Looking towards end of residency and have begun to think about ways to give back a little. I think if I aim to maximize my income in my regular jobs I will have time available to dedicate towards more gestures of good will. Been thinking about spending at least part of my time potentially chartering a sail boat and cruising around the Pacific doing psychiatric assessments for the locals living on various islands I happen upon. Might also try to create a small formulary and get Eli Lily to donate some prozac or antipsychotics I could drop off as well. Maybe some sunscreen too. Anyone know how realistic this might this be? Okay okay, I kid. But seriously, I'm thinking about doing a free clinic a half day a week, or maybe a couple days a month. Is there any particular liability associated with this? Anything I should consider? Would free psychiatric care not be as helpful as I think it might be? Curious to hear thoughts.
Pro Bono Psychiatry
- Thread starter jbomba
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I will give you some perspective from someone who worked in a free health care, private practice and a low-income clinic (it was a very cheap price, mostly to help) in another country. When it is free, a lot of people tend not to give enough value. I have no idea about the liability here, but in terms of how well it works, I would advise to charge a small fee, maybe $20-50 or something like that.
Also, when it is free you get a lot of malingering if you don't select the patients beforehand, so just my two cents.
Also, when it is free you get a lot of malingering if you don't select the patients beforehand, so just my two cents.
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Work at community mental health center 1 day a week. Then re-evaluate your career goals after 1-2 years. This will essentially be a free clinic. Secondly, no one needs a free clinic anymore with the ACA and state based exchanges. The people who aren't insured either chose to not pick up insurance, don't know how to navigate enrollments or missed their window for eligible enrollment and just need to wait a few more months before the next open enrollment. The real bottle neck is Medicaid accepting folks, i.e. working at a community mental health clinic.
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Dude this isn’t true. In the states that haven’t expanded Medicaid, although there are income based subsidies for ACA exchange plans, the deductibles and OOP maxes for these are still often insane for someone making even 19,320 a year (150% of federal poverty level for a single person which is still where you can contribute 0% of your income to premiums) when your deductible is 5K. Even this years subsidy which is more generous than in the past still caps at 8.5% of income for PREMIUMS. That’s not a ton when you’re making 200k a year but it can be 20+% of your income total depending on how much healthcare you’re using. There’s plenty of uninsured people, especially single adults at low paying jobs (12 dollars an hour x 40 x 48 weeks a year = 23K), who hit that hole where they make too much for Medicaid but an ACA plan still means they’d be paying thousands of dollars towards a deductible every year.
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Another volunteer option: I do psych evaluations for asylum seekers due to abuse/trauma in their home country where I act as an expert witness. There’s free training and mentoring thru physicians for human rights and evals are via zoom with interpreter. They take 2-4h plus similar time to write my affidavit. I do as many or as few as I want (~6 /year). No treatment or follow up of any kind, the lawyer knows if there’s a chance of being called to testify and I try to avoid those as I don’t want to deal with scheduling court.
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OP, thanks for this thread. Thought it was going to be a solid troll thread, but is turning out a bit better.
Beyond the training you described, is there any other additional training you have done for this? How did you go about finding this opportunity? Are you affiliated with some refugee organizations?
Physicians for Human Rights has free training. I was not required to do the training as I did similar evals during my Forensic Psychiatry fellowship.
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Is this something you would be willing to expand upon here or in it's own thread? I'm curious how long you spend on the evals, what involvement you have at the legal level and just your overall experience. I'm particularly interested in the human trafficking work if it includes child/adolescent population in the US.
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Wife looked in to the local charity clinic and it all sounded great until she talked to someone who did it for a bit. Apparently they got all types of inappropriate patients. SMI mostly but also folks who didn't speak English and no interpreters outside of family if you were lucky. And there was no hope of ever following up because there were always more patients being added to their schedule. On top of that I don't think the clinic could provide malpractice so the doc had to pay for the privilege of being a part of that medicolegal disaster waiting to happen.
So look before you leap.
So look before you leap.
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I agree with the idea of charging a nominal fee - people will not value something if they don't have some kind of skin in the game. As far as liability goes, I imagine this will depend on your state and whether your practice falls under applicable "Good Samaritan" statutes. If you're accepting any kind of fee, I would expect no protection whatsoever.
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One of my mentors was a geriatric psychiatrist and would hold a free session once a month on educating families on dementia and how to take care of family members with Neurocognitive disorders. I eventually envision myself doing something in the child/adolescent realm with giving advice on behavior modification and other concepts
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I am an adult psychiatrist and have no formal forensic training. I did a free one day course in residency through PHR (now available by zoom), shadowed a case and then started doing them myself with mentoring from forensic attendings. I now know psychiatrists from the community who were mentored through PHR as they were not affiliated with academia. You don't need to be affiliated with any refugee organization. Once you are trained, PHR will list you in their database and local lawyers who do pro bono immigration law will send referrals--PHR will make it easy for you to get started. You can take as many or as few as you want depending on your other commitments. The first few affidavits took a long time 5+ hours but now I can do them in 2-3h. I'm at an academic medical center and we have medical students who help with coordinating cases with the lawyers as well as scribing but over zoom it's easy enough to type during the eval.
