Patient wanting to see 2 Providers

[ucsbgirl]

In my practice, I will sometimes get patients who want to see more than one Psychiatrist at the same time for medications.

It is my understanding that this is at the very least not ethical or legal if there is no communication between the 2 providers.

I have been pressured by " the powers that be" to see some of these patients and give them medications despite not having access to the other provider records or having any communication with the other provider. There are not capacity or forensic cases, but run of the mill depression, anxiety, schizophrenia cases.

Especially for the Forensic Psychiatrists on this Forum: Can someone direct me to a written policy by AAPL ( or a legal case, etc) that explicitly states that it is inappropriate to see more than one Psychiatrist for medications at the same time ( given usual circumstances)?

I would like to have something " in hand" next time this happens to back up my position.

Thanks!

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[hamstergang]

It is my understanding that this is at the very least not ethical or legal if there is no communication between the 2 providers.

It's not good care and not standard practice, but it's not illegal nor unethical.

 

[splik]

What the hell has this got to do with forensic psychiatrists or AAPL?

This would be considered poor form. You should absolutely contact any concurrent psychiatrists or therapists and do not need patient consent for this. Though patients can obviously lie and so you might not know if they are seeing someone else. You should also check to see if they are being prescribed controlled substances elsewhere.

I actually do see patients who have another psychiatrist. In which case I am the consultant and make recommendations to the patient and their treating psychiatrists. I see patients who other psychiatrists don’t know what to do with. Patients are free to seek a second, third, fourth or fifth opinion in their case.

I try to avoid taking on patients but I recently agreed to take on a complex patient who already has a psychiatrist but on the understanding that I never prescribe medications.

You cannot be forced to practice below your own standard of care.

 

[nexus73]

It doesn't make sense for there to be two psychiatrists managing medications on the same patient. Also, red flag if patient doesn't want you to get the other psychiatrist's records. I wouldn't agree to treat such a patient. One time visit for second opinion sounds ok...oddly I haven't heard this happening much in psychiatry (outside of patients shopping around themselves for benzo rx).

 

[Crayola227]

I think in this case where you don't have communication with the other provider and that the patient is also getting meds elsewhere - NO WAY would I Rx meds in that scenario.

I would never want to knowingly Rx to a patient that does not have a complete and verifiable list of meds on board. Confusion and lies happen... but you get what I mean. I hope.

 

[futuredo32]

I will do it as a consult but not as a regular thing.

 

[dl2dp2]

There are rare examples where this might be appropriate, but not without communication. For example, addiction specialist for suboxone and regular psychiatrist for other issues. Or, some psychiatrist specifically focuses on therapy with BPD, and often they don't do med mgmt as that might interfere with transference.

 

[thoffen]

As others have said, not illegal in the least. But why in the world? There are legit reasons if the treatment modality is specialized or doesn't overlap or someone is serving a consultation / second opinion role, or someone is in an IOP/PHP program and still maintaining continuity with outpatient provider, but I can't imagine 2 providers overlapping in their treatment without communication ever being in the patient's interest.

 

[FlowRate]

Schrodinger's psychiatry patient.

 

[birchswing]

I was seeing a therapist and wanted to see a sex therapist and was told by the sex therapist I was trying to book with that I couldn't unless I stopped seeing my regular therapist. I thought it was very odd and unhelpful.

But for meds, that seems like too many cooks in the kitchen.

 

[SpongeBob DoctorPants]

It makes little sense for someone to see two of the same specialist simultaneously, but whatever reason a patient may have for doing this, you'll need to know exactly what the other doctor is prescribing. And, of course, you'll need to check the state database for controlled meds being dispensed.

I recently started treating a child whose mother has been taking him to see an "ADHD specialist" four hours away. I'm in a small city with no other child psychiatrists, so he had been seeing this other doctor long before I came to town. He came to see me for concerns about depression. I said I can also manage the ADHD, but the mother is at least for now continuing to have him see the other doctor. It's no big deal; I just document what I'm prescribing and what the other doctor is doing. It just doesn't make sense to me why someone would travel so far for a service I can provide locally.

 

[ryerica22]

Seems really fishy to me. The patient needs to decide on one doc. Plain and simple. You don't have the time to go around trying to contact another Psychiatrist for records.

