Why are Psychiatrists the least likely of all physicians to get sued?

[Leukocyte]

A recent study showed that Psychiatrists are the least likely of all physicians to get sued.

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

Why is that? My impression is that psychiatric patients are usually more emotionaly labile, irritated and paranoid compared to other patients. Also, psychiatrists usually deal with lots of legal/ethical issues (such as the need for hospitalization of patients that could pose a risk to themselves...).

So why is that?

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[nitemagi]

Because the most protective factor from being sued is the doctor-patient relationship. Which specialty encourages that the most?

 

[Leukocyte]

Yes, but my impression is that the doctor-patient relationship in Psychiatry can sometimes be "rough" (specially at first), since factors like transferance, paranoia, distrust, anger can affect it. Given the patient population in psychiatry, and given that there are many sticky situations in psychiatry from a legal-ethical standpoint, I find it strange that psychiatrists are amongt the least sued. I mean if a psychiatrist finds the need to hospitalize a patient, and the patient does not want to be hopitalized...is this not a seed for being sued? Offcourse, there is no malpractice case here, since the psychiatrist would be doing what he has to do, but can't the patient sue if he wanted to? And how do psychiatrists deal with the paranoid patient? A paranoid patient can sue if he thinks of anything, even though in reality it did not happen. Again, there might not be malpractice, but any patient can sue just for the heck of it. And how about the emergency cases in psychiatry where the doctor-patient relationship is breif and could be very rough?

It is a good thing that psychiatrists are the least likely of all doctors to get sued. It seems like psychiatrists really know how to talk and deal with people.

 

[nitemagi]

True there are emergency situations with brief interactions. It's tougher in those situations to evidence harm. Involuntary commitment laws exist in most states protecting mental health providers from being sued just for hospitalizing someone.

Your points about transference is an interesting one, and likely does lead to some lawsuits.

In the unfortunate truth I think psychiatrists should be sued much more often than they are, but we often treat the disenfranchised who others dismiss, and few recognize how much harm is being done out there with crappy polypharmacy. In some ways I wish we could educate malpractice attorneys how to find and go after the bad ones. Though more likely they'd only go after the well-insured ones.

I see plenty of psychiatrists with horrible people skills, and I've seen emergency room physicians with a gentle hand and bedside manner.

 

[whopper]

My theory is that if someone suffered malpracticed or some of the other issues that were likely to cause a lawsuit, the person doesn't want to reopen emotional wounds.

I've seen plenty of patients that suffered some form of malpractice. I've encouraged such patients to report the actions of the other doctor to the state medical board. Most of them did not, citing that they didn't want to go back on that painful part of their life.

While the same could be said of any medical profession, with psychiatry, patients have to openly admit to being mentally ill. I think that's the difference. I believe such patients feel even more vulnerable.

I mean if a psychiatrist finds the need to hospitalize a patient, and the patient does not want to be hopitalized...is this not a seed for being sued?

The two biggest causes of lawsuits in psychiatry are one-suicide and two-abandonment. The thing with involuntary hospitalization is in virtually all states, the patient will get a hearing from a court within 72 business hours. A doctor could be sued for malpractice for holding someone against their will, but remember that for the criteria for malpractice to have been done, the standard of care must have been violated, and there has to be measurable damage as a result of that doctor's decisions (among others, but I'm only going to mention the cogent ones here).

The problem here is that within 3 days, most people cannot bring up damages that IMHO courts or the potential plaintiffs would find meaningful. If a guy lost a day at work or even three, no he's likely not going to sue for that even if he was wrongly held. If a guy were held against his will and shouldn't have been hospitalized in the first place, well the same states usually only give doctors a very limited time to decide if that person should've been held bringing up the argument that the request for commitment was reasonable given the limited information. After the 3 days, it's the court's responsibility. If the person was committed, it's the court at fault, not the doctor. Remember, doctors don't commit patients, courts do. Doctors can only ask courts to commit patients. You can't sue the court. You can only appeal if you disagree with their decision. Another factor is involuntary commitment is a multistep process. While a professional such as a psychiatrist could request for a hold, in most states, other people also have to agree with that. E.g. if you're an ER doc and you request a hold, the person is then transferred to psychiatry. Psychiatry could then discharge the patient. In most states, one can only be held after several parties, including the original person who requested the hold, another professional for verification, then the psychiatrist on the unit all have to keep it up.

