I've been out of residency a few weeks now and the thought of a malpractice suit is killing me. It's on my mind in every patient interaction. I find myself bending over backwards to accommodate patients because I'm afraid of a potential lawsuit down the road. Everyday I go to work in wondering if today is the day something happens that leads to a suit. It feels unsustainable to work in a career where this is always going to be a concern. I never thought I'd be so impacted by this yet here I am...
Thinking of getting sued is consuming me
- Thread starter jbomba
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If you aren't already in therapy, it would be a good idea to start. What you are struggling with would probably respond very well to CBT.
In the meantime, try this exercise, to help with reducing distress (and recognizing that it is ok to ignore the anxiety) until you get to therapy:
1. Take your malpractice premium, which we'll use as an estimation of how at risk you are for a malpractice suit and some other factors
2. Divide that number by how many patients you see during the premium period
3. Ask yourself: If someone offered me that amount of money to feel the distress I am experiencing from my anxiety that this patient will sue me, would I take them up on that offer?
3a. Alternatively, ask yourself if you would bet that amount of money the patient you are seeing will sue you
4. If the answer is no, then it just isn't worth it to feel the anxiety the way you do
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It was quoted on this forum once that almost every psychiatrist is statistically guaranteed to face a lawsuit at least once in their careers. The overwhelming majority of these do not result in the psychiatrist losing or having to face any penalties because in most cases the psychiatrist was not at fault and it's just an upset patient / family.
Maybe it would be helpful to reframe this thought as acceptance of the likelihood of being sued along with the likely outcome of it turning out fine based on the numbers.
Maybe it would be helpful to reframe this thought as acceptance of the likelihood of being sued along with the likely outcome of it turning out fine based on the numbers.
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Accommodate what exactly? Missed appointments and you are rescheduling them earlier than you can, refilling meds with missed appointments, early refills, giving them medication they ask for and not what your assessment tells you that they need?
Do you have senior attendings at your new job? Might be good to setup some kind of "supervision" or chats with more senior folks in your facility.
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It's tough. I was the same when i finished training. Sometimes it feels like the system "infantilizes" individuals when they are "patients", whereas in most other areas of life they bear responsibility/accountability and the onus for due diligence. Like that case of the patient who was repeatedly told to get Li levels and failed to do so.
But in the end, that's no way to live or work. The "standard of care" is so diverse in psych. Most of the time a room of psychiatrist cannot even agree on diagnosis or treatment. Someone on here mentioned that psychiatrists are funny in that we seem to be the specialty that's most neurotic about a lawsuit even though we are least likely of all the fields of medicine.
But in the end, that's no way to live or work. The "standard of care" is so diverse in psych. Most of the time a room of psychiatrist cannot even agree on diagnosis or treatment. Someone on here mentioned that psychiatrists are funny in that we seem to be the specialty that's most neurotic about a lawsuit even though we are least likely of all the fields of medicine.
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Agree with the therapy, even just paying a mentor for an hour of "supervision" once a week or maybe trying to get together with some peers.
Yes, it's actually very likely for most physicians to get sued SOMETIME during their careers. If you take the average % of physicians who get sued every year and multiply that by the number of years most people practice, it approaches 100% generally. Whether that's next year or 20 years for now is a totally different thing. Your risk is actually going to accumulate more the longer along in your career you go (that's why your malpractice premiums go up every year until about 5 years in or so) so you're statistically at the lowest risk of your whole career right now.
Another way to think about this is to look at the people who literally make malpractice suits their business....your malpractice insurance. Psychiatrists have some of the lowest malpractice insurance premiums of any speciality, because they're much less likely on a yearly basis to be sued and payouts tend to be much lower than other specialities (mostly because what we do it's typically very difficulty to prove causation of a bad outcome unless it's particularly egregious). These guys employ actuaries whose ONLY job is to make sure they make money off their insurance premiums so their business stays viable...they have no vested interest in making you feel better by telling you your malpractice risk is low, it's just numbers, statistics and business.
Edit: This is the paper that looked at risk by speciality and estimate cumulative risk up to age 65.
Malpractice Risk According to Physician Specialty - PMC
Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty. We analyzed malpractice data from 1991 through 2005 for all ...
www.ncbi.nlm.nih.gov
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Thanks for the helpful article, Calvnandhobbs68.
