Psychiatrist and psychologist sharing practice

[DucktorQuack]

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[st2205]

Do you mean share office space?

 

[nitemagi]

Would they be able to refer patients to one another? Thanks!

Yes

 

[Bartelby]

I think some private practices have a psychiatrist and psychologists so that the psychiatrist can do med management and send the patients to the psychologist for therapy. I imagine this could work pretty well. The advantage to you I guess would be getting a cut of the therapy patient volume, or having therapists redily available, not really sure.

 

[whopper]

No. There's a law against it. Psychologists and psychiatrists if in the same office must draw pistols and shoot each other.

Seriously, I don't see why anyone would think there is a problem with both fields working together. The bottom line is both mental health professionals have different training and to work together in a complementary manner would only serve to make a better practice.

The only cons I see with working with psychologists and this would be true of anyone in any field is whenever you have multiple people in a team, some are idiots. You might be working with a guy who doesn't work well with you and that's not a psychiatry/psychology issue, but a human issue. The only other con I could see is someone, out if insecurity, might try to bring up some type of professional rivalry in an nonconstructive manner.

In general, I've found actually more frustration with psychiatrists as a whole vs psychologist as a whole, though I've seen idiots in both fields, just like there will be idiots everywhere.

 

[nitemagi]

No. There's a law against it. Psychologists and psychiatrists if in the same office must draw pistols and shoot each other.

Seriously, I don't see why anyone would think there is a problem with both fields working together. The bottom line is both mental health professionals have different training and to work together in a complementary manner would only serve to make a better practice.

The only cons I see with working with psychologists and this would be true of anyone in any field is whenever you have multiple people in a team, some are idiots. You might be working with a guy who doesn't work well with you and that's not a psychiatry/psychology issue, but a human issue. The only other con I could see is someone, out if insecurity, might try to bring up some type of professional rivalry in an nonconstructive manner.

In general, I've found actually more frustration with psychiatrists as a whole vs psychologist as a whole, though I've seen idiots in both fields, just like there will be idiots everywhere.

Great post, whopper.

Brings me back to one of my favorite quotes -

Only two things are infinite, the universe and human stupidity, and I'm not sure about the former.
-Einstein

 

[TheWowEffect]

No. There's a law against it. Psychologists and psychiatrists if in the same office must draw pistols and shoot each other.

Seriously, I don't see why anyone would think there is a problem with both fields working together. The bottom line is both mental health professionals have different training and to work together in a complementary manner would only serve to make a better practice.

The only cons I see with working with psychologists and this would be true of anyone in any field is whenever you have multiple people in a team, some are idiots. You might be working with a guy who doesn't work well with you and that's not a psychiatry/psychology issue, but a human issue. The only other con I could see is someone, out if insecurity, might try to bring up some type of professional rivalry in an nonconstructive manner.

In general, I've found actually more frustration with psychiatrists as a whole vs psychologist as a whole, though I've seen idiots in both fields, just like there will be idiots everywhere.

I don't think the original poster's question implied any concerns of rivalry between them. I guess he was just wanted more information about the logistics involved.

I guess we should try not to get on the soapbox too quickely. Sometimes, a question is just a question, and not an attempt to start an unnecessary arguement.

 

[whopper]

The only problem I've had working with psychologists is some of them are terrible, but it's because the person is not good at what they do, not because the person's a psychologist.

 

[Manicsleep]

Is it possible for a psychiatrist to share a practice with a psychologist? If so, what are the pros and cons of being a psychiatrist in that scenario? Would they be able to refer patients to one another? Thanks!

I will give you 3 off the top of my head for each.

Pros:
You get therapy for your patients. This can be done with social workers and MFTs as well and in rare cases psychiatrists who do only analysis or analysis plus therapy only.
You get to see the patient through different eyes. This really becomes useful if they don't see primary care.
The patient usually gets seen more often and this is usually a good thing.

Cons:
Lots of poorly trained therapists out there. Choose carefully who you will work with.
Therapists can often overstep their bounds and start giving advice about non therapeutic things, like medication, where they have no expertise.
This may lead you as a psychiatrist to stop doing therapy which is detrimental in the long run to the patient, even if you are referring them to a therapist.

 

[whopper]

This may lead you as a psychiatrist to stop doing therapy which is detrimental in the long run to the patient, even if you are referring them to a therapist.

Two people doing psychotherapy makes things complicated. If this is being done, both should at least touch base to make sure they're not undermining the other's work.

