CaliforniaGreen

10+ Year Member
Jul 31, 2008
131
0
Status
Pre-Medical
With psychiatry, it is expected that we will incur a certain amount of patient abuse, but when is it too much?

Say you are working solo in private practice, when can you discontinue working with a patient who routinely argues with you, insults you and staff, routinely misses appointments, and makes a scene in your office.

What is the protocol for letting them go, while covering your bases legally?
 

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,938
1,732
Visit site
Status
Attending Physician
Stopping services to a patient without following the proper guidelines is considered abandonment. Next to suicides, it is the largest cause of malpractice lawsuits against psychiatrists.

Stopping services is going to depend on the state. Pretty much all states require the provider to provide referrals to other providers but the specifics vary by state. Some states only require referral to one doctor, some require 3. If patient do not follow guidelines set forth that they agreed to follow, the provider can terminate the patient. E.g. a patient that is a no-show several times, but again you need to be wary of the specifics the state demands. Some states may require a specific number of no shows.

Just an example, here are the state laws of Ohio where I practice. Many states will have their laws printed online for you to reference.
http://codes.ohio.gov/oac/4731-27

If a patient is pissing staff off, that is not enough grounds to terminate treatment. Several psychiatric patients fit profiles where they will be very difficult. Further, some personality disorders such as borderline PD need treatment and people with this profile often upset people.

I've seen cases where doctors stopped services to borderline patients without referrals because they were difficult. IMHO, those cases are on thin ice for losing lawsuits but I never saw a malpractice case yet from it. I've also talked about this before on this forum. Many psychiatrists treat borderline patients with psychotropics even though that is not the first line treatment and meds have only minor benefits for borderlines. A psychiatrist abandoning a borderline is playing with fire. You got...

1) a patient with a profile where they are more likely to sue
2) a patient who may have been improperly treated (not given the first line treatment and not given DBT which is considered the appropriate treatment)
3) abandonment that fits the legal definition of the term.

IMHO this is even more reason why psychiatrists should not treat borderline patients with meds and either provide DBT or refer the patient to someone who can do DBT. Unfortunately the trend I see is the psychiatrist diagnoses them as bipolar disordered, gives them a mood stabilizer and the patient gains 100 lbs and is no better off.
 
Last edited:

sunlioness

Fierce. Proud. Strong
10+ Year Member
Feb 23, 2007
1,535
766
Status
Attending Physician
I had a formal office policy that covered this that patients were asked to read and sign at their initial visit. Basically it said that I reserved the right to discharge a patient after either 3 no shows or cancellations without 24 hours notice. I think if you actually feel physically threatened by a patient that would be reason enough to discharge them too. It never came up with me, but I was mindful of it being a woman in solo practice in an isolated suite in the back of an office building. I also discharged people for refusing treatment recommendations -- not meds per se, but there was an instance or two in which I recommended IOP and the patient refused and I discharged them because I felt I couldn't help them without a higher level of care. I have also discharged people for refusing referrals to rehab. In all of these cases, I told the patients I would see them again upon graduating either from an IOP or rehab program and they were provided with several referrals.

But you have to make sure you discharge them in a way that doesn't constitute abandonment, as Whopper stated above. Your liability insurance people can help you navigate this if you have questions.
 

kugel

10+ Year Member
7+ Year Member
Feb 6, 2007
826
16
Status
Attending Physician
Although I'm not in private practice, I would think this is a great question for the Risk Mgt lawyers at your Malpractice Insurance company. When you have a question about what is legal and how to protect yourself from lawsuits - that's what these people are paid to answer.
 

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,938
1,732
Visit site
Status
Attending Physician
At least in the Ohio guidelines this is also spelled out.

I have to provide at least emergency services for a month after I inform the patient of termination of my services.

The patient needs to be referred to others or told to go to the hospital.

The reality, however, and this is unfortunate, is several patients cannot even get another psychiatrist. Another reality is several doctors do not follow the rules. I have several patients I am treating with Suboxone who have a doctor who simply just stopped working. He did not give the patients advance warning nor gave them no referral. It's already moving the Earth trying to find a doctor to provide this medication.

Most of those patients, at least in the psychiatric category don't seem interested in pursuing a lawsuit, and data shows that psychiatrists as a category rank quite low in terms of getting sued vs other doctors. Why this is I'm not certain though I speculate that the process of revealing your psychiatric problems in front of a Court could be quite embaressing and lead to more discomfort on the part of the patient. I know of several psychiatrists that I believe are doing strange care and with the exception of one that went over a large extreme (gave rectal exams and told his patients to take off their clothes for physical exams---in outpatient, and no he was not treating their physical medical problems), I don't see them being sued.
 
