Treating children without a C&A fellowship?

[bisell26]

Is this ok to do? Especially if one doesn't have the financial means to lose an attending salary?

Is there risk of malpractice suit later on if one is just adult certified and not child certified?

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[TexasPhysician]

Is this ok to do? Especially if one doesn't have the financial means to lose an attending salary?

Is there risk of malpractice suit later on if one is just adult certified and not child certified?

Two ways to look at this.

1. The medical board licenses physicians not specialties. As a child psychiatrist, I could open up a clinic called “Skin Experts” and treat everything derm.

2. While I can open “Skin Experts”, my malpractice insurance may not cover practicing outside my trained specialty, and I’ll have a much more difficult time in a court room. A jury is not truly a jury of our peers (not medically trained). If you cause harm to a 6 year old, opposing counsel will point out that child psychiatry is a fellowship and you didn’t do the fellowship. Regardless of your explanation, a jury may not hear anything else.

 

[Sushirolls]

Psychiatry residency is not adult residency its general psychiatry residency, that means gero, forensics, addiction, C&A, C&L etc are all capable jobs. And people do land these jobs or have practice niches that include these. My residency had excellent C&A rotations that I would feel comfortable treating 13yo and up. However, personally, I loathe C&A and simply only do 18 and up.

But to answer your question, there are numerous Psychiatrists who do treat say 13+, or 16+, etc. The younger you go, IMO, the less likely you are to see a non-fellowship trained person doing it. I do believe there is a reason why C&A is a 2 year fellowship and is truly worthy of being its own specialty. The key will be to simply cherry pick the simpler, easy cases, and refer anything else to C&A. Some geographic locations, that just isn't feasible to restrict to 18+, and you will be it as your neighbors beat down your door. Once you do get one C&A in a geographic proximal spot, you can then unload your caseload. Other options if possible are to find a C&A and have them do the initial consult, and you do the follow up work. The bigger liability concern will be med side effects. So, do thorough R/B discussions, get signed consent forms, provide written educational material, etc.

I believe it is sad, wrong, and complete disgrace for our country to permit ARNP doing full spectrum psychiatry with C&A cases. I wouldn't want my own family to be treated by an ARNP for C&A work, I just can't recommend them to others either.

 

[Monocles]

I believe it is sad, wrong, and complete disgrace for our country to permit ARNP doing full spectrum psychiatry with C&A cases. I wouldn't want my own family to be treated by an ARNP for C&A work, I just can't recommend them to others either.

Had to look up what an anrp is.

Just to play devil's advocate though, while I agree with you that a fellowship trained CAP is probably more knowledgeable than an ARNP, what about super rural areas? Isn't having a practioner with SOME experience working with kids better than none?

 

[TexasPhysician]

Had to look up what an anrp is.

Just to play devil's advocate though, while I agree with you that a fellowship trained CAP is probably more knowledgeable than an ARNP, what about super rural areas? Isn't having a practioner with SOME experience working with kids better than none?

While state law may vary, telepsychiatry has essentially destroyed that argument in many areas.

 

[Bartelby]

I would check with your malpractice insurer before trying something like this. It may be considered outside of your scope of practice, and practicing uninsured (and under qualified) is a bad idea. I agree with Sushirolls that our training is general in nature and includes exposure to all subspecialties, and I think having a rural provider occasionally see people who are nearing 18 might be okay, but personally I would not feel qualified to start independently practicing child psychiatry without additional training.

 

[NickNaylor]

I think seeing patients in the outpatient setting without having formal C&A training is a bit dicey for the medicolegal risk mentioned above. The general advice we have been provided is that seeing patients 13 and up is less fraught with risk than seeing younger patients. This seems to be quite arbitrary but has been consistently provided advice. As a generalist, I don't think you're outside of your scope for seeing and treating patients with relatively straightforward presentations. Anything with any degree of complexity, however, and you'd probably be better served referring out.

 

[Attending1985]

Why would you want to is the question

 

[Dharma]

Why would you want to is the question

Not OP, but there are some potentially lucrative jobs out there looking for 15/16 and up. FWIW I would feel plenty comfortable seeing this population without a fellowship. The existence of parents would keep me from doing so though and not because of potential litigation...