It's pretty much the same whenever there's too many people involved. I got plenty of patients and I don't know WTF their PCP is doing. I got a guy for example, and each time he's been in my office, his BP has been over 180/100. I tell the guy he needs a BP med, but I can't provide it because I'm his psychiatrist. Then he tells me his PCP tells him not to worry about hypertension. The guy's only been in my office 10 times now, and when I take his BP, he insists he is calm. Like I said, the problem is not that the other doctor is a PCP, it's that the PCP is not working within the guidelines.

 

[Manicsleep]

Two people doing psychotherapy makes things complicated. If this is being done, both should at least touch base to make sure they're not undermining the other's work.

It's pretty much the same whenever there's too many people involved. I got plenty of patients and I don't know WTF their PCP is doing. I got a guy for example, and each time he's been in my office, his BP has been over 180/100. I tell the guy he needs a BP med, but I can't provide it because I'm his psychiatrist. Then he tells me his PCP tells him not to worry about hypertension. The guy's only been in my office 10 times now, and when I take his BP, he insists he is calm. Like I said, the problem is not that the other doctor is a PCP, it's that the PCP is not working within the guidelines.

Thats not what I meant and I agree that we should work with the therapists. BTW, I hope there is more to the HTN story...not quite sure why you are checking BP so often but they are in the range of a hypertensive crisis and if they have any organ system involvement its a medical emergency. Thats if it happens once, you say its happened 10 out of 10 times. I think you are a better doc than that and wouldn't make such a huge mistake so I hope you are just making a story up.

Anyways. If I am following someone for bipolar disorder and they need more intensive psychotherapy, I refer them. But in the end, they are going to follow with me for years so I am going to do a lot of therapy. It is always good to refer and do that with expectations and communication. If I have already tried CBT, I don't want to have them do it again etc and if they are doing CBT I don't want to sabotage it. I would probably limit myself to supportive therapy at that point.

But perhaps your post made my point. People get afraid, risk averse and so they just stop doing what they are good at. If you are and can do therapy, its better in the long run than 2 people doing individual things. Its also better for the healthcare economics.

 

[whopper]

not quite sure why you are checking BP so often but they are in the range of a hypertensive crisis and if they have any organ system involvement its a medical emergency.

I take a BP regularly because a psychotropic medication can affect BP, and it will influence my choice. E.g. a guy's got HTN, I'm less likely to give Effexor.

but they are in the range of a hypertensive crisis and if they have any organ system involvement its a medical emergency. Thats if it happens once, you say its happened 10 out of 10 times

BP was up, but close to and not over the definition of HTN crisis. Also the organ system involvement was not detected. No symptoms or signs of a problem other than the BP reading. That's not HTN crisis, though it's of extreme concern, hence the referral that he get it checked up and treated, and the frustration and hair-pulling on my end because the PCP apparently isn't doing anything about it. I told him that if I were his PCP I would treat it but my insurance carrier will only cover treatment that's psychiatric, for him to read the literature, because based on what's going on, it's not meeting the recommended standards of treatment. I informed him that a BP that high is not safe, and he needs to get it treated ASAP, though it's not within the acute crisis category.

If you are and can do therapy, its better in the long run than 2 people doing individual things. Its also better for the healthcare economics.

Any good psychiatrist is going to do some psychotherapy. At least some. Even in simple medication management, some supportive treatment and listening should be done so you understand what's going on.

But psychotherapy could enter phases where one therapist is trying to do something that could take months, possibly even years before it gets to it's completion. Such therapies can enter critical stages, and for that reason, all involved in the treatment should be on the same page. One person should not undermine the other person's treatment.

I've seen the above happen a few times. I currently have a guy with panic disorder who told me his PCP told him that my SSRI recommendation is wrong and that he needs perphenazine. I figure the guy's either off or this PCP doesn't know WTF he's talking about, or the truth is somewhere in between, so I call the PCP, and his office played the typical "let's not let anyone talk to the attending" game (I'm sure you know what I'm talking about). In any case, I can't get my patient to take SSRIs for over 1 week before he stops the meds because he tells me he sees his PCP who then tells him to stop the SSRI.

So I told the patient, that if he wants me to treat him, he needs to let me treat him or let the PCP treat the panic disorder because I'm not going to go along with the perphenazine recommendation, and being that the PCP will not talk to me over the phone, I don't know where he's coming from. I mentioned that doctors should work together, and not against each other, with patients getting caught in the middle. I got no problem with someone getting a second opinion, but he's getting two contradicting treatments from providers that aren't communicating with no resolution. This is the problem I'm talking about, and I've encountered it with psychotherapists. I've seen psychotherapists and psychiatrists give contradicting statements, make recommendations that counter the other, and have completely different opinions on the diagnosis.

