Current Psychiatry. 2014 September;13(9):54-57
Author(s):
Christopher P. Marett, MD, MPH
Fellow in Forensic Psychiatry
Douglas Mossman, MD
Professor of Clinical Psychiatry and Director
Division of Forensic Psychiatry
University of Cincinnati College of Medicine
Cincinnati, Ohio
Dear Dr. Mossman,
When I take a call from a treatment-seeker at our outpatient clinic, I ask brief screening questions to determine whether our services would be appropriate. Shortly after I screened one caller, Ms. C, she called back requesting a medication refill and asking about her diagnosis.
What obligation do I have to Ms. C? Is she my patient? Would I be liable if I didn’t help her out and something bad happened to her?
Submitted by “Dr. S”
Office and hospital Web sites, LinkedIn profiles, and Facebook pages are just a few of the ways that people find physicians and learn about their services. But most 21st century doctor-patient relationships still start with 19th century technology: a telephone call.
Talking with prospective patients before setting up an appointment makes sense. A short conversation can clarify whether you offer the services that a caller needs and increases the show-up rate for initial appointments.1
But if you ask for some personal history and information about symptoms in a screening interview, does that make the caller your patient? Ms. C seemed to have thought so. To find out whether Ms. C was right and to learn how Dr. S should handle initial telephone calls, we’ll look at:
• the rationale for screening callers before initiating treatment
• features of screening that can create a doctor-patient relationship
• how to fulfill duties that result from screening.
Why screen prospective patients?
Mental health treatment has become more diversified and specialized over the past 30 years. No psychiatrist nowadays has all the therapeutic skills that all potential patients might need.
Before speaking to you, a treatment-seeker often won’t know whether your practice style will fit his (her) needs. You might prefer not to provide medication management for another clinician’s psychotherapy patient or, if you’re like most psychiatrists, you might not offer psychotherapy.
In the absence of prior obligation (eg, agreeing to provide coverage for an emergency room), physicians may structure their practices and contract for their services as they see fit2—but this leaves you with some obligation to screen potential patients for appropriate mutual fit. In years past, some psychiatrists saw potential patients for an in-office evaluation to decide whether to provide treatment—a practicethat remains acceptable if the person is told, when the appointment is made, that the first meeting is “to meet each other and see if you want to establish a treatment relationship.”3
Good treatment plans take into account patients’ temperament, emotional state, cognitive capacity, culture, family circumstances, substance use, and medical history.4 Common mental conditions often can be identified in a telephone call.5,6 Although the diagnostic accuracy of such efforts is uncertain,7 such calls can help practitioners determine whether they offer the right services for callers. Good decisions about initiating care always take financial pressures and constraints into account,8 and a pre-appointment telephone call can address those issues, too.
For all these reasons, talking to a prospective patient before he comes to see you makes sense. Screening lets you decide:
• whether you’re the right clinician for his needs
• who the right clinician is if you are not
• whether he should seek emergency evaluation when the situation sounds urgent.
Do phone calls start treatment?
As Dr. S’s questions show, telephone screenings might leave some callers thinking that treatment has started, even before their first office appointment. Having a treatment relationship is a prerequisite to malpractice liability,9 and courts have concluded that, under the right circumstances, telephone assessments do create physician-patient relationships.
Creating a physician-patient relationship
How or when might telephone screening make someone your patient? This question doesn’t have a precise answer, but how courts decided similar questions has depended on the questions the physician asked and whether the physician offered what sounded like medical advice.10,11 A physician-patient relationship forms when the physician takes some implied or affirmative action to treat, see, examine, care for, or offer a diagnosis to the patient,9,12,13 such as:
• knowingly accepting someone as a patient14
• explicitly agreeing to treat a person
• “acting in some other way such that the patient might reasonably be led to assume a doctor-patient relationship has been established.”15
Also, the “fact that a physician does not deal directly with a patient does not necessarily preclude the existence of a physician-patient relationship,”12 so a telephone conversation can create such a relationship if it contains the right elements. Table 116 highlights actions that, during the course of screening, might constitute initiation of a physician-patient relationship. Table 2 offers suggestions for managing initial telephone contacts to reduce the chance of inadvertently creating a physician-patient relationship.
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https://www.mdedge.com/sites/default/files/Image/September-2017/RTEmagicC_CP013090054_t2.jpg.jpg
In the eyes of the law, whether a physician-patient relationship was formed depends on specific facts of the situation and may be decided by a jury.13,14 In the case of Ms. C, Dr. S might avoid premature creation of a physician-patient relationship by refraining from offering a diagnosis at the conclusion of the screening call.17
Prescribing
Although features of the original screening interview indicated that Ms. C was not yet Dr. S’s patient, prescribing certainly would commence a physician-patient relationship.18 But even if the screening had made Ms. C a patient, refilling her prescription now probably is a bad idea.