Anecdotally, maybe one in 10 psychiatrists I have spoken to say they have been named in a lawsuit, and not a single one has ever been found liable. I have heard a couple of stories from colleagues who told me a lawsuit they felt had no merit dragged out for 5 years, only for the insurance company to settle. Their main complaint was the annoyances worry of having to inform the medical board and hospital and write mini-essays on the allegations and outcomes at time to renew licenses and credentialing, and just having the litigation hanging over their head. In the end it made no material difference other than the stress experienced. I can't help but wonder if the risk of being sued as a psychiatrist is overblown. I will admit, I myself am a bit neurotic and worry more than I probably should. I want to be perfect!
Anyways, one possible way to lower the risk of being sued is to work for the federal government, like the VA. The down sides are the well known complaints doctors have working for the government. Government physicians are difficult to sue directly. Patients have to file a "tort claim" against the government, not the individual physician. A tort claim is essentially going through a legal process where the court decides if a patient has a case and deserves compensation from the government, not the individual physician. I have provided expert testimony for the government on such cases a couple of times. The claims were bogus - stuff like an intoxicated patient with history of heavy meth use pointed a gun at police and got shot and the family wanted to blame the psychiatrist who told the patient to stop meth many times and offered rehab and therapy multiple times. My opinion, to say the least, did not favor the plaintiff. Attorneys have told me VA physicians may be sued directly in cases of extreme malpractice, but that this is very rare (e.g.; you beat up a patient.) They also told me that tort claims are a major pain and are not high yield so many attorneys do not like to attempt them except in egregious cases.
Anecdotally, maybe one in 10 psychiatrists I have spoken to say they have been named in a lawsuit, and not a single one has ever been found liable. I have heard a couple of stories from colleagues who told me a lawsuit they felt had no merit dragged out for 5 years, only for the insurance company to settle. Their main complaint was the annoyances worry of having to inform the medical board and hospital and write mini-essays on the allegations and outcomes at time to renew licenses and credentialing, and just having the litigation hanging over their head. In the end it made no material difference other than the stress experienced. I can't help but wonder if the risk of being sued as a psychiatrist is overblown. I will admit, I myself am a bit neurotic and worry more than I probably should. I want to be perfect!
Anyways, one possible way to lower the risk of being sued is to work for the federal government, like the VA. The down sides are the well known complaints doctors have working for the government. Government physicians are difficult to sue directly. Patients have to file a "tort claim" against the government, not the individual physician. A tort claim is essentially going through a legal process where the court decides if a patient has a case and deserves compensation from the government, not the individual physician. I have provided expert testimony for the government on such cases a couple of times. The claims were bogus - stuff like an intoxicated patient with history of heavy meth use pointed a gun at police and got shot and the family wanted to blame the psychiatrist who told the patient to stop meth many times and offered rehab and therapy multiple times. My opinion, to say the least, did not favor the plaintiff. Attorneys have told me VA physicians may be sued directly in cases of extreme malpractice, but that this is very rare (e.g.; you beat up a patient.) They also told me that tort claims are a major pain and are not high yield so many attorneys do not like to attempt them except in egregious cases.
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Your angst will burn out over time.
You will radically accept it will happen to you at least once.
You will get back to the basics of just practicing.
You will shrug off the angst you have now, and chalk it up to 'the cost of doing business.'
In the words of my unsympathetic friend I griped to once, "That's why you make the big bucks."
You will radically accept it will happen to you at least once.
You will get back to the basics of just practicing.
You will shrug off the angst you have now, and chalk it up to 'the cost of doing business.'
In the words of my unsympathetic friend I griped to once, "That's why you make the big bucks."
I feel the same as OP. I find myself responding very quickly to portal messages, sometimes multiple times a day. Accommodating requests for phone calls between visits. This is primarily what I'm referring to. Nothing with regards to safety, or inappropriate meds, etc. But allowing them to suck up more of my time/personal time.
Also a new grad.
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I used to do this. Many organizations will pressure you to do these things. This will burn you out and cause you to leave practice, and then you help no one. Stop it!
One business day response time for routine, non-emergency messages and phone calls is more than adequate. Do not see last minute appointments or see patients who walk in and demand to see you because of routine life stress ("I spent my money at the casino and now I am behind on my rent", "My mom said nasty things to me on the phone again when I called her last night like she always does", "I feel like my adderall isn't working and I need more", etc, etc.) It is *therapeutic* to have firm boundaries and address these types of routine issues at their scheduled appointment time. Part of our job as psychiatrists is modeling normal behavior and normal doctor/patient relationships for these folks who often have poor boundaries, poor impulse control, poor judgement, and hyper-reactivity. When facility staff pressure you to take care of these "urgent" type things that the patient feels is an emergency but really isn't, say you are busy ( you are) and will get to it when you can and advise the patient to bring these concerns to their scheduled appointment. You don't have to be confrontational. When patients get angry about minor inconvenience of waiting, that is an opportunity for teaching them what is normal. Do not tolerate abusive behavior from anyone, in a calm manner.