Sometimes simply touching base can clear up a lot, possibly even make you realize the other guy is right on something you missed.

 

[TheWowEffect]

Thats not what I meant and I agree that we should work with the therapists. BTW, I hope there is more to the HTN story...not quite sure why you are checking BP so often but they are in the range of a hypertensive crisis and if they have any organ system involvement its a medical emergency. Thats if it happens once, you say its happened 10 out of 10 times. I think you are a better doc than that and wouldn't make such a huge mistake so I hope you are just making a story up.


Anyways. If I am following someone for bipolar disorder and they need more intensive psychotherapy, I refer them. But in the end, they are going to follow with me for years so I am going to do a lot of therapy. It is always good to refer and do that with expectations and communication. If I have already tried CBT, I don't want to have them do it again etc and if they are doing CBT I don't want to sabotage it. I would probably limit myself to supportive therapy at that point.

But perhaps your post made my point. People get afraid, risk averse and so they just stop doing what they are good at. If you are and can do therapy, its better in the long run than 2 people doing individual things. Its also better for the healthcare economics.

 

[Technotronic]

 

[whopper]

True.

But I did tell the patient of the risk, and the patient did have the capacity to make a decision that he did not want to go to the hospital.

I mentioned the incident because it was of extreme frustration to me. I even asked the patient at one time to go to a different PCP, consider going to an ER, or urgent care. Each time he told me he talked to his PCP, and the PCP told him not to worry but didn't do anything in changing his BP meds (and it's possible he wasn't taking his meds). The point being that whenever you work with other professionals, you could have someone in that framework that isn't doing their end. I've attempted to call this particular doctor on more than one occasion, and each time I call, the office puts me on hold for several minutes, then tells me the doctor is too busy to talk to me at the moment, I leave my contact info, but I never get a call back.

You can't force someone to go to a hospital or get medical treatment against their will unless they meet the legal criteria for it. A parallel situation, If a guy smokes and has COPD, and understands that his cigarettes can kill him, I still can't keep him away from them if he still wants to smoke. I can, however, recommend he not do it and try to steer him in the right direction, and he can refuse me. Which is what I tried.

The only thing I haven't done that I can think of is giving the guy an ultimatum of getting his BP under better control or I won't treat him anymore, but IMHO, that would be defensive medicine on my part to his detriment. He told me his symptoms of anxiety were not under control until he saw me. He told me it'd take him several months to find another psychiatrist.

But if you think you'd want to give him a BP med, which was outside my insurance agreement, even though he said he would leave this up with his PCP, and wasn't looking to get his BP treated with me, you could've tried that in this situation, which I did consider, but given his answer, I decided not to do so.

In addition to this guy I mentioned, I've seen this type of thing happen several times. While a fellow, I had someone with diabetes, and on lithium, and she never controlled her diabetes well. She'd often forget her diabetic meds, ate fast-food regularly, and a I told her several times that she was at high risk for kidney problems, among pretty much every single diabetic problem you could imagine. Again, attempts to call her PCP led to no real contact. She was able to state to me practically verbatim the consequences of not controlling her diabetes, and she did not want me to try her on a different mood stabilizer despite her knowing that lithium and diabetes makes kidney problems even more likely. There's more to the story than that, but it's extraneous (e.g. I did tell the attending that I was considering stopping her lithium and giving her a different med for bipolar disorder, but he told me to leave it alone. I also suspected she didn't have bipolar disorder because I never saw her show any signs of it, but he didn't want me stopping her meds).

I'll also add that if you've never seen a patient who controlled their HTN or diabetes badly, I'd question if you were a doctor. All of us know full-well that we can't force treatments unless they meet a criteria. Any downtown ER will often have patients with poorly controlled diabetes, HTN, what have you, that you know that if you stabilize, the patient will most likely just stop their treatment after they walk out the door.

(I'm actually surprised with the responses above given that patient non-compliance is so high, but I'm only giving this issue this level of detail because it's been brought up more than once).