Assuming that a physician-patient relationship exists, it is unlikely that a short telephone interview gave Dr. S enough information about Ms. C’s medical history and present mental status to ensure that his diagnostic reasoning would not be faulty. It also is unlikely that telephone screening allowed Dr. S to meet the standard of care for prescribing—a process that involves choosing medications suitable to the patient’s clinical needs, checking the results of any necessary lab tests, and obtaining appropriate informed consent.19
Satisfying duties
Outpatient facilities can instruct telephone screeners to conduct interviews in ways that reduce inadvertent establishment of a treatment relationship, but establishing such a relationship cannot be avoided in all cases. If a caller is distraught or in crisis, for example, compassion dictates helping him, and some callers (eg, Ms. C) may feel they have a firmer treatment relationship than actually exists.
Once you have created a physician-patient relationship, you must continue that relationship until you end it appropriately.3 That does not mean you have to provide definitive treatment; you simply need to exercise “reasonable care according to the standards of the profession.”16,20 If a caller telephones in an emergency situation, for example, the screening clinician should take appropriate steps to ensure safety, which might include calling law enforcement or facilitating hospitalization.3
One way to fulfill the duties of a physician-patient relationship inadvertently established during initial screening is through explicit discharge (if medically appropriate) or transfer of care to another physician.15 A prudent clinic or practitioner will describe other mental health resources in the community and sometimes assist with referral if the inquiring potential patient needs services that the provider does not offer.
In many communities, finding appropriate mental health resources is difficult. Creative approaches to this problem include transitional psychiatry or crisis support clinics that serve as a “bridge” to longer-term services,21,22 preliminary process groups,23 and telepsychiatry transitional clinics.24 When a clinic does not accept a person as a patient, the clinic should clearly document 1) key features of the contact and 2) the rationale for that decision
Bottom Line
You have a right and a responsibility to screen prospective patients for good fit to your treatment services. In doing so, however, you might inadvertently create a physician-patient relationship. If this happens, you should fulfill your clinical responsibilities, as you would for any patient, by helping the patient get appropriate care from you or another provider.
References
1. Shoffner J, Staudt M, Marcus S, et al. Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia. Psychiatr Serv. 2007;58(6):872-875.
2. Hiser v Randolph, 1980 617 P2d 774 (Ariz App).
3. American Psychiatric Association. Practice management for early career psychiatrists: a reference guide, 6th edition.
Home │ psychiatry.org starting-a-practice. Published October 16, 2006. Accessed July 8, 2014.
4. Delgado SV, Strawn JR. Difficult psychiatric consultations: an integrated approach. New York, NY: Springer; 2014.
5. Aziz MA, Kenford S. Comparability of telephone and face-to-face interviews in assessing patients with posttraumatic stress disorder. J Psychiatric Pract. 2004;10(5): 307-313.
6. Michel C, Schimmelmann BG, Kupferschmid S, et al. Reliability of telephone assessments of at-risk criteria of psychosis: a comparison to face-to-face interviews. Schizophr Res. 2014;153(1-3):251-253.
7. Muskens EM, Lucassen P, Groenleer W, et al. Psychiatric diagnosis by telephone: is it an opportunity [published online March 15, 2014]? Soc Psychiatry Psychiatr Epidemiol. doi: 10.1007/s00127-014-0861-9.
8. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.
9. Roberts v Sankey, 2004 813 NE2d 1195 (Ind App).
10. O’Neill v Montefiore Hospital, 1960 202 NYS 2d 436 (NY App).
11. McKinney v Schlatter, 1997 692 NE2d 1045 (Ohio App).
12. Dehn v Edgecombe, 865 A2d 603 (Md 2005).
13. Kelley v Middle Tennessee Emergency Physicians, 133 SW3d 587 (Tenn 2004).
14. Oliver v Brock, 342 So2d 1 (Ala 1976).
15. Appelbaum PS, Gutheil TG. Malpractice and other forms of liability. In: Appelbaum PS, Gutheil TG, eds. Clinical Handbook of Psychiatry and the Law, 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007:115-116.
16. Simon RI, Shuman DW. The doctor-patient relationship. Focus. 2007;5(4):423-431.
17. Torres A, Wagner R. Establishing the physician-patient relationship. J Dermatol Surg Oncol. 1993;19(2):147-149.
18. Aboff BM, Collier VU, Farber NJ, et al. Residents’ prescription writing for nonpatients. JAMA. 2002;288(3):381-385.
19. Edersheim JG, Stern TA. Liability associated with prescribing medications. Prim Care Companion J Clin Psychiatry. 2009;11(3):115-119.
20. Brown v Koulizakis, 331 SE2d 440 (Va 1985).
21. University of Michigan Department of Psychiatry. Crisis support clinic.
Patient Care | Psychiatry | Michigan Medicine | University of Michigan. Accessed July 9, 2014.
22. UAB Department of Psychiatry.
UAB - The University of Alabama at Birmingham - Home medicine/psychiatry. Accessed July 9, 2014.
23. Stone WN, Klein EB. The waiting-list group. Int J Group Psychother. 1999;49(4):417-428.
24. Detweiler MB, Arif S, Candelario J, et al. A telepsychiatry transition clinic: the first 12 months experience. J Telemed Telecare. 2011;17(6):293-297.
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