According to the American Hospital Association, one in four Americans will experience a mental illness or substance use issue every year.1 Although one study suggests that 17% of all Americans have comorbid psychiatric and medical conditions,2 a study conducted of Medicaid beneficiaries in New York concluded that 69% of individuals hospitalized for a medical condition also had a history of mental illness, and 54% of those hospitalized for a medical condition had a history of both mental conditions and psychiatric illness.3 Behavioral health issues and the treatment required can have a profound impact on comorbid medical conditions. For example, many medications prescribed for mental illness have significant metabolic, cardiovascular, and hepatic implications. Medical consequences from the prescription of psychiatric medications necessitate medical monitoring, but patients with serious psychiatric disorders frequently have significant difficulty in accessing primary care. Factors influencing access to primary care include decreased access to health insurance as well as the cost of medical care copays. Moreover, individuals with mental illness are less likely to seek preventative care or screenings, thereby creating acute medical situations because preventative measures were never sought or undertaken.
IDENTIFICATION OF THE PROBLEM
So, what is the psychiatrist to do when faced with a patient requiring medical care for conditions that are unrelated to the psychiatric treatment? How can you reduce your risk when confronted with a patient who requires medical follow-up or care for comorbid physical conditions? The answer starts with the identification of the problem. When new patients seek psychiatric care, it is important to conduct a thorough evaluation, including the identification of his/her primary care physician, as well as known comorbid conditions. If a patient does not have a primary care physician, the psychiatrist’s decision on whether to prescribe medications for a physical illness needs to be balanced between the benefit of the medication versus the risk of creating a medical consequence, knowing that follow-up with a primary care physician may not occur. Incumbent in the plan to prescribe medications or other treatments is the plan for follow-up and medical monitoring. Furthermore, patient compliance with the follow-up plan should be a condition of the treatment and its continuation.
Communication is the next step in tackling this issue. If a psychiatrist treats a non-psychiatric condition, it is optimal for the psychiatrist to speak with the primary care physician concerning medications prescribed and monitoring required. The challenge arises when a patient does not have a primary care physician or the patient does not consent for the psychiatrist to speak with the primary care physician. Prescribing medications for a psychiatric condition can be conditioned on the patient’s agreement and follow through with the medical follow-up needed for his co-morbid medical condition. If the patient is non-compliant with follow up care, the continued physician-patient relationship may need to be re-evaluated and possibly terminated. Consult with your local attorney or risk manager to determine your obligations under state law when terminating with a patient in these types of situations.
From a professional liability perspective, there can be liability risks when prescribing a medication with potential adverse medical consequences while not recognizing limitations for follow-up medical monitoring. In the situation where a patient has no primary care physician, it is then incumbent upon the psychiatrist to consider follow-up, or the potential lack thereof, as much as the prescription of treatment itself. A psychiatrist prescribing a treatment is responsible for also formulating a plan for follow-up medical monitoring, whether done by a primary provider, a medical clinic, or the psychiatrist him/herself. The psychiatrist’s dialog with a patient concerning the expectations for compliance is an important part of the overall formulation of a treatment plan.
Documentation is a key element in minimizing the risk to the psychiatrist. Many times, healthcare providers write scant notes and believe that either their memory will serve them if needed down the line or that documenting conversations is not necessary. Consider this: what did you do three years ago today between 2 and 3 pm? Unless something traumatic or monumental occurred, you will very likely not be able to answer that question or provide details for that period of time. Thus, when instructions are given to a patient for follow-up, it should be documented.
When a patient informs the psychiatrist about symptoms as a result of a comorbid condition, documentation becomes even more important. For example, if a patient describes cardiac symptoms to a psychiatrist, he may not have sufficient expertise in providing the necessary cardiac evaluation and subsequent treatment. As the patient confided in the psychiatrist, he/she may believe that the psychiatrist will undertake that aspect of care when considering the treatment plan. The following are important considerations which should be documented:
- Did you inform the patient that you are not the specialist to treat the condition?
- Did you inform the patient on where to go for medical follow-up?
- Did the patient agree to follow-up as instructed?
- Did the patient demonstrate understanding of the instructions?
It can be anxiety provoking when a psychiatrist receives a request for records from a patient’s attorney. The documentation in your records is one means by which an attorney determines whether or not to accept a case and pursue litigation. When documentation is sparse, it is a safe bet that you may not remember all of the details of conversations with a patient from years prior. Even if memories prevail, the lack of documentation in a record is always a difficult hurdle to tackle at the time of trial due to the maxim “not documented, not done.”