There is a huge need to people who can do the psych evals. We get referrals for physical torture, genital mutilation, trafficking, etc and have EM/FM/OB do the ones that require a more in depth physical exam but the majority of our referrals are for psych. We get a number of child adolescent cases and parents/families seeking asylum and currently only have one CAP in our clinic.
I'm happy to answer any additional questions here or by PM. I've found this work to be humbling and rewarding.
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Many states do have Good Samaritan laws as well as associated state run malpractice for coverage in free/charity clinics. In my state for example it took all of 10 min on my phone completing an application and I got verification of coverage within a week.
Most people I've seen in free mental health clinics are either undocumented or between insurances/in the application process for medicaid. For undocumented patients, they tend to follow up, and for the ones between, they usually go to the CMHC or academic medical center once they get insurance. I've never heard of anyone at our local free mental health clinic being sued, and from talking to others involved it's never happened in the past 15 years of the clinic's history.
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Our state does not have an exemption for free/charity work. It seems like some (most?) states do but people shouldn't assume their state does without looking into it.
Those clinics sound fairly well run. From what I understand the charity clinic is very well run for medical issues but for mental health it was a disaster. There was no mechanism for getting folks into the local CMHC, the patients still needed to see one of the CMHC therapists twice before they could be referred to a Psychiatrist per their usual protocol. There is no local academic medical center (it's an hour and change away) and the "Regional Center" in town has always had huge waitlists and only took referrals from PCPs back before they lost all of their Psychiatrists, lord only knows what it's like now... they aren't even taking new referrals until 1/1/22.
When she was talking to the charity clinic folks it all sounded great. It was just lucky chance that she ran into someone who had done it before. My point was really just to do some research before you do any pro bono work.
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Are you ever called into testify or do things stop upon completion of the evaluation? Any sense to the impact it makes having the eval done?
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I have never been called to testify. The lawyer will sometimes say that they think testimony may be required and I avoid those cases but it's a possibility.
"Between 2000 and 2004, 1663 asylum seekers received medical evaluations from PHR; the adjudication status (either granted or denied) was determined in 746 cases at the time of the study. Of these cases, 89% were granted asylum, compared to the national average of 37.5% among US asylum seekers who did not receive PHR evaluations. Medical evaluations may be critical in the adjudications of asylum cases when maltreatment is alleged."
Source: Asylum Grant Rates Following Medical Evaluations of Maltreatment among Political Asylum Applicants in the United States
The confounder is that cases that have medical evaluations might be stronger to begin with but the affidavit likely helps.
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If you're going to volunteer via face to face care I'd imagine the best way is in some setting where you can provide longitudinal treatment. I think sushi's CMH recommendation is an apt one. If you're not concerned with money you could probably even argue to be given a reasonable panel and appointment times and maybe even volunteer to use that extended time to see some of the more complex patients.
The other option would be seeing poor people who don't have SPMI in which case you'd need some way of getting pre-screened referrals, maybe through local primary care docs who do volunteer work or even from religious leaders.
The other option would be seeing poor people who don't have SPMI in which case you'd need some way of getting pre-screened referrals, maybe through local primary care docs who do volunteer work or even from religious leaders.
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Any time you serve as an expert in a legal matter you should assume that there is the possibility of testimony. Though even in civil and criminal cases most cases do not need testimony, so immigration court (which is classified as an administrative court but is not a real court in any meaningful sense) is far less likely to require testimony. Immigration court is part of the department of justice (and thus not an independent judiciary) and many cases are heard within minutes. The likelihood of the pt getting a decent hearing (and thus the likelihood of expert testimony) is going to depend on the judge and the jurisdiction. In more liberal areas, there is more of a chance that there may be expert testimony heard. Often testimony can be provided remotely (e.g. via telephone) which was true even before COVID.
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I do these cases too and have never had to testify (though I was called to do so once, just never actually materialized). I'm not forensic trained - like the other poster I did a PHR training and had supervision (non-forensic trained, also) when I was a resident. I have templates and video tutorials if anyone is interested. PM me.
Apart from physicians for human rights, Mt. Sinai remote evaluation network also does tele evaluations.
These cases feel special. It's a different sort of itch that this work scratches, at least for me. In some cases you can play a significant role in giving someone a chance at a new life.
The interview usually will be 2-4 hours. Many will involve an interpreter so that increases the time. As a forensic psychiatrist accustomed to detailed and long reports I am not accustomed to doing shorter reports would be ideal for pro-bono work (so that I will have the time to do more of them). Since as a forensic psychiatrist I am accustomed to doing this type of work, it won't be as challenging to me as it would be to a non-forensic psychiatrist. However, there is such a demand and non-psychiatrists to pro-bono cases as well (i.e. OBG to examine injuries in human trafficking cases). I recommend the training and then whenever you do a case, ask the immigration attorney to send you redacted reports and that will give you an idea. FYI I have even seen SW do the training as well. Feel free to PM me.