 

[Ceke2002]

As we sometimes say in the Australian vernacular, 'Eff that for a joke'! Second opinion, fine - wants to see another Psychiatrist because *insert whatever reason*, meh I don't see it myself, but okay, I guess - doesn't want to hand over medical records or allow flow of information between the two psychiatrists? Hell to the no.

 

[birchswing]

As we sometimes say in the Australian vernacular, 'Eff that for a joke'! Second opinion, fine - wants to see another Psychiatrist because *insert whatever reason*, meh I don't see it myself, but okay, I guess - doesn't want to hand over medical records or allow flow of information between the two psychiatrists? Hell to the no.

My understanding, and I would love to be edified if I am wrong, is that doctors can discuss patient care even without signing a release in the US. I get that from paragraph 4 here:
https://www.gpo.gov/fdsys/pkg/CFR-2003-title45-vol1/xml/CFR-2003-title45-vol1-sec164-506.xml

The rub would be that each provider would need to know that a particular patient was the patient of another provider, and I don't know if there's any mechanism for knowing that without the patient disclosing it.

And the strange thing is that every US doctor's office I've been has you sign a release of information allowing that doctor to talk to your other doctors, which as I said I don't believe is required by law (but I could be wrong).

The more practical issue is that doctors tend to not talk to each other about patients even when you really want them to. As a doctor I see says, "I don't get paid for that."

 

[hamstergang]

My understanding, and I would love to be edified if I am wrong, is that doctors can discuss patient care even without signing a release in the US.

That's certainly allowed by federal law (I'm not sure if any state doesn't allow treating doctors to discuss a patient without explicit consent, but it's possible). Hospital or clinic policy almost always requires the forms to be filled out. If a patient explicitly prohibits the communication, then I think the law supports that decision.

 

[thoffen]

That's certainly allowed by federal law (I'm not sure if any state doesn't allow treating doctors to discuss a patient without explicit consent, but it's possible). Hospital or clinic policy almost always requires the forms to be filled out. If a patient explicitly prohibits the communication, then I think the law supports that decision.

Yeah other than psychotherapy notes HIPAA doesn't protect this communication so the state laws are what ends up being relevant from a purely legal standpoint here. Beyond that, though, a provider is free to have consent requirements stricter than state laws.

 

[randomdoc1]

hells to the no

 

[SeniorWrangler]

Without communication between prescribers, it is very easy to imagine the patient suffering a medication interaction with serious effects. If that happened, you don't need to be a lawyer to say that the doctor should have known better. How on earth would you defend this practice to a judge, family member or reporter?
If you are working in a larger institution, it probably has a risk management department or attorney who is on retainer. Ask to talk to them about it and get their opinion in writing.

 

[smalltownpsych]

If the patient doesn’t have a reasonable rationale for seeing two psychiatrists such as obtaining a second opinion or even one as silly as “the other guy or gal is my ADHD doc and I just need you to treat my depression” then it raises major red flags for me. Drug abuse is the easy go to, but I would also think personality disorder traits as well. I am also thinking that if I was in th situation, I doubt that I would prescribe anything and you could just do what I do, provide psychotherapy and tell them to talk to the other doc who has already prescribed their medications about any issues with the medications. I even educate them a bit on how to have that conversation and might even role play it if the patient has some core issues in the way of effective collaboration with their provider.

 

[birchswing]

And what about the frame? Won't someone please think of the frame?

 

[Ceke2002]

My understanding, and I would love to be edified if I am wrong, is that doctors can discuss patient care even without signing a release in the US. I get that from paragraph 4 here:
https://www.gpo.gov/fdsys/pkg/CFR-2003-title45-vol1/xml/CFR-2003-title45-vol1-sec164-506.xml

The rub would be that each provider would need to know that a particular patient was the patient of another provider, and I don't know if there's any mechanism for knowing that without the patient disclosing it.

And the strange thing is that every US doctor's office I've been has you sign a release of information allowing that doctor to talk to your other doctors, which as I said I don't believe is required by law (but I could be wrong).

The more practical issue is that doctors tend to not talk to each other about patients even when you really want them to. As a doctor I see says, "I don't get paid for that."

Yes, it's pretty much the same here - pertinent medical information can be shared between Doctors as part of a patient's overall treatment. A patient that wants to see any Doctor and insists that none of their other medical records be viewed or discussed, or an organisation insisting upon letting a Doctor treat a patient under those circumstances just sounds like a huge 'Nope' to me.