prescribing before the intake?

[alina_s]

I work in a large outpatient system where most of the primary care providers are very uncomfortable with anything psychiatric, particularly if the patient is under 18. We get lots of referrals on kids who have just been discharged from inpatient. There is another psychiatrist here who was left with an absurdly large caseload after several departures and perhaps as a result of this, she is ok with prescribing for kids before she has met them the first time, to "bridge" medications between discharge from inpatient and whenever the intake assessment can be scheduled. This seems pretty high-risk to me; am I being overly rigid in trying to get the primary care providers, who have actually seen them, to continue psych meds until I meet the kid? We get at least the discharge med list from the outside hospitals and never rely on parents' reports about meds and doses.

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[NickNaylor]

I don't think you're being unreasonable. You've never even seen the patient - what happens if you disagree with the diagnosis? Or if they're responding poorly to the current regimen? Or having side effects?

Personally, I wouldn't do it. If the PCP is uncomfortable, perhaps being available for an informal consult might assuage some of their fears.

 

[dl2dp2]

This is high risk behavior. Once a med is prescribed, your doctor-patient relationship is unquestionable in a court of law. If anything bad happens you'll likely have little leverage during a litigation process. General approach is have inpatient team deal with this aspect of "bridge".

 

[hamstergang]

I would never do it. It's up to the inpatient unit to provide enough meds. I guess if the intake is really far out then someone would have to bridge, but that had better see the patient in their office first.

 

[nrmp]

You should not prescribe where you don't have physician-patient relationship yet. This is similar to what providers often prescribe to families/relatives where you don't have physician-patient relationship and neither records are documented.

 

[TexasPhysician]

Absolutely not! Never.

 

[Armadillos]

I rotated at a community mental health center where it was policy docs could refill hospital DC meds to span until psychiatrist appointment after the patient did an intake with licensed therapist or social worker. The psychiatrists were government employees so didn’t have to worry about individual liability and I guess the center as whole felt risks of abrupt medication discontinuation were greater than risk of refilling short supply of DC meds based on intake with social worker.

 

[dl2dp2]

I rotated at a community mental health center where it was policy docs could refill hospital DC meds to span until psychiatrist appointment after the patient did an intake with licensed therapist or social worker. The psychiatrists were government employees so didn’t have to worry about individual liability and I guess the center as whole felt risks of abrupt medication discontinuation were greater than risk of refilling short supply of DC meds based on intake with social worker.

Yup. I would say this is not rare esp. if the inpatient/outpatient groups have some existing relationship, coupled with high need population. This is why I say "general approach". I hate working at CMHC for this (among others) reason.

 

[alina_s]

I rotated at a community mental health center where it was policy docs could refill hospital DC meds to span until psychiatrist appointment after the patient did an intake with licensed therapist or social worker. The psychiatrists were government employees so didn’t have to worry about individual liability and I guess the center as whole felt risks of abrupt medication discontinuation were greater than risk of refilling short supply of DC meds based on intake with social worker.

Maybe the quasi-federal status here explains it? But I'm expected to refill meds with no visits by anyone in the mental health clinic. Thanks for all the responses, I feel better about drawing a line.

 

[milesed]

In my state, you must see a patient to begin a medical record which is required to prescribe any meds.

 

[jettavr6]

Writing a prescription without having seen a patient first is the quickest way to end your career.

 

[Merovinge]

The question is which of the following is a bigger risk/less optimal:

1) Psychiatrist refilling meds for a patient they have never seen

2) PCP refilling meds for a patient in their clinic

90%+ of PCPs I know would even agree that number 2 is more appropriate. This is a core part of being a PCP, bridging a patient with their expertise as a physician until they get in to see a specialist.

 

[Splenda88]

In my state, you must see a patient to begin a medical record which is required to prescribe any meds.

That's probably everywhere... How can you treat someone if you have never established a physician-patient relationship with that person?

 

[shahseh22]

I work in a large outpatient system where most of the primary care providers are very uncomfortable with anything psychiatric, particularly if the patient is under 18. We get lots of referrals on kids who have just been discharged from inpatient. There is another psychiatrist here who was left with an absurdly large caseload after several departures and perhaps as a result of this, she is ok with prescribing for kids before she has met them the first time, to "bridge" medications between discharge from inpatient and whenever the intake assessment can be scheduled. This seems pretty high-risk to me; am I being overly rigid in trying to get the primary care providers, who have actually seen them, to continue psych meds until I meet the kid? We get at least the discharge med list from the outside hospitals and never rely on parents' reports about meds and doses.

why are they not being discharged with adequate supply of meds until they get a follow up appointment?