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Please seek out therapy. You know this is not a rational thought pattern, and it is very treatable.
I'm not trying to be a jerk, but being over accommodating of patients often leads to worse care and is not protective of a lawsuit. I get better rapport with clear boundaries and the most high risk patients self select out. Real life example--pt has been getting high dose stimulant and benzos for years. Patient was already in a dangerous car accident, the drugs may have contributed. Patient LOVES their candyman but he retires. Pt seeks new psychiatrist. New psychiatrist refuses to provide those meds at those doses. Pt storms out and finds someone who will. Pt gets in another car accident and is badly hurt, harms someone else, faces legal trouble and now blames being on the meds. Who is in more danger of being sued? The doc who accomodates or the one who held firm?
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Replying that quickly literally makes the patients worse. It sets up unrealistic expectations and turns you into another person who will disappoint them when you aren't able to always do that, instead of a model of a caring, consistent, but boundaried authority figure. It burns you out without helping the patient
Epic has a function that let's you time messages to send later. Use it!
TheRightMedication
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You have to iron these problems out, and you have to start ASAP.
It's totally okay to have problems with boundaries at this stage in your career.
It's not okay to fail to act on it.
And you'll feel better.
It's totally okay to have problems with boundaries at this stage in your career.
It's not okay to fail to act on it.
And you'll feel better.
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I saw one of my attendings who got sued during residency - patient had unfortunately killed herself 1 day after discharge and parents sued. He just let it run like water runs off a ducks back. I still remember how calm and unfazed he was during that time. "Thats why you pay malpractice insurance". He did use to vacation quite frequently . If you cannot get past it, just get a government job . Psych outpatient is least like to be sued out of all med specialities.
It also reinforces their perception that these problems are urgent, which is countertherapuetic. Not just unhelpful, but oftentimes actively harmful.
I've also considered this. What is the ultimate consequence of being sued (and losing) a malpractice suit. Assuming it's not something egregious - you discharge a patient you thought was safe and he/she ultimately kills themselves (vs patient misconduct, etc).
We all make mistakes, so it could happen at some point. But what career, insurability, etc impact does this have in the future?
The OP definitely needs some supervision and personal therapy. HOWEVER, I'm very glad someone else brought up the VA and federal employment in general. If this is something the OP really obsesses about, it might actually make them a better provider to just remove that as a concept. As a previous poster said, you can't be sued directly as a VA physician for your work. This has to do with the separation of powers between the judiciary and executive branch. Many (most?) malpractice attorneys will not take on federal medicine cases at all because the bar is extremely high. The federal government has to agree to be sued themselves (remember, the physician cannot be). They generally have a very high bar for that, ie the case would reflect very poorly on the agency or institution if they did not allow it to go forward. The case above about substance abuse and police involvement would likely not meet that bar. The government may also, at its sole discretion, elect to settle a claim. HOWEVER, the claim and thus settlement was never made against the specific provider and as such is not automatically filed with the NPDB. For settlements, a board of three physicians in the person's specialty review the care provided and determine if, in their opinion, malpractice was involved. If they do, the settlement is attached to the provider in the NPDB and reported to the person's medical board as it would be in any other sort of malpractice settle. However, if the independent physicians do not (and they generally don't in my experience), the settlement is considered to have been between the VA and the patient. The provider is not named or involved.
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That’s just poor boundaries dude.
Get some supervision and work on it. Poor boundaries are not good for patients.
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I am in a high risk surgical specialty in one of the disaster states. Been in practice for 4 years. I know it’s coming, but all you can do is do your best. Can’t imagine psych to be too litigious, I wouldn’t fret too much. Most patients are reasonable. Lawyers on the other hand….
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Therapists don't understand this as they don't have the same level of risk physicians do
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I have a PP and respond to majority of my patient messages promptly (same or next day). It puts out fires and prevents me from having to call patients... I've called maybe 4-5 people in past 4-5 years. Even if my response is simply, 'that's a lot of stuff etc, and we really need to unpackage all that in the office. I have an appointment as soon as XYZ, please cancel your current appointment and come in sooner so we can address these issues.'