I also do cases for a local organization that helps victims of sexual abuse (mostly spousal abuse). Another organization that settles North Korean refugees did contact me for immigration exams.
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Don't disagree with any of the above.
I hate saying it but if you offer cheaper/free services there is a small segment that will then not respect you. I've done it. I still do it, but I only allow patients to not be charged or lower rates if I'm confident they're telling me the truth about their dire straights.
I also feel that being a professor, working in Medicaid offices for years was my own payback to society. I earned a lot less in those roles than I could've in private practice.
I still do allow patients to not be charged or lesser rates but usually only if I've had the patient for over a year, feel there's a level of trust, and their story that I know very well gels together with their inability to pay.
I remember the exact day I when it crystallized I couldn't let patients go as much. A patient who grossed over $ 1 million in his business a year kept telling me he couldn't pay, and I already let him go a few times. I did some looking into this guy, saw a court document that showed his finances, and told my assistant never to let him in again unless he paid. From that day onwards I never did pro-bono work unless I already had the patient, already knew them well, and the person told me they were having some serious problems paying.
Add to this be careful. Doing pro-bono could make you look worse. In addition to some possibly interpreting you as a lower-rung doctor, let's say for argument's sake the person you are providing pro-bono services to is a very sexually attractive person. IF any legal issues happened someone could interpret your pro-bono benevolent intents in something other than what it was.
Another area where I at first wanted to be beneficent was doing volunteer work for the VA. I used to work for a state hospital with the same exact setup as the VA and used to work in a VA 2-3 days a week not as a VA employee but as a forensic examiner for the court. There were loads of inefficiency that I thought wasn't the result of good intent but rather ineptitude. While I strongly support veterans and wounded warriors I felt this was an enabling problem by helping an institution that wasn't doing it's own efforts to get it's own house in order. I still remember while in a state hospital the CMO giving me the worst patients of the other doctors who didn't do their jobs, I'd get them better, then they'd transfer them back to the bad doctors who then got them worse again against my idiot-proof directions. E.g. "Dr. X, patient was tried on 5 meds and the current medication regimen improved the patient's GAF from a 30 to a 65." Then within 1 day the patient was placed back on their previous medication regimen by the prior and now current doctor. While I was proud at first to be given the honor after a few months of it I noticed these other doctors were seriously just lazy and not doing their jobs. I had one doctor even tell me they intentionally worked at the place so they could have a do-nothing job. Great I was enabling this problem instead of the management putting these people in order.
Of course not all VAs or state hospitals are the same and not all staff members in such institutions are bad, but I had my own fill of it.
I hate saying it but if you offer cheaper/free services there is a small segment that will then not respect you. I've done it. I still do it, but I only allow patients to not be charged or lower rates if I'm confident they're telling me the truth about their dire straights.
I also feel that being a professor, working in Medicaid offices for years was my own payback to society. I earned a lot less in those roles than I could've in private practice.
I still do allow patients to not be charged or lesser rates but usually only if I've had the patient for over a year, feel there's a level of trust, and their story that I know very well gels together with their inability to pay.
I remember the exact day I when it crystallized I couldn't let patients go as much. A patient who grossed over $ 1 million in his business a year kept telling me he couldn't pay, and I already let him go a few times. I did some looking into this guy, saw a court document that showed his finances, and told my assistant never to let him in again unless he paid. From that day onwards I never did pro-bono work unless I already had the patient, already knew them well, and the person told me they were having some serious problems paying.
Add to this be careful. Doing pro-bono could make you look worse. In addition to some possibly interpreting you as a lower-rung doctor, let's say for argument's sake the person you are providing pro-bono services to is a very sexually attractive person. IF any legal issues happened someone could interpret your pro-bono benevolent intents in something other than what it was.
Another area where I at first wanted to be beneficent was doing volunteer work for the VA. I used to work for a state hospital with the same exact setup as the VA and used to work in a VA 2-3 days a week not as a VA employee but as a forensic examiner for the court. There were loads of inefficiency that I thought wasn't the result of good intent but rather ineptitude. While I strongly support veterans and wounded warriors I felt this was an enabling problem by helping an institution that wasn't doing it's own efforts to get it's own house in order. I still remember while in a state hospital the CMO giving me the worst patients of the other doctors who didn't do their jobs, I'd get them better, then they'd transfer them back to the bad doctors who then got them worse again against my idiot-proof directions. E.g. "Dr. X, patient was tried on 5 meds and the current medication regimen improved the patient's GAF from a 30 to a 65." Then within 1 day the patient was placed back on their previous medication regimen by the prior and now current doctor. While I was proud at first to be given the honor after a few months of it I noticed these other doctors were seriously just lazy and not doing their jobs. I had one doctor even tell me they intentionally worked at the place so they could have a do-nothing job. Great I was enabling this problem instead of the management putting these people in order.
Of course not all VAs or state hospitals are the same and not all staff members in such institutions are bad, but I had my own fill of it.
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