Last edited:

heyjack70

Junior Member
10+ Year Member
7+ Year Member
Nov 24, 2005
745
247
Status
At least in the Ohio guidelines this is also spelled out.

I have to provide at least emergency services for a month after I inform the patient of termination of my services.

The patient needs to be referred to others or told to go to the hospital.

The reality, however, and this is unfortunate, is several patients cannot even get another psychiatrist. Another reality is several doctors do not follow the rules. I have several patients I am treating with Suboxone who have a doctor who simply just stopped working. He did not give the patients advance warning nor gave them no referral. It's already moving the Earth trying to find a doctor to provide this medication.

Most of those patients, at least in the psychiatric category don't seem interested in pursuing a lawsuit, and data shows that psychiatrists as a category rank quite low in terms of getting sued vs other doctors. Why this is I'm not certain though I speculate that the process of revealing your psychiatric problems in front of a Court could be quite embaressing and lead to more discomfort on the part of the patient.
He sounds like a flake, to put it lightly. Was there actual injury in these patient's, beyond withdrawal effects? Did any of them go back to using? I could only imagine these two events as possibilities. If there is no injury, there is no malpractice. And I'm not sure what dollar amount you can place on withdrawal. Food for thought.
 
Sep 1, 2009
135
0
Status
Non-Student
You can have all of the fancy office guidelines and policies, but they are just another form of informed consent. You should know that in our litigious society an informed consent is NOT a barrier to a malpractice suit.
 

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,938
1,732
Visit site
Status
Attending Physician
I don't know the exact numbers because I got about 5 of his patients, all of whom told me they were scrambling to find someone to provide them suboxone.

All 5 out of 5 told me once they were stabilized on Suboxone, they wanted to be weaned off the medication but that other psychiatrist wouldn't wean them off and continue to charge them over $200 for a 5 minute visit per month.

Another problem was that, in case you didn't know, the first time a doctor sees someone and gives them Suboxone, you have to spend a session that the company recommends be at least one hour but could take as many as 5, and during that time the doctors a huge fee (around $500 in my parts) that is most often not reimbursed by insurance.

My policy is I will not charge for that initial examination (called the induction) so long as the the patient is already on Suboxone and they provide me with records from the previous doctor showing an induction was done. This other doctor didn't provide any of the records so I had to charge the new patients for another induction (that I by the way charge the least amount of any doctor I know of in the community, less than $300, and I'm doing that because I'd like to be able to sleep at night). I also tell my staff to bend over backwards trying to get the previous records because some of the patients I got can barely afford their treatment.

I hate saying this but from my experience, > 50% of the outpatient psychiatrists in my area, I have lots of evidence that they are not doing quality practice, and very few of them are getting sued. The same goes for the area I trained (South NJ). The only places I've seen where there is consistently good practice are from doctors who actually give a damn (and this is an individual quality), or doctors in university settings. Even in the latter, there's still bad doctors, just that there ratio of good to bad is better vs. non-university settings in the community.

Where I did fellowship, things were different. Each doctor I worked with IMHO were one of the best I've ever seen, and 3 of them were ranked to be some of America's best doctors (and there were less than 10 that taught in my program, the others were some of the best in the state, but not the country), but that too can lead to some problems. E.g. it's not the real world.
 

KHE

Senior Member
10+ Year Member
Jun 14, 2005
3,337
328
Status
Optometrist
Although I'm not in private practice, I would think this is a great question for the Risk Mgt lawyers at your Malpractice Insurance company. When you have a question about what is legal and how to protect yourself from lawsuits - that's what these people are paid to answer.
I stumbled into this thread but I would respectfully disagree with that. Risk management attorney at the malpractice insurance company will do whatever is in the best interest of the malpractice insurnace company which may or MAY NOT be what's in the best interest of YOU.

If this is a serious enough issue for someone to need a legal opinion, I would suggest springing a couple of hundred bucks or whatever and getting an outside, neutral opinion on that.
 

MellowYellowCA

10+ Year Member
5+ Year Member
Aug 29, 2008
60
0
Status
Medical Student
At least in the Ohio guidelines this is also spelled out.

I have to provide at least emergency services for a month after I inform the patient of termination of my services.
what organization does one go to read up on this type of information? where can this information be found? who decides these rules?
 

michaelrack

All In at the wrong time
10+ Year Member
Dec 22, 2007
3,956
1,095
Memphis TN
Status
Attending Physician
what organization does one go to read up on this type of information? where can this information be found? who decides these rules?
In many cases:

1. your state medical board or medical association
2. your state medical board or medical association
3 state medical board
 

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,938
1,732
Visit site
Status
Attending Physician
That and I gave the link above.

Each state has it's own guidelines. Many states (in fact all the ones I've known of so far) has their laws printed online.