All-in-all, I see this type of teamwork problem literally every week in several clinical scenarios. I know of several IM doctors in the VA and state system that regularly blow off their patients, and when I've brought this up with the administration, they too don't do anything about it. A conversation with a boss basically came down to a (note that the words are from memory, not an exact quote) "James, if we fire that guy, we'll just have him replaced with someone possibly worse. At least we know just how bad this guy is, but if we got a new guy it'd take us a few months to figure it out." Eventually they actually did fire the main guy I complained about, only to be in a position where they couldn't replace him----for months. The IM docs were short-staffed, leading all of them to complain that they were being overworked.

I also know of a psychologist that will pretty much, always, on a review to see if someone who committed a major crime while mentally ill and in a forensic unit could be released into the community, recommend a person be released from the hospital, even if the person did something dangerous within the last few days. I've gotten into a debate with her, where she started yelling at me. Her argument to me was that the person could always be prevented discharge by other people, so we should always allow the discharge. My counter-argument was that this defeated the purpose of the evaluation if she was just going to let every single person go without doing a real evaluation that met the definition of what we were supposed to be doing by state guidelines. At that particular moment, we were both working on the evaluation because the state requires at least a two-person review. I refused to let the person go (and it just requires 1 person for that). She started yelling at me, and I repeatedly told her, "If you dont' like my answer, tell the answer you told me to the administration." That caused her to get red-faced but she knew they wouldn't buy her argument.

Which is getting to another point. The reality of interacting with doctors and other professionals you disagree with strongly, on a level where it could lead to a patient being in a very bad predicament isn't low. I'd argue it's high if you have a caseload of patients where you're seeing several dozen, like most doctors do in a year. It happened to me (and most people I know) several times during consults, cases with ER doctors where patients are medically cleared despite obvious severe problems, during cases where both a psychiatrist and another non-psychiatric M.D. worked on a patient with a suspected psychosomatic illness, (with the non-psychiatric doctor several times assuming it's psychosomatic without ruling out a physical problem on their end, even after reminding them to do so).

 

[digitlnoize]

I know of at least 2 situations where a psychiatrist and psychologist work together amiably. One is at the state psych hospital where I did one of my 3rd year rotations. The psychiatrist handled the medical issues and brief supportive therapy. The psychologist handled the hardcore therapy. There was also a team of social workers handling that end of things. They really had a great team setup. They met daily with the entire staff to have a briefing at shift change. They met weekly for a couple of hours to go over all of the cases in detail and figure out treatment plans. It worked very, very well.

The other situation I know of is a private practice here in town with a psychiatrist and a psychologist. I don't have as much first hand knowledge, but from what I hear, they also have a good success rate and are well-respected around the area.

 

[billypilgrim37]

SBP of 180 is hypertensive urgency.

Yes, which is an entirely different ball game than a hypertensive emergency. A psychiatrist trying to manage hypertensive urgency is about as ill-advised as the primary care doc in the Abilify-Zyprexa thread trying to play psychiatrist. Your only responsibility (and appropriate action that you are qualified for) in an outpatient setting is to assess for end organ damage by symptom and a brief physical exam and to refer to a higher level of care, which the pt can refuse. In an ED or hospital setting, your responsibility might include acutely treating and monitoring with whatever agent some non-MD in your administration decided was thing that they were going to let your nurses administer and monitoring closely to see if there's an indication for an immediate transfer to a higher level of care which the pt can again refuse.

Of course, the best is when you do find end-organ damage, and it's delirium which is diminishing the patient's capacity to refuse emergent care in your outpatient office. Which is then really fun trying to then convince the police and ambulance driver to transport the psychiatric patient to the hospital when they can't understand why you think they can do that without a commitment, even though a commitment would have nothing to do with their hypertensive emergency and being combative if this wasn't a psychiatrist's office...

 

[whopper]

In general, I've found working with psychologists better than psychiatrists because the psychologists are very very happy to work with a psychiatrist. They often times can't find someone to prescribe psychotropic meds for their client who they believe need to be on one.

 

[zenman]

True.

But I did tell the patient of the risk, and the patient did have the capacity to make a decision that he did not want to go to the hospital.

I mentioned the incident because it was of extreme frustration to me.

"Sir you've been having nightmares. Yes sir, you have. Now I'm going to give you some Prazosin to help with that."

 

[whopper]

I also didn't mention the reason why I kept on checking his BP with each visit was because given the high values, I was hoping he was starting to get it under control with his other doctor, and that perhaps the first readings I got were flukes. I also considered giving him a B-blocker on the argument that he had an anxiety disorder, but by that time his anxiety was under control and I didn't think I should've fudged on his chart to slip it in. I think I'm beating a dead horse now...