I'm okay with extra effort towards luminello message responses if prevents phone calls.
I don't think OP needs therapy for this angst.
I'm okay with extra effort towards luminello message responses if prevents phone calls.
I don't think OP needs therapy for this angst.
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We ought to be careful and not put this as some sort of failure by OP and imply they are broken and need therapy! Institutions from med school to residency to attend jobs have all tried very hard to scare me with tales of litigation as a way to work me like a dog. They constantly implied I'm a bad doctor if I don't see every single patient immediately whenever they darken the clinic threshold. In the VA, and particularly mine, they also imply you are not patriotic if you don't drop everything to help "one of our nation's heroes" for whatever non-emergent thing. If OP has had my experience, or anything close, they have always had great evaluations and a desire to help and have been taken advantage of. Medical training and early practice can be traumatizing like this. If OP wants to do therapy, that is great, but there are a number of ways to get advice on handling unrealistic expectations, and asking long practicing psychiatrists here is a great start.
I myself am facing the same pressures again right now after a period of calmness, as we have had changes in leadership. They are asking us to utilize our clinic as a psychiatric urgent care seeing whomever walks in, whilst I have scheduled patients all day already. My attitude has been to be calm, and to observe in a detached way how long it will take them to reinvent the wheel and staff the clinic properly again, as they are not interested in my suggestions. As the serenity prayer goes:
"God, grant me the serenity
to accept the things I cannot change,
the courage to change the things I can,
and the wisdom to know the difference."
I myself am facing the same pressures again right now after a period of calmness, as we have had changes in leadership. They are asking us to utilize our clinic as a psychiatric urgent care seeing whomever walks in, whilst I have scheduled patients all day already. My attitude has been to be calm, and to observe in a detached way how long it will take them to reinvent the wheel and staff the clinic properly again, as they are not interested in my suggestions. As the serenity prayer goes:
"God, grant me the serenity
to accept the things I cannot change,
the courage to change the things I can,
and the wisdom to know the difference."
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Being stalked by a patient or being wrongfully accused of sexual impropriety are more terrifying than being sued!
Patients and family members don't sue doctors that they like. Provide great care, avoid working in high volume/high liability settings, keep good documentation, and focus on making strong relationships with patients and your already low chances of being sued will decrease dramatically.
It is really hard to be sued as an outpatient psychiatrist. The number of times I've reviewed a case and said "this was bad, but it's not malpractice" and the case has gone away... though most of the malpractice cases I've reviewed have been related to inpatient, ER, or C-L settings. Correctional settings also have high rates of lawsuits but they are either really flimsly or institutionally egregious - which is to say, the psychiatrist is not usually the one at fault.
Patients and family members don't sue doctors that they like. Provide great care, avoid working in high volume/high liability settings, keep good documentation, and focus on making strong relationships with patients and your already low chances of being sued will decrease dramatically.
It is really hard to be sued as an outpatient psychiatrist. The number of times I've reviewed a case and said "this was bad, but it's not malpractice" and the case has gone away... though most of the malpractice cases I've reviewed have been related to inpatient, ER, or C-L settings. Correctional settings also have high rates of lawsuits but they are either really flimsly or institutionally egregious - which is to say, the psychiatrist is not usually the one at fault.
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Interestingly (and maybe comforting for OP?) Psych is actually the lowest med-mal risk of all specialties in most reports.
Also interesting to me is the correlation between specialties at the bottom of the list and specialties that I see more NPs practicing independently…
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I mean, it was therapy during residency that was instrumental in extricating myself from exactly that mindset, as well as support from my peers. This board certainly played an important supporting role. If the OP is, as they say, 'consumed during every patient interaction', then they need SOME type of targeted therapeutic interaction. Call it coaching instead of therapy if you wish, it boils down to the same thing.
I was fortunate enough to have an MD as a therapist. I paid through the nose for it (thank you, moonlighting) but was worth every penny.
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Then that increases risk for the physician who is supervising them.
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lol do you often view patients as "you're broken and need therapy"?
A lot of this is just cognitive distortions and can be addressed like any other cognitive distortion. Anxious part of brain is making probability of unlikely event seem much higher imminently than it actually is or making it seem catastrophic and person is modifying behavior to try to relieve this anxiety.