 

[Stagg737]

Had to look up what an anrp is.

Just to play devil's advocate though, while I agree with you that a fellowship trained CAP is probably more knowledgeable than an ARNP, what about super rural areas? Isn't having a practioner with SOME experience working with kids better than none?

I'd argue that sometimes no care is better than none. For example, an gen peds colleague said that where she's at regularly sees kids started on 100mg of Lamictal after spending 5 days on an inpatient unit, always prescribed by NPs. She also said several of these patients came to her after developing a rash a few weeks after discharge. During 4th year saw a middle school kid who was on 10mg of Adderall q1H from 8am until 5pm and was seeing my attending (outpt) because mom said he "always seemed anxious" and the NP wanted to start him on Seroquel.

I also see some down downright scary plans in adults from midlevels (mostly NPs, but occasionally PharmDs prescribing). Most recent was a guy on Venlafaxine 75mg TID, Bupropion 150mg BID, Buspar 5mg TID, and Seroquel 25mg QID (for anxiety) with night-time dose being 50mg who was entering a residential program and on initial H+P said he was having multiple panic attacks per day which started about 9 months earlier when his Sertraline was switched to Venlafaxine and they got worse about a 1-2 months later (guess what was started at that time, Bupropion). In 2 weeks got the guy down to Venlafaxine SA 225mg, Seroquel 50mg QHS for sleep, and a little prn Hydroxyzine for anxiety which he didn't take after the first week because he said he was feeling better than he had in years. Oh, this was also in the context of drinking at least a 12-pack of beer daily, which was only documented in 1 out of 5 or 6 notes.

/rant, but all of these patients would likely have been better off not being treated by those individuals than getting medications which caused their conditions to get worse. I've also seen much more egregious things in adults which even as an med student I would have known was completely inappropriate.

 

[Attending1985]

Not OP, but there are some potentially lucrative jobs out there looking for 15/16 and up. FWIW I would feel plenty comfortable seeing this population without a fellowship. The existence of parents would keep me from doing so though and not because of potential litigation...

In my practice I stared out saying I would see 16 and up because I thought I would like it. Never again for me. In both cases I was dealing with dysfunctional family structure and burgeoning personality pathology. I just didn’t feel I had the support or skills to do it right.

 

[Monocles]

I'd argue that sometimes no care is better than none. For example, an gen peds colleague said that where she's at regularly sees kids started on 100mg of Lamictal after spending 5 days on an inpatient unit, always prescribed by NPs. She also said several of these patients came to her after developing a rash a few weeks after discharge. During 4th year saw a middle school kid who was on 10mg of Adderall q1H from 8am until 5pm and was seeing my attending (outpt) because mom said he "always seemed anxious" and the NP wanted to start him on Seroquel.

Okay yikes those are terrifying...

 

[NickNaylor]

Okay yikes those are terrifying...

I think the argument that "some care is better than no care" is a huge fallacy when it comes to arguing for expanded scope. Our medications may only rarely kill people, but that doesn't mean that they can't make people feel much worse or make their functioning worse than their untreated disorder.

 

[Merovinge]

Is this ok to do? Especially if one doesn't have the financial means to lose an attending salary?

Is there risk of malpractice suit later on if one is just adult certified and not child certified?

I am most confused by "doesn't have the means to lose an attending salary". Where in the heck are you practicing that there is only one job and it's a job that actively wants non-fellowship trained psychiatrists for the CAP population? May want to strongly consider telepsychiatry (or moving but I suspect you have ties to the area if you are even asking).

 

[TexasPhysician]

I am most confused by "doesn't have the means to lose an attending salary". Where in the heck are you practicing that there is only one job and it's a job that actively wants non-fellowship trained psychiatrists for the CAP population? May want to strongly consider telepsychiatry (or moving but I suspect you have ties to the area if you are even asking).

OP is arguing that doing additional 1 year of CAP is “losing” a faculty salary year.

There are many fellowships that allow moonlighting. I out-earned many of my child faculty as a PGY-5.

 

[Merovinge]

That makes way more sense. I moonlighted about 10-15 hours per week and made almost as much as our junior faculty during my PGY5 year as well . It even expanded my CV in a meaningful way since it was a different type of practice than most.