 

[Manicsleep]

As long as the patient is okay.

RE: the psychiatrist and therapist conversation, I think it helps. However, I really like working with other psychiatrists because it allows me to bounce ideas off them. The best situation obviously is a small multispecialty group.

 

[whopper]

Hmm well so far he is...that is on the outside. During one session, I showed him slides of arteriosclerotic arteries, mentioned erectile dysfunction, among other problems he could experience if he doesn't get it under control. (sorry, beating the dead horse).

 

[billypilgrim37]

...mentioned erectile dysfunction... beating the dead horse...

Whopper, I didn't realize you were so psychodynamic.

 

[zenman]

Whopper, I didn't realize you were so psychodynamic.

Originally Posted by whopper
...mentioned erectile dysfunction... beating the dead horse...

And don't forget his screen name...Whooper...

 

[Manicsleep]

His name is whopper not whooper, unless my computer is showing something odd.

This thread has been fully hijacked...twice.

 

[zenman]

His name is whopper not whooper, unless my computer is showing something odd.

This thread has been fully hijacked...twice.

Yes, my bad. It's Whopper.

Isn't thread hijacking a skill on SDN?

 

[Majesty]

Isn't thread hijacking a skill on SDN?

Huh?

 

[aequitasveritas]

I used to have a psychiatrist in the office next door to me. I have to say it was nice that I had someone to go to for clients in need of meds or at least for a referral chain of docs who might be able to help a lower income patient.

In Cal...almost impossible to find a psychiatrist who is willing to take on medicare-medical patients. So when I have a solid referral it's kind of a life saver.

I think the most notable benefit of having a (competent) psychologist around is neurocognitive and personality assessment. Also, depending on the orientation and experience level, which can be a crap-shoot or a dream-boat with us ologists, case conceptualization and therapeutic planning etc may be bolstered.

 

[michaelrack]

I think most of us agree that it's great for a psychiatrist and psychologist to work closely together.

Getting back to the OP, anyone with any experience with a psychiatrist hiring a psychologist in a private practice setting? Can a psychiatrist and psychologist legally share a (private) practice??

 

[Manicsleep]

I think most of us agree that it's great for a psychiatrist and psychologist to work closely together.

Getting back to the OP, anyone with any experience with a psychiatrist hiring a psychologist in a private practice setting? Can a psychiatrist and psychologist legally share a (private) practice??

Well, I have psychologists and other therapists that work for our group as employees but they aren't partners. The partners in the mental health group are all psychiatrists. So I am not sure if that answers your question. The psychiatrists are all able to cover for each other etc which the therapists couldn't do so I guess from that standpoint they can't legally share but I suppose they could legally have shares in the corporation. In our case that would be a mess with respect to division of profits and productivity so we choose not to do it but I suppose it could be done.

 

[michaelrack]

Well, I have psychologists and other therapists that work for our group as employees but they aren't partners. The partners in the mental health group are all psychiatrists. So I am not sure if that answers your question. The psychiatrists are all able to cover for each other etc which the therapists couldn't do so I guess from that standpoint they can't legally share but I suppose they could legally have shares in the corporation. In our case that would be a mess with respect to division of profits and productivity so we choose not to do it but I suppose it could be done.

thank you. Are the psychologist's services billed through their own "insurance numbers"?

 

[whopper]

I don't see any legal reason why the two cannot share a practice, unless there's something specific in a state saying they can't. I can't for the life of me think of anything in any state law along those lines, but I haven't read all the laws of every single state regarding this.

I was hired by a psychologist to work in his office. I've seen several psychiatric offices employ a psychologist. The PP I work at, I'm the only psychiatrist. It's nice being able to refer to someone in the same office for something far specialized that most psychiatrists don't know how to treat such as DBT for borderlines, EMDR for PTSD, getting an MMPI or a TOVA test for diagnostic purposes, and having someone give a second opinion on a very strange case that has a different set of training.

As for insurance codes, there are different codes for psychologists, but I don't know if every single code is different. There may be billing codes that are the same. I do know at the hospital I work at, the psychologists have a completely different billing sheet, but again, perhaps some of the codes are the same.

 

[Scorcher31]

I was curious about this as well. Would the Stark laws apply in this scenario? I thought we are not legally allowed to internally refer if you own the practice and the referral would also benefit you financially.

Of note, my understanding of the law is very basic and it could be completly wrong.