Scenario One: A records request came to the group practice for a patient that was seen about two years prior and is now deceased. The psychiatrist and therapist who saw the patient are no longer at the practice. The progress notes are hand written and mostly illegible. There is no documentation of any instructions given to the patient for medical follow-up, but the records make it very difficult to determine what medical follow-up would have been necessary. This may be a difficult case to defend if the patient’s estate is now claiming that the psychiatrist never told the patient to follow-up for cardiac symptoms that he thought were related to anxiety.
Scenario Two: A psychiatrist saw a patient almost two years ago who complained of multiple comorbid conditions and symptoms. The patient is now deceased. The progress notes documented the discussion between the psychiatrist and the patient on the need for medical follow-up, including the names of several specialists that the psychiatrist provided. The psychiatrist sent a letter to the clinic where the patient (sometimes) went for medical care, and copied the patient. A copy of that letter was retained in the patient’s records. The progress notes are legible, or typed, and document the psychiatrist’s questioning of the patient at every visit on whether the patient followed the instructions for medical follow-up. This matter creates a significant question and deterrent for any plaintiff’s attorney considering whether to invest time and money into pursuing litigation and investigating claims that the psychiatrist undertook specialty care outside his scope of practice and missed a medical diagnosis, leading to the patient’s demise.
TAKING ON MORE THAN YOUR SPECIALTY
Coordination of medical care and psychiatric care is always important, and for the psychiatrist confronted with a patient who has behavioral health issues and comorbid medical conditions, it is important to understand your limitations. The standard of care may vary from state to state, but generally the standards of care for a particular specialty apply to all those providing care to patients in that particular specialty. The standards of care are measured by what a professional in the same or similar specialty would do under the same or similar circumstances. Thus, it is important that the psychiatrist understand the standards of care in the jurisdiction where they are practicing.
For a psychiatrist working in a rural area where the population has limited access to medical and behavioral health treatment, that psychiatrist’s care is generally measured by what a psychiatrist with limited access to specialty care is able to provide. In contrast, in an urban setting with hospitals, physician groups, specialists, and clinics, the standards of care are measured with that availability in mind.
If, for example, your patient presents with diabetic foot ulcers and is complaining of uncontrolled diabetic related symptoms, it is important that your patient understand that endocrine issues are outside the scope of your practice – and document the discussion. If, though, a psychiatrist orders blood work for a fasting blood sugar and becomes involved in the diabetic care to even a small degree, the door opens to the standards of care. At that point, depending on the jurisdiction, the psychiatrist’s standard of care may change to include what an endocrinologist would do under the same or similar circumstances rather than that of a psychiatrist. The same is true for all medical conditions such as cardiac complaints, pulmonary symptoms, renal disease, neurologic complaints, etc. However, if there is an adverse outcome, the psychiatrist may/may not be held liable for providing medical care that could be considered outside his scope of practice. This may likely depend on the specific facts of the case and the court determination.
To treat or not to treat? It depends. Psychiatrists may not necessarily have training and expertise to treat medical conditions which fall outside the scope of psychiatry. Safeguards should be in place when taking on the psychiatric care of a patient who has comorbid medical conditions or requires medical follow-up due to medications prescribed. Consider consulting with your local attorney or risk manager for assistance with questions you may have regarding your liability exposure in these types of patient encounters.
Risk Management Tips
- Formulate a mutually agreeable plan for how medical issues will be monitored and treated
- For patients without a primary care physician, a specific plan for follow up care with a medical physician or clinic should be developed
- Document thoroughly at each appointment, the patient’s compliance with the formulated plan
- Do not expand your scope of care beyond those areas that are within your training and expertise
- Consult your professional liability carrier to discuss coverage for your practice particularly if it falls outside the scope of psychiatry.
- American Hospital Association, “Trendwatch: Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes,” (January 2012) (citing, Kessler, RC, et al. (2005). Prevalence, Severity and Comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627.
- Druss, B.G. and Walker, E.R., (February 2011). Mental Disorders and Medical Comorbidity Research Synthesis Report No. 21. Princeton, NJ, The Robert Wood Johnson Foundation.
- New York State Health Foundation. (April 2011). Grant Outcomes Report: Improving Chronic Illness Care in New York State.