 

[hallowmann]

90%+ of PCPs I know would even agree that number 2 is more appropriate. This is a core part of being a PCP, bridging a patient with their expertise as a physician until they get in to see a specialist.

That is the PCP's job. Not refilling without a reason (adverse reaction, etc.), would likely be a higher liability. Can you imagine a patient with epilepsy coming to their PCP after discharge, running out of AEDs, with an outpatient Neuro appointment in a month? The PCP can't just say, whelp, I'm not used to using AEDs, so too bad.

Where I am, PCPs don't have the luxury of being "very uncomfortable with anything psychiatric," because of the lack of psychiatric care. Most will absolutely continue a med prescribed by a specialist in a hospital to get the patient to follow-up.

 

[Animal Mother]

Bridging is allowed here from my reading of the law provided it's under 30 days, the dose doesn't exceed what was previously prescribed, and you have a chance to review some medical records. Seems super common at CMHC. It doesn't seem much different than refilling a prescription for a colleague's patient while your colleague is on vacation. A lot of hospitals refuse to give more than 2 weeks of refills, and patients often can't get an appointment slot for a month or more sometimes in underserved areas. What do you do? Give this guy 2 more weeks of Clozapine until you can see him or have him go crazy and cut off more of his fingers?

 

[romanticscience]

Bridging is allowed here from my reading of the law provided it's under 30 days, the dose doesn't exceed what was previously prescribed, and you have a chance to review some medical records. Seems super common at CMHC. It doesn't seem much different than refilling a prescription for a colleague's patient while your colleague is on vacation. A lot of hospitals refuse to give more than 2 weeks of refills, and patients often can't get an appointment slot for a month or more sometimes in underserved areas. What do you do? Give this guy 2 more weeks of Clozapine until you can see him or have him go crazy and cut off more of his fingers?

Interesting point. I always wondered about "doctor coverage" liability. I'm also aware that there has been a case of a patient-doctor relationship created just by scheduling someone an appointment (1).

(1) https://mdedge-files-live.s3.us-eas...ptember-2017/054_0914CP_Malpractice_FINAL.pdf

 

[TexasPhysician]

Bridging is allowed here from my reading of the law provided it's under 30 days, the dose doesn't exceed what was previously prescribed, and you have a chance to review some medical records. Seems super common at CMHC. It doesn't seem much different than refilling a prescription for a colleague's patient while your colleague is on vacation. A lot of hospitals refuse to give more than 2 weeks of refills, and patients often can't get an appointment slot for a month or more sometimes in underserved areas. What do you do? Give this guy 2 more weeks of Clozapine until you can see him or have him go crazy and cut off more of his fingers?

Hospitals that I’ve worked at all schedule a follow-up within 2 weeks. It may be at a CMHC, private psych, or PCP but it happens. Discharging someone without a plan is a poor care model, and that is on them. It isn’t my problem to bail out an entire hospital.

I know how my colleagues prescribe, and I won’t cover for docs I don’t trust. I certainly would never cover for random community docs.

By the time a patient calls me post hospital discharge, it’s been a few days. Getting the hospital to send me complete records will take weeks. Patients are typically seen by me before records could arrive.

It is much harder for an attorney to win a lawsuit that you harmed a patient prior to treating them than if you actually harmed a patient and never even met for an appointment by prescribing.

I would never recommend anyone Rx before establishing a relationship through an appointment.

 

[Animal Mother]

Hospitals that I’ve worked at all schedule a follow-up within 2 weeks. It may be at a CMHC, private psych, or PCP but it happens. Discharging someone without a plan is a poor care model, and that is on them. It isn’t my problem to bail out an entire hospital.

I know how my colleagues prescribe, and I won’t cover for docs I don’t trust. I certainly would never cover for random community docs.

By the time a patient calls me post hospital discharge, it’s been a few days. Getting the hospital to send me complete records will take weeks. Patients are typically seen by me before records could arrive.

It is much harder for an attorney to win a lawsuit that you harmed a patient prior to treating them than if you actually harmed a patient and never even met for an appointment by prescribing.

I would never recommend anyone Rx before establishing a relationship through an appointment.