I agree that much of this can likely be modified by engaging in peer support or supervision which may lead to an improved ability to challenge these distortions but that's basically what it boils down to at the end of the day.
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No, I don't. Maybe it's just my own transference but some of the comments were starting to feel that way to me, and I don't want anyone to feel that way. My apologies.
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OP said in a recent post they'd be starting an inpatient job after residency. I'm guessing a lot of the anxiety is coming from patients making demands on the inpatient unit or saying things like "if you (don't/) discharge me now I'll do XYZ".
Exactly. I have people who will threaten suicide on the day of discharge. I believe it to be straight malingering. Yet here I am concerned of what will happen if they do act on it and I discharge them despite them claiming to be suicidal. In my mind I would get an automatic judgement against me.
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I would be be careful about recommending a government job for malpractice safety. As wolfvgang22 mentioned, while malpractice risk is lower, there’s more pressure to bend boundaries, appease, and tolerate behaviours that are otherwise not tolerated outside the VA setting, precisely for the reasons wolfvgang22 mentioned.
While most people here seem reasonable, it also doesn’t help that there are “whorish” expert witnesses out there who make the standard of care seem way higher than it actually is.
While most people here seem reasonable, it also doesn’t help that there are “whorish” expert witnesses out there who make the standard of care seem way higher than it actually is.
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My primary setting is the ER, so I deal with this all the time as well but typically have even less evidence of malingering. It is very stressful during the first few weeks to months as an attending since everyone is a new patient, but once you see the frequent flyers and get to know local problem patients it eases up a bit.
To CYA for liability, strong documentation with relevant details from history and past actions are your friend here. Document their lack of SI on days before d/c day, affect changes, areas of secondary gain, etc. If you have collateral from outside hospitals or past admissions even better. This is also where I will disagree with some of my colleagues that it's not appropriate to document personality traits (or even disorders if you have the collateral/evidence) during an inpatient admission. If there are clear signs of malingering or personality traits like manipulativeness, deceitfulness, attention seeking, etc. then document it professionally when appropriate. Make sure you're documenting why you're discharging them and why you think they're either not at risk or why inpatient admission is no longer appropriate. These are things that should be taught during residency and that you probably learned, but it definitely feels different knowing you're the attending and your safety net is gone.
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As others have said, if it’s any consolation, Psych has one the lowest malpractice risks.
Even as a resident, malpractice risk scares me. I think most doctors realize that if you really do your best with every patient, that’s all you can do, and accept that there is some risk of malpractice. I also agree with others that it’s probably good to look at some therapy.
If it’s really an issue you can’t get over, an extreme option is to look at a career in the VA or other federal facilities. Under the federal tort act, physicians can’t be personally sued. Good luck.
Even as a resident, malpractice risk scares me. I think most doctors realize that if you really do your best with every patient, that’s all you can do, and accept that there is some risk of malpractice. I also agree with others that it’s probably good to look at some therapy.
If it’s really an issue you can’t get over, an extreme option is to look at a career in the VA or other federal facilities. Under the federal tort act, physicians can’t be personally sued. Good luck.
Thanks for that. I also work shifts in the ER so that also scares me. How do you document to discharge someone who you strongly believe to be malingering?
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I wouldn't fret over my clinical practice based on what a plaintiff ***** might write in a report or say under oath. These people are easily rebutted. And, if you do forensic work like some of us, you learn to love these people. They're the reason we get paid so well on the other side for actually knowing what we're talking about.
I'm coming up on my 1 year anniversary of being an attending and this was a fear of mine at the beginning. The thing is, you can do everything perfectly right and still get sued. It is not sustainable for your mental health to be constantly worried about this outcome. I actually met with my company's legal counsel just to learn more about the process of malpractice and it was very helpful in allaying my fears. You do the best you can for your patient and document appropriately and that is all that you can do. Hugs, friend! It does get better. 🤗🤗🤗🤗
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Can’t you just keep them until they deny SI? I see people doing that all the time lol
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It's something that is always on the back of your mind.
But it doesn't have to be a negative. It can make you a better doctor. You don't have a lot of power on whether you're getting sued or not, but you can make sure that you're doing what you can to deliver good care, your documentation is stellar and that you're following the standard of care. If you are doing this, very unlikely this will impact your career, even if there is a bad outcome. Documentation is your friend.
So my opinion, it's not a bad thing people worry about this. You just have to make sure you compartmentalize it properly.