So if a guy was held for the full 72 hours, and that guy sued the original guy who requested the hold, his defense attorney could bring up that several people continued the hold who agreed with him, strengthening that this act was under the standard of care.

In my current job setting my problem is not keeping patients in but getting them out. Several times I've had patients that were safe for discharge but the court had to discharge them because they were charged with a crime and were put in the hospital for legal reasons. I've had situations where I wrote letters to the court saying the patient was fine for discharge and it's sitting on the desk of a judge who for whatever reason doesn't start reading it till about 3-4 months after it's placed on his or her desk. All the while the guy keeps asking me "why am I not being discharged?"

 

[Riff]

Let's speculate about possible reason, brainstorm, shall we?

1. Deflection. No matter what you say or how you behave, you can always deflect any criticism, making it about the people in patient's life now or in the past. "It's not me that you're mad at for canceling appointments a few times or showing up late or dozing off just now (while you were retelling that story for the nth time), but your dad, who did not show up at your soccer game and you kept waiting and waiting in the rain...but he never showed. You felt like you did not matter. And it happened more than once, isn't that right? Yes, yes, at least five times! So when I came late and canceled that appointment the last minute, those feelings resurfaced. I understand that you're angry but it's not me you're so angry at. Yes, minor annoyance, of course, but this kind of rage, no, this is about your dad."

This method won't work if you're a plastic surgeon who messed up the boob job. No way to reframe that or deflect the blame.

2. Psychiatrists are in general nice people. I mean why else become a psychiatrist, unless you do care about others? Yes, yes, some do get burned out and there are some ******* psychiatrist but most are nice and caring people. They have also learned how to establish rapport. They don't treat patients like a piece of meat to be operated on. They see the whole person and of course they need to, since the patient is not, say, the passenger but actually the co-driver. Or better yet, the psychiatrist is the supervising driver who is teaching the patient how to drive his body and mind and how to fix it when it gets stuck.

3. The science behind psychiatry is hardly an exact science at all. There is no blood test, no MRI. There is no sending a sample to pathology. There is no sign, no mark, nothing, of the treatment left on the body, except stitches on the psyche. How to find out where it went wrong? In fact, how to find out when it went right! Psychiatry is at the crossroads of science and art, of philosophy, religion, anthropology, sociology, medicine, and biology. There should be less responsibility put on the shoulder of the shrink when things turn out well, but also less blame when they do go wrong. Unless, of course, people in the field advertise miraculous cures and balancing the chemicals.

4. As it has been suggested, many patients are just happy to have someone listen to them, hear their story of suffering and pain. They're not going to sue such a person that easily. This is a professional who is also a friend. And we don't sue friends.

 

[whopper]

I mean why else become a psychiatrist, unless you do care about others?

Unfortunately I've seen a subset simply pick this profession because they wanted to avoid call.

Unfortunately many medstudents pick a profession simply based on the lifestyle. While lifestyle certainly is an important foundation in the decision making process, so too must be a passion for the specific field of medicine.

I had a triad in residency that I sorted out, lazy, crazy, and passionate. (Mind you this was simply a pneumonic saying. The use of the word crazy and lazy is somewhat inappropriate). 1/3 go into psychiatry because they were medstudents that didn't have a passion for any specific field and they wanted the one without call and they didn't have to be exposed to blood or rectal exams, 1/3 went in because they had a psychiatric issue and wanted to better understand it for themselves (though that same attitude may or may not have carried over to patients depending on the quality of that doctor), or they had a sincere passion for it. Number two could've gone hand-in-hand with # three if the doctor was a good one.

 

[DebDynamite]

Don't forget the "4 D's":

Duty: Duty exists when the physician-patient relationship has been established. The patient has sought the assistance of the physician, and the physician has knowingly undertaken to provide the needed medical service.

