Scope of practice for a general psychiatrist?

[sprawl2]

I need your honest opinion about this.
I just graduated in Canada this year and I started working as a general psychiatrist in Ontario.
For Canada, our programs are 5 years in length and that include 6 months of Child & Adolescent psych.

I spent a lot of those months doing various modalities of psychotherapies on children and adolescents and I loved it. However, I decided against doing 2 more years of subspecialty trainings due to my old age. Towards the end of my residency, most of my therapy patients were aged 18-24.

Here's the thing, I went for a locum opportunity at a local family practice clinic in a city an hour away from Toronto because my girlfriend is finishing up her graduate studies there. The head GP asked if I want to see some of his kids assuming they are patients from his practice. I said why not. He knows that I am a general psychiatrist.
However, little did I know, the centralized referral system now advertises me as an Adult Psychiatrist AND as a Child & Adolescent Psychiatrist. This week, I started receiving referrals as young as age 3 and I need to cancel a few new assessments that his secretaries booked for me without me triaging.

Obviously I just contacted the referral system to take that Child Adolescent destination off my name!!!!!
My question is: Is it kosher for me to treat adolescents for simple cases? I generally explain to the parents that I am a GENERAL psychiatrist and if the case is outside the comfort of my expertise, I would refer them to CHILD psychiatrist?

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[wolfvgang22]

You are doing exactly the right thing.

 

[splik]

I can't comment on the scope of practice of psychiatrists in Canada but I can tell you that in the United States psychiatry residency is just that it is in the training of psychiatry, not adult psychiatry.

Which is to say that psychiatrist can treat the patients of all ages. you do not need child psychiatry training or certification in order to treat children. Hhowever most psychiatrists would not feel comfortable treating younger patients. I think most psychiatrist would feel comfortable treating older adolescents. Many psychiatrists feel comfortable treating children with pure ADHD. Typically when psychiatrists see patients who are minors they will receive supervision from a child psychiatrist so they can discuss more complicated cases.

In the US in more rural areas it is very common for general psychiatrist to treat children. There is no one else. It is common for psychiatrists in the ER or C/L service yo evaluate kids. Depending on your training in this area you are most likely a far better place to be evaluating children and their families than a family physician.

An important thing to bear in mind about scope of practice is that it is important for the individual practitioner to know the limits of their competence. For example, you may not feel comfortable treating adolescence but another general psychiatrist made. It is important to make it explicitly clear what it is that you can and cannot competently treat. it explicitly clear what it is that you can and cannot competently treat.if you have your own malpractice you may wish to speak with a representative from your malpractice carrier about whether you are covered for treating children and adolescents.

 

[Liquid8]

Don't have any issue with you declining to see patients outside your expertise.

To help clarify the referral process, I would look at setting a lower age limit that you are comfortable with, and stipulate that anyone younger needs will only be accepted on a case by case basis pending your own review or discussion with the referrer.

 

[nitemagi]

Agree with above.

 

[Attending1985]

In my practice I may see older teens like seventeen but they have to be screened by myself first for appropriateness

 

[sprawl2]

Thanks for you the support, guy! Really appreciated.

Yah, I just have my secretary cancel the 2 "below 16" appointments and apologize on my behalf for the miscommunication about the age limit I have. She will send out a reminder notice to the local practice stating that I only receive 16+.


I think that would be most appropriate.
I am quickly learning how to only see cases that I want to see. Certainly, I have the knowledge and skill set to see all general psychiatric cases but I don't HAVE to. Ie. I don't want to see patients currently with multiple substance use especially given that I don't have a team who can work with them.

 

[NickNaylor]

Most people here are comfortable treating folks 16+, some even as young as 13+. Younger than that and it starts to get a little dicey.

 

[PistolPete]

In residency I was told I could see adolescents 14 and above without child fellowship. Having completed Child fellowship, I would say that’s probably ok. Don’t think I’d go below 12-13 though with only general adult training.

 

[Blitz2006]

In residency I was told I could see adolescents 14 and above without child fellowship. Having completed Child fellowship, I would say that’s probably ok. Don’t think I’d go below 12-13 though with only general adult training.

but what about medico-legally? if anything happens to a patient, and they are <18, you're cooked right?

 

[TexasPhysician]

but what about medico-legally? if anything happens to a patient, and they are <18, you're cooked right?

It doesn’t help. It hurts a lot more if you aren’t treating adolescents as a fellowship trained psychiatrist would.

Paroxetine is a reasonable 1st line option for some adults. It’ll get you burned in adolescents.

