Rural Case Consultation

[Dr. M Toboggan]

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I live and practice in a rural area. I have been approached by several rural FM friends who work at various clinics in my state about the possibility for informal case consultations. Their admin seem on board with it and paying fairly well for it. I'm wondering what the liability of something like this would be if there was a contract in place about my advice being hypothetical/educational and that in no way should it be construed as direct patient care. If structured this way, would it be feasible or a lawsuit waiting to happen? A lot of these docs and mid-levels have no psychiatrists around. I know there is something called Project ECHO for rural clinics treating children, but I do not know much about it.

I found an old EM forum discussing something similar for an EM providing consultation to a rural FM working in an ER, and at least one person seemed to believe it was a lawsuit waiting to happen. Of course EM vs FM clinic are very different settings, and ER vs psych consultation are also very different. Just wondering what the opinions on here would be.

 

[comp1]

Liability is a question for your malpractice carrier. We can't really answer that, but they need to be aware and can give you specifics. As with anything else in psych, the liability is generally much lower than other specialties, but it's never zero. This sort of setup is certainly not unheard of. Your carrier can and should be the one guiding you.

 

[splik]

very low liability - this is a great way of being able to provide your expertise to patients who don’t get to see a psychiatrist! Of course you could be named in a lawsuit but you aren’t supervising here.

 

[TexasPhysician]

It really depends on documentation of the practitioner and you. This is a concern.

Example: The concern liability wise is that they are going to type out on the note “Dr Toboggan advised Zyprexa 200mg qhs and I will start.” You may have said 20mg, but the practitioner heard 200mg. There is a phone call log that could be pulled proving the conversation occurred. You are a phone consultant and didn’t write your own note. Will you instead type your own notes?

Additionally you don’t have all of the information. The practitioner did the assessment. You could give the wrong advice because you are lacking information. Again this looks bad on you.

 

[Dr. M Toboggan]

This would be my concern...but I wonder if a contract spelling out my role mitigates this for the most part (i.e., educational, not direct patient care). In addition, regarding midlevels, NPs in our state have independent practice authority. That probably changes nothing if my name gets thrown in a note and a negative outcome occurs. With at least one clinic, they are agreeable have me on retainer for a minimum of 2 hours per week @ $300/hr. That would probably be my minimum with any clinic I would offer my services for. I am still undecided in this endeavor.

 

[comp1]

Yeah I don't think the NP thing matters at all. It's all the same risk for you. Anyways, run this by your carrier. It's a good/important thing, just needs to be done right from the insurance side.

 

[PsyDr]

Olick, R. S. and G. R. Bergus (2003). "Malpractice liability for informal consultations." Fam Med 35(7): 476-481.

 

[comp1]

This is a formal consultation, no question. It is just an asynchronous, highly limited consultation. I still think it's well within standard of care. It being a formal consult is what makes the malpractice carrier knowledge so critical.

 

[Dr. M Toboggan]

This is a formal consultation, no question. It is just an asynchronous, highly limited consultation.

Yeah, I think the above checklist was probably in relation to me using "informal consult" in my initial post, but it does appear I would most likely have to state this was a more formal consultation but spell out the limitations in a contract.

 

[FlowRate]

This is a formal consultation, no question. It is just an asynchronous, highly limited consultation. I still think it's well within standard of care. It being a formal consult is what makes the malpractice carrier knowledge so critical.

This seems overly concrete. If the consulters ask questions in an appropriate informal-consult way then it's not automatically a formal consultation just because they are thinking about a specific patient. "Typically when a patient with OCD hasn't responded to two SSRI medications, what do you do next?" "Hypothetically, I would want to know the doses tried. Often patients with OCD need higher than typical FDA-labeled dosing."

 

[Sushirolls]

Glad the rural FM in your area even value Psych.

In my area they don't. And believe psych isn't needed except for Bipolar I and Schizophrenia. The local rural FM residency program is even teaching their residents this framework, too.

 

[comp1]

I didn't get the idea that the primary care doctors would at all avoid discussing specific patients. It seemed to me that this discussion would very much be about specific patients. If that's true and the OP is being paid (for this service in particular), it's formal. If the primary care doctors are just sort of looking for a regular seminar on common mental health topics with a Q&A, that's not a formal consult. However, I seriously doubt that's what they want to pay the OP for. I also would kind of doubt the value for the PCP in that. They can use Uptodate for generic third line OCD treatments.

 

[psydocc]

Glad the rural FM in your area even value Psych.

In my area they don't. And believe psych isn't needed except for Bipolar I and Schizophrenia. The local rural FM residency program is even teaching their residents this framework, too.

I wish the only messes we had to clean up from them was for bipolar and schizophrenia. Too many PCPs feel like they can easily handle most mental health cases only to then use Xanax 2mg TID to treat GAD, Adderall 30mg BID to treat cannabis abuse, and Ambien 10mg to treat sleep apnea. Thankfully most of my PCP referral sources quickly learn that I'll accept their referrals as long they put the rx pad down and step away from the psych patient.

 

[comp1]

It's so weird how when you are in an integrated system of care it totally gets flipped and PCPs refuse to take back a patient who has been on a stable FDA indicated dose of stimulants for 10 years without a concrete interservice line agreement that mandates them to (with the specific drug names attached.)