Dereliction: Dereliction, or failure to perform a duty, is the second element required. There must be proof that the physician somehow neglected the duty to the patient.

Direct cause: There must be proof that the harm to the patient was directly caused by the physician's actions or failure to act and that the harm would not otherwise have occurred.

Damages: The patient must prove that a loss or harm has resulted from the actions of the physician.

Read more: (http://wiki.answers.com/Q/What_are_the_4_D's_of_negligence_for_physicians#ixzz1cqkbGyqs)

Usually, but not always, our patients do like us. Since patients are much less likely to sue a doctor they like, that takes care of the majority of our patient base. But when a patient comes along that has more axis 2, doesn't like boundaries being set (can't get their xanex, or call you at all hours of the night), etc... they would still have to prove damages, dereliction, and so on.

Also, think about the level of organization it actually takes to hire an attorney and present your case. I have had patients in the ER threaten to sue. They are usually drunk, high, or not getting what they want. I tell them how to spell my name, and proceed with the plan of care just the same.

 

[DebDynamite]

I had a triad in residency that I sorted out, lazy, crazy, and passionate. (Mind you this was simply a pneumonic saying. The use of the word crazy and lazy is somewhat inappropriate). 1/3 go into psychiatry because they were medstudents that didn't have a passion for any specific field and they wanted the one without call and they didn't have to be exposed to blood or rectal exams, 1/3 went in because they had a psychiatric issue and wanted to better understand it for themselves (though that same attitude may or may not have carried over to patients depending on the quality of that doctor), or they had a sincere passion for it. Number two could've gone hand-in-hand with # three if the doctor was a good one.

Love it.

 

[F0nzie]

Physicians with the highest malpractice typically perform invasive procedures. ECT the only invasive procedure psychiatrists perform and very few even do.

Paranoid, delusional, or psychotic patients who don't have case will have problems getting a lawyer to accept a case and if they do these patients don't typically do well on the stand in front of a judge.

Suicide is the #1 malpractice lawsuit in psychiatry. Psychiatrists have an ethical and legal duty to report imminent danger to self or others: eg. Contacting family members (huge protective factor) and involuntary commitment to protect the individual. A suicide risk assessment should always be documented for legal protection to prove you have looked at both the risk factors and protective factors and a justification for your decision to place an individual in the least restrictive environment to mitigate their risk for self harm.

 

[nitemagi]

(Mind you this was simply a pneumonic saying. The use of the word crazy and lazy is somewhat inappropriate).

I think you mean mnemonic.

 

[F0nzie]

I had a triad in residency that I sorted out, lazy, crazy, and passionate.

The triad gives me 7-10 handoffs of unseen patients at the start of my shifts when I'm on call or moonlighting. You should add the 1% hard worker category. Maybe I'm just a machine but I don't take 1.5 hours to do a psych evaluation in an emergency setting.

 

[Leukocyte]

I have had patients in the ER threaten to sue. They are usually drunk, high, or not getting what they want. I tell them how to spell my name, and proceed with the plan of care just the same.

That is EXACTLY what I mean. I imagine that psychiatrists deal with senarios like this very often. How do you guys (Psychiatrists) deal with this in general. Psychiatrists are human beings too, and hearing something like that, even if it is from a drunk or psychotic patient, can certainly affect the mood of the Psychitrist. How do you guys go along with your day as usual after hearing something as this? To be fair, since ALL people are equal under the law, this is a threat. Why can't a doctor sue his patient for making threatning comments like these?

It takes nerves of steel to be able to hear a threatening comment like this and be able to carry on with the rest of the day as usual.

 

[strangeglove]

That is EXACTLY what I mean. I imagine that psychiatrists deal with senarios like this very often. How do you guys (Psychiatrists) deal with this in general. Psychiatrists are human beings too, and hearing something like that, even if it is from a drunk or psychotic patient, can certainly affect the mood of the Psychitrist. How do you guys go along with your day as usual after hearing something as this? To be fair, since ALL people are equal under the law, this is a threat. Why can't a doctor sue his patient for making threatning comments like these?

It takes nerves of steel to be able to hear a threatening comment like this and be able to carry on with the rest of the day as usual.