You’re right that it’s poor care to discharge someone without enough meds to last until follow up. A lot of these new patients are stepdowns from IMDs where they’ve lived for 2 years and some are hospital discharges. If the area is very underserved and there’s only one place in the county seeing these Medicaid patients, I don’t see an easy solution if the hospitals won’t change their medication policy.

I’ve struggled with this. It’s certainly not ideal, and there is some risk involved assuming the records are accurate, this person really has schizophrenia, and is doing well on their clozapine. But what’s the risk of trusting these records vs the risk to the patient of abrupt discontinuation of meds and decompensation? And when I’m saying risk, I’m talking about patient well-being, not your increased liability. Of course, your not going to get sued for not prescribing a med for a patient you’ve never seen. Also, I feel a lot of times that the clinical interview is often not as important for a lot of these patients. Sure, it’s nice to lay eyes on them and do a physical exam if needed, but many of them have no insight into their illness, can’t provide any history, and we end up relying on past records and collateral for decisions almost 100% anyway. Im not saying I’m right, and maybe I need to re examine how I’m doing things. It’s just a tough situation, and I’ve been trying to do what I think makes sense and is best for the patients wellbeing.

 

[TexasPhysician]

You’re right that it’s poor care to discharge someone without enough meds to last until follow up. A lot of these new patients are stepdowns from IMDs where they’ve lived for 2 years and some are hospital discharges. If the area is very underserved and there’s only one place in the county seeing these Medicaid patients, I don’t see an easy solution if the hospitals won’t change their medication policy.

I’ve struggled with this. It’s certainly not ideal, and there is some risk involved assuming the records are accurate, this person really has schizophrenia, and is doing well on their clozapine. But what’s the risk of trusting these records vs the risk to the patient of abrupt discontinuation of meds and decompensation? And when I’m saying risk, I’m talking about patient well-being, not your increased liability. Of course, your not going to get sued for not prescribing a med for a patient you’ve never seen. Also, I feel a lot of times that the clinical interview is often not as important for a lot of these patients. Sure, it’s nice to lay eyes on them and do a physical exam if needed, but many of them have no insight into their illness, can’t provide any history, and we end up relying on past records and collateral for decisions almost 100% anyway. Im not saying I’m right, and maybe I need to re examine how I’m doing things. It’s just a tough situation, and I’ve been trying to do what I think makes sense and is best for the patients wellbeing.

The hospital and county entity should then get together and work on a bridge process to ensure quality public mental health.

I get that you want to better the community, but as individual physicians, we need to recognize our limitations. I can’t ensure everyone in my city has availability to a psychiatrist within 2 weeks. If the records were slightly inaccurate, you misread them, or the patient has an adverse event from your script, you could lose your license in my state for this. Then who is there to treat your patients?

 

[FlowRate]

If the records were slightly inaccurate, you misread them, or the patient has an adverse event from your script, you could lose your license in my state for this.

Connecting the dots, this is because it's considered (rightfully) negligent to prescribe meds with serious potential toxicities when you've never examined a patient.

I think that it's easy to forget as psychiatrists that the rest of medicine does physical exams and they'd probably never treat a patient without having laid hands first. First rule of intern year -- "go see the patient."

 

[Armadillos]

Connecting the dots, this is because it's considered (rightfully) negligent to prescribe meds with serious potential toxicities when you've never examined a patient.

I think that it's easy to forget as psychiatrists that the rest of medicine does physical exams and they'd probably never treat a patient without having laid hands first. First rule of intern year -- "go see the patient."

To play devils advocate (I’m not actually suggesting to prescribe before intake unless your in a system specifically supporting this, but I also think folks are maybe putting too much stock into how much we could improve safety with a single visit).

It seems pretty hard to imagine likely scenarios where a face to face interview would prevent a substantial harm from occurring compared to reviewing hospital records, 5 minute call to patient to document mental status exam/Med tolerability and then calling in 15-30 day supply of the hospital DC meds to span to the intake. I would suggest it’s probably even safer for a psychiatrist to do that then for a PCP to just continue the psych meds because PCP are less likely to immediately catch illogical or unsafe med combinations than the psychiatrist.

Again not recommending psychiatrists should do this outside CMHC/VA/organized health system given it’s not standard of care (yet), but if done responsibly it genuinely seems in patients best interest given shortage of psychiatrists.