But it doesn't have to be a negative. It can make you a better doctor. You don't have a lot of power on whether you're getting sued or not, but you can make sure that you're doing what you can to deliver good care, your documentation is stellar and that you're following the standard of care. If you are doing this, very unlikely this will impact your career, even if there is a bad outcome. Documentation is your friend.
So my opinion, it's not a bad thing people worry about this. You just have to make sure you compartmentalize it properly.
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I'm about 6 years out.
Named in one law suit a few years ago. Finally got dropped.
Just got served with another lawsuit. Completely bogus and I should get dropped.
It's just part of the game.
Haven't lost a bit of sleep with either.
I practice good medicine and do the right thing. I cannot control a bad outcome. A lawsuit will happen with a bad outcome. That is the current reality. You have to mentally get over that hurdle and accept the rules of the game.
"It is possible to commit no mistakes and still lose. That is not a weakness. That is life."
Captain Picard
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It's interesting and probably makes sense, your last statement.
It was drilled into my head, over and over, that the data shows the physician most likely to be sued, made the patient feel unheard.
If making your patients feel heard is the way to avoid lawsuits... I can see how psychiatrists have the leg up on other specialties.
This is why I try to make "standard of care" irrelevant - they can always find somebody to testify you didn't meet it. In all my ED and IP discharges my final assessment would be why patient doesn't meet criteria for retention and that is why I have no choice to let them go, e.g. "it is not reasonably likely to be true that patient has a mental illness for which inpatient psychiatric treatment is appropriate or essential, and therefore they are not a candidate for admission (voluntary or involuntary) under state mental health law" (wording and criteria would depend on the state).
So since:
1) Malpractice requires duty
2) There can be no duty to do that which the law forbids
3) The law forbade me to do anything but discharge/release the patient
to be successfully sued they would have to prove that, as a matter of law, my interpretation and application of law was not reasonable before they can even begin to talk about things like standard of care.
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Yup. Find the statutory language, use the statutory language, lay out why your decision is what is required by the statutory language. You could still be wrong but it becomes real difficult to say you were negligent.
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I'd be curious if this is correct.
My hunch is that it is not.
Even if you can document that you have 'applied the law', they can still sue you in regards to how you reached your decision that the "patient doesn't have a mental illness for which inpatient psychiatric treatment is appropriate or essential", and that will involve the standard of care.
For how important statute is in our line of work, the amount of training we get reading, understanding, using, etc. it is pitiful. Especially since if you release a patient you could have held, it might be malpractice...and if you hold a patient you weren't allowed to, that could be a felony.
@jbomba reading up the statute will also help you with cases (esp in ED) when you think the patient is not appropriate for hospitalization and should be released, but collateral or family is advocating for hospitalization and possibly threatening lawsuit. For example, if the patient is dangerously abusing substances, you can empathize and validate the families concerns for their safety, but explain that since the state doesn't allow involuntary commitment for substance use disorders (assuming that is the case in your state) it would be criminal to hold the patient, and pivot to a discussion about how to help/support the patient outpatient and return precautions.
Its not bulletproof and it of course my conclusion must have justification. But for a number of reasons it becomes very difficult to surmount, e.g. now the standard is "reasonable" so they must prove (I think) that no reasonable fact finder could come to the same conclusion I did vis a vis whether the patient met involuntary crtieria, rather than that I failed to meet the standard of care.
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I use statutory language when I am discharging someone who I offered admission to but does not meet involuntary criteria, but for someone who is malingering or for whom inpatient hospitalization has become maladaptive (important to note that's true for some but not all cluster Bs) instead I use language that explicitly describes why I don't think inpatient hospitalization will benefit the patisnt and/or why it might harm them, and why outpatient is the appropriate setting. After all, these patients often are quite mentally ill and suffering, and I place more faith in a lawyer and/or jury believing I was trying to do my best for them even if that wasn't what the patient wanted, than an appeal to the legal language.
I find myself wondering why the OP is struggling so much--is the patient population where they are now working very different than in residency? Discharging malingerer or maladapted borderlines was a daily exercise on any call or inpatient rotation in my residency. It was in outpatient that that mindset of 'you aren't a good doctor if you don't bend over backwards for your patient' was more prominent. The inpatient units had a more grounded view by necessity.
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One thing I also make clear is that the patient can still be at high risk of violence or outright mention that they could go out and commit violent acts against self and others, but that an inpatient hospitalization for the treatment of a mental illness will not alter that risk or benefit them. This is true for those with high level chronic risk factors such as ASPD.