Some would say that this is what you learn in training that really helps your patients, more than the stuff about receptors and such. Good psychiatry training teaches you how to recognize and manage your feelings towards your patients, rather than acting on them. And it takes training, not just being a naturally "good person". Not suing your patients for threatening you means that they will tend to feel better when you prescribe them medications.

 

[whopper]

I think you mean mnemonic.

Yep.

 

[digitlnoize]

Do you guys think the economic situation of our patients is also a factor? Many psych patients are not in a good enough financial situation to handle the cost of a lawsuit. Add to this the level of functioning needed to initiate a lawsuit, and you have two huge reasons we don't get sued.

It's no surprise then, that the #1 reason for being sued is suicide. Presumably, we're being sued by the higher functioning, financially stable family after the patient died.

Just my take. Also, I like Whopper's mnemonic. For the record, I am #3, but I don't dislike #1 (hahaha). There are a number of "good lifestyle" fields in medicine (see the ROAD thread), but psych was, to me, the most interesting by far.

 

[Riff]

I wonder if similar triads (lazy, crazy, passionate) exist in other specialties, like surgery, derm, etc. In fact, I wonder if there are any proctologists in the "passionate" group.

 

[billypilgrim37]

I wonder if similar triads (lazy, crazy, passionate) exist in other specialties, like surgery, derm, etc. In fact, I wonder if there are any proctologists in the "passionate" group.

All the GI surgeons I knew fell into those groups quite clearly. I used to have nightmares (like, literally waking up from sleep nightmares, not figuratively) that I would need an appy, go to the ER, and find out that the GI doc on call was the "lazy" one.

The "crazy" one told me he would make sure I got Honors because I knew what pickups were in the Eric Clapton Stratocaster. And he meant it.

 

[sunlioness]

My theory is that if someone suffered malpracticed or some of the other issues that were likely to cause a lawsuit, the person doesn't want to reopen emotional wounds.

I've seen plenty of patients that suffered some form of malpractice. I've encouraged such patients to report the actions of the other doctor to the state medical board. Most of them did not, citing that they didn't want to go back on that painful part of their life.

While the same could be said of any medical profession, with psychiatry, patients have to openly admit to being mentally ill. I think that's the difference. I believe such patients feel even more vulnerable.

I think this pretty much nails it. In order to go after your doctor, you have to make public your own stuff and be willing to have it exploited by the physician's defense who will not be shy about going after any perceived vulnerability. Who wants to put themselves through that?

I got threatened with legal action fairly routinely though as an inpatient doc. It was mainly people venting their frustrations, but it was still hard for me to hear. It generally fell under one of two categories.

1. You're not treating my anxiety/pain appropriately and I'm going to sue you.

2. You are discharging my loved one before I feel they're ready to go home. You need to keep them in the hospital indefinitely because I am terrified of what might happen when they get home.

I didn't worry about the first one overly much because drug seekers say a lot of things and that's usually generally acknowledged. But I really felt for the people in the latter situation because I could see their point, recognize their fear and acknowledge that I didn't have a magic crystal ball and couldn't guarantee the patient's safety. But neither could I keep a patient hospitalized against established criteria and their desires just based on that fear. I tried to listen and work with families on that and my doing so usually helped, but not always. And many of the times what was going on was that the patient had a serious drug problem and the family was desperate to believe they were mentally ill when they weren't to explain the addict behavior or else they wanted me to commit the patient to rehab and didn't understand why I couldn't do that.

 

[Ibid]

. Also, I like Whopper's mnemonic. .

Small point but I prefer the pnemonic. In Aldous Huxley’s Brave New World high caste men took the drug soma and went from pneumatic girl to pneumatic girl. An unusual use of that word but it could make a pneumonic the most precise word for ordering a set of attractive qualities in people. A pneumonic would be a subset of mnemonic in that it “would be more of a code” than a simple memory strategy.

Obviously Whopper is not one to trifle over this sort of thing....