 

[Blitz2006]

It doesn’t help. It hurts a lot more if you aren’t treating adolescents as a fellowship trained psychiatrist would.

Paroxetine is a reasonable 1st line option for some adults. It’ll get you burned in adolescents.

I see your point

 

[splik]

but what about medico-legally? if anything happens to a patient, and they are <18, you're cooked right?

nope. plenty of forensic psychiatrists who aren't child psychiatrists evaluate adolescents and they aren't thrown out of court for not been board in child psychiatry. hell, some even evaluate younger kids. as mentioned above, we are boarded in psychiatry. not adult psychiatry. psychiatry. thus we can treat the range of patients from infancy to old age and that is within the scope of practice. you just need to know the limits of your ability, refer as appropriate and consult as necessary. In many parts of the country there are no child psychiatrists. even in parts of the country where there are ER and C/L psychiatrists evaluate and treat kids.

Edit: board certification is not part of the criteria for negligence. its just duty, derliction, damages, and direct causation. there are plenty of incompetent boarded child psychiatrists so clearly it does not inoculate against negligent care. you just want to make sure you are providing care that a reasonably prudent practitioner would do. the standard of care is so low in psych that its hard to get sued doing outpatient, and child psychiatrists aren't more likely to be sued than other psychiatrists.

 

[Blitz2006]

nope. plenty of forensic psychiatrists who aren't child psychiatrists evaluate adolescents and they aren't thrown out of court for not been board in child psychiatry. hell, some even evaluate younger kids. as mentioned above, we are boarded in psychiatry. not adult psychiatry. psychiatry. thus we can treat the range of patients from infancy to old age and that is within the scope of practice. you just need to know the limits of your ability, refer as appropriate and consult as necessary. In many parts of the country there are no child psychiatrists. even in parts of the country where there are ER and C/L psychiatrists evaluate and treat kids.

Interesting. Yet then how come the general mantra in the psych world is that "child psych fellowship is the only psych fellowship that you really need", if this is not really the case?

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[splik]

Interesting. Yet then how come the general mantra in the psych world is that "child psych fellowship is the only psych fellowship that you really need", if this is not really the case?

that is not a general mantra. that is just what people on SDN say. I think the point is that child psychiatry fellowship is a very good idea if you plan to predominantly or exclusively treat kids given that most people don't do more than 2 months training during residency. i suppose you could use all your elective time to get more child and adolescent psych exposure. You should also have a consultation/supervisory relationship with a child psychiatrist. But I know several psychiatrists who have been employed/contracted to treat children. your employment options would be more limited (better hospitals would not hire you to see children, and obviously you would not be able to work in an academic medical center etc). it would be silly not to do a child fellowship if you wanted to see lots of kids basically.

 

[TexasPhysician]

Interesting. Yet then how come the general mantra in the psych world is that "child psych fellowship is the only psych fellowship that you really need", if this is not really the case?

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A C&A evaluation and proper medications are much different than adults. 4 months of training is not enough to do it well. Also medico-legally, there is added risk. Parents are also more likely to sue for harm to their children than themselves.

I’d strongly recommend general psychiatrists referring those under 18 to C&A. If one isn’t nearby, general psych is better than anyone else.

 

[hamstergang]

Interesting. Yet then how come the general mantra in the psych world is that "child psych fellowship is the only psych fellowship that you really need", if this is not really the case?

You don't need the CAP Fellowship to be allowed to treat kids; you need it to gain competence to safely treat kids. It's a valuable fellowship for all you learn in it.

 

[michaelrack]

What is the problem with giving Paxil to a teenager, especially a male.... I know it's not one of the fda approved pediatric antidepressants, but any specific issues with it?

 

[michaelrack]

In a quick pub med search, I found both positive and negative studies for Paxil in teenage depression

 

[TexasPhysician]

What is the problem with giving Paxil to a teenager, especially a male.... I know it's not one of the fda approved pediatric antidepressants, but any specific issues with it?

The large studies performed in an effort to reach FDA approval in children/adolescents were all negative for MDD. 0 for 3. Last I checked, it had the highest number of failed large studies without a positive one. I’m not talking about the smaller studies. The C&A community very much believes that pediatric/adolescent brains respond quite differently than adults.

Many C&A programs essentially condemn it as all risk and no benefit under 18y/o, especially for MDD. A few C&A people I know would line-up to take a court case against Paroxetine related to an adverse event in a child/adolescent. Very high medicolegal risk in C&A.