then insurance would drop me or something. I have no idea if that's a realistic worry, since I don't know how exactly insurances work.

Again, I don't have a great solution. Personal therapy is in part helpful. As is just taking it one day at a time and conserving your energy so that you can be present and do your best if **** *does* go down. Worrying all the time is exhausting.

I wonder how other specialties not worry about this so much. Maybe it's selection bias, but in the time I've spent with other specialties, no one needs to mention liability quite as often as psychiatrists, and psychiatrists are supposedly among the least sued. I have a theory that it's because 1) "bad outcomes" such as MI's, strokes, falls, infections are just more common in other specialties so others get desensitized to them and 2) we are more acutely aware of how little control we have other patients' behavior, yet society tends to erroneously assume that suicide, violence, etc are somehow preventable, and if someone's going to prevent them it's psychiatry. Whereas if someone develops an MI, they think, "well, that sucks," but typically the cardiologist or family doc doesn't get blamed.

 

[smalltownpsych]

I always tell my patients that worry about being a good parent, that is a great sign of being a good parent. The really bad parents never seem to worry about it. From what I have seen, it looks like the same holds up for psychiatrists.

Maybe not for that one neurotic worried guy that I worked with during my internship, I’m not sure if he worried about making mistakes or if he was just anxious about everything. I literally saved him from being punched by an agitated patient because he was saying such stupid things and I used my well-honed clinical skills, aka, playground bully avoidance skills to redirect, make a wisecrack and lighten the mood so that the poor guy didn’t get hit. I think he was arguing with them about why they had to take their antipsychotic and didn’t know that the patient had already agreed with the plan with me before hand. Bad psychiatrist is don’t listen to your patient when they are getting pissed and you are in striking range and fail to even recognize that you are in danger. No wonder the guy was anxious.

 

[Alemo]

Some points:

The legal standard of care (typically “what would a reasonable psychiatrist do in similar circumstances”) is usually LOWER than clinical standards of care that we hold ourselves too.

For this reason (and because lawyers want money and usually are paid on a contingent basis when working for the plaintiff), suits are only taken far (i.e to settlement) if there is an egregious lapse.

The academic standard that we are trained to in residency is much higher than what any given practicing psychiatrist needs to do in approximating “standard of care.”
EDITED damn I wrote it backwards

 

[forchinet121]

Some points:

The legal standard of care (typically “what would a reasonable psychiatrist do in similar circumstances”) is usually HIGHER than clinical standards of care that we hold ourselves too.

For this reason (and because lawyers want money), suits are only taken far (I.e to settlement) if there is an egregious lapse.

I feel like what you’re saying is backwards

 

[ObsequiousAplomb]

I feel like what you’re saying is backwards

Yeah, I feel like he either means the legal standard is lower or the threshold for violating the legal standard is higher. Because that's what the second part of his comment says.

 

[jbomba]

Yeah, I feel like he either means the legal standard is lower or the threshold for violating the legal standard is higher. Because that's what the second part of his comment says.

I think by higher he means it's harder to breach that standard because it's more lax than what we hold ourselves to.

 

[deleted1100659]

Yea, just kind of gets thrown at patients a lot here at non-therapeutic dosing, especially by mid-levels. Not uncommon for me to encounter people on doses of 50mg or less or doses over 300mg without a seizure history.

YES. THIS. Or where I was, had people on 400mg. Lots of midlevels were giving it to borderline patients. Except theres one huge problem with that as many may guess: borderline patients have recurrent suicidal thoughts and do stuff like ODIngs or just taking the wrong amount/too much meds in general. Had a midlevel who was refilling a patients lamictal, turns out she was DOUBLING her dose on her own without telling anyone, we found out after she was running out too fast.

Personally I hate lamictal. If bipolar depression, I would much rather use a SGA any day of the week. Correct me if im wrong, but the benign form of the rash is near 10% incidence and some literature says to stop it if that occurs, because you're at higher risk for SJS. And then the super long titration period while the patient sits there depressed waiting for any kind of effect. I know its used for maintenance but still, its just not my first choice ideally. Lots of overlapping sx with borderline and bipolar 2, and I hate borderline patients on lamictal.

Tp add to the original thread: after finishing my first year as an attending, the scariest thing for me wasnt my clinical decisions, but being over midlevels and being potentially liable for theirs. I can control what I do, but I cant see everything a midlevel does and wont always be there. To me, that is terrifying and I hated it. Not knowning whats happening under your name.

In tough situations, i try to go off evidence based medicine and asking myself what any reasonable psychiatrist would do in my situation. I dont think you can do much more then that besides solid documentation.