 

[digitlnoize]

Small point but I prefer the pnemonic. In Aldous Huxley’s Brave New World high caste men took the drug soma and went from pneumatic girl to pneumatic girl. An unusual use of that word but it could make a pneumonic the most precise word for ordering a set of attractive qualities in people. A pneumonic would be a subset of mnemonic in that it “would be more of a code” than a simple memory strategy.

You know, I've never read that. It's been on my list for some time, but other things keep jumping in front of it.

I like your point, except that it might get too confusing with the official definition of pneumonic:

http://www.merriam-webster.com/dictionary/pneumonic

Basically: pertaining to the lungs.

Not that I've ever heard anyone USE it that way...

 

[heyjack70]

I believe another is reason for lack of lawsuits is this: when suing for damages what are you suing for? Basically it's lost wages, loss of consortium, loss of something etc. You don't get punitive damages unless you can prove gross negligence, which is beyond negligence, and I believe fairly rare. A lot of the severely mentally ill are broke and single so there what can you claim in damages? The answer is not much and lawyers know this. You can't sue for the $550/mo disability check.

I think in most cognitive specialties the most common lawsuit is for missing a diagnosis. Well in psychiatry, all of our diagnoses are syndromic and based on clinical opinion (ie soft) and are best diagnosed over time. And if you miss a depression diagnosis, it's not like you didn't order a lab test and missed it, it's because you did not believe it was present. If you justify your reasoning in your note who can argue with you.

 

[DebDynamite]

While it is true that the "standard of care" often depends on the setting, I would just like to point out that it is negligent if we don't order labs and imaging at times. If my family member is getting worked up for depression and TSH/free t4 are not at the least obtained from recent PCP records, I am going to be highly annoyed and make some phone calls. Not to mention situations inpatient when imaging is required as part of the psych work up, etc. I had a friend who recently was prescribed abilify to augment her SNRI. She's in her early 30's and sexually active. The psychiatrist didn't order b-HCG. As she is a psychiatrist herself, she promptly went and found herself another provider.

 

[heyjack70]

While it is true that the "standard of care" often depends on the setting, I would just like to point out that it is negligent if we don't order labs and imaging at times. If my family member is getting worked up for depression and TSH/free t4 are not at the least obtained from recent PCP records, I am going to be highly annoyed and make some phone calls. Not to mention situations inpatient when imaging is required as part of the psych work up, etc. I had a friend who recently was prescribed abilify to augment her SNRI. She's in her early 30's and sexually active. The psychiatrist didn't order b-HCG. As she is a psychiatrist herself, she promptly went and found herself another provider.

Agree. I think the issue protecting psychiatrists from malpractice when ruling out medical issues, is that most of the time, there is not a medical condition present. No intracranial mass, no hypothyroidism, no sz d/o. Sure it happens but it's rare. So for the psychiatrists that do not check for medical causes of symptoms, the odds are with them.

 

[nitemagi]

Agree. I think the issue protecting psychiatrists from malpractice when ruling out medical issues, is that most of the time, there is not a medical condition present. No intracranial mass, no hypothyroidism, no sz d/o. Sure it happens but it's rare. So for the psychiatrists that do not check for medical causes of symptoms, the odds are with them.

If you don't look for it, you won't find it.

 

[DebDynamite]

If you don't look for it, you won't find it.

So true. And, an interesting position to be in. I had a 43 YOCM come to see me for depression a couple years back. He was a big guy with a huge neck. Rarely went to see his PCP, if ever. I educated him that I was concerned that he might have sleep apnea and repeatedly urged him to go back to his PCP and request a sleep study. It took about six months of urging him to go. Eventually he ended up with a CPAP. He also had man boobs and I really didn't think his T would be low, but I also urged him to ask for a level when he went to his PCP. So, I documented all along some of my concerns about his medical conditions that could have been contributing to his depression. In the world of CYA medicine, this is essentially adequate for a psychiatrist, bc I don't treat OSA or low T ( his was not, but I have found low T in a couple of my patients and then sent them to their primary or endocrine).

It's our job to remember the medical workups (rule- outs) that go along with treating mental illness. Even if outside of our scope of practice, we can recommend to the patient that they follow with another provider. We can document what we recommended. Otherwise, there is often a degree of negligence involved.