Talk Not Cheap If You Lower Your Guard

The risk management strategies below are based on the experience of the Psychiatrists’ Program, the APA-endorsed professional liability insurance program, in defending psychiatrists in claims, lawsuits, and administrative actions where communication via telephone was a significant factor in the allegations against the psychiatrist.

• Implement a system for documenting telephone calls and messages from patients, as well as the response to those calls and messages.

In a recent malpractice lawsuit involving a suicide, there were factual disputes between the plaintiff (that is, patient’s estate) and the defendant (that is, psychiatrist) about how many times the deceased patient’s wife had called the doctor’s office, what messages were given to the office staff, whether the psychiatrist responded to all the messages, and when the psychiatrist responded to the messages. The telephone log book and notations of the psychiatrist’s receptionist became critical evidence in establishing the facts in the lawsuit because they contained the only documentation of the telephone events, relevant dates and times, and so on.

• Document all phone calls in which clinical information is discussed, including after-hours phone calls with patients and phone calls received when covering for colleagues. The documentation should be part of the patient’s record.

Document the date and time of the call, the reason the patient called, and the response given. This documentation supports patient care. In addition, if a patient challenges the quality of care received by telephone, or claims that he/she made multiple calls and received no response or inadequate assistance, such documentation can be used to defend the psychiatrist.

• Train office staff to triage calls appropriately.

Give staff guidelines about the symptoms or conditions that require immediate referral to the psychiatrist, as well as procedures for handling routine, nonemergency patient calls. The threshold for obtaining a physician’s response should be relatively low—any uncertainty on the part of the staff means it is discussed with the doctor.

• Only staff with the appropriate training and professional credentials should provide clinical information or recommendations to patients.

Employers are responsible for the acts of their employees, and the liability resulting from the acts of those employees is directly imputed to the employer.

In each situation you have to decide whether it is reasonable to evaluate over the telephone and give specific advice. Is this an established patient? Do you know this patient well enough to assess by telephone? If medical advice is given, instruct the patient to call or seek emergency treatment for changes or worsening of a condition or with additional questions.

• Recognize the risks associated with prescribing medications over the telephone.

Again, assess what is reasonable to do. Is this an established patient? When was the last face-to-face clinical evaluation? How does this fit into the patient’s treatment plan? If medication is prescribed, should it be for a limited period of time? Is the minimal amount necessary being prescribed? Should time restrictions be placed on when patient must be seen in person? Does the patient have a pattern of requesting extra refills during off hours or when a colleague is covering?

• Recognize the risks associated with long-term telephone treatment.

The major clinical hurdle is whether long-term treatment via telephone falls within an acceptable range of psychiatric practice. Can the quality of care the patient needs be provided without face-to-face interaction? Can you adequately evaluate the patient’s clinical status over time by telephone?

• Recognize the risks associated with long-distance telephone treatment.

When a patient is located a considerable distance away, the major problem is how will crises or emergencies be managed? In long-distance situations, it is usually best to assist the patient with a referral and transfer to a local psychiatrist, if he/she will be out of state for more than a brief stay. For a patient caught without his or her current medication while out of state temporarily, prescribing an amount to cover the limited period may be appropriate. However, when the symptoms the patient is describing suggest the need for new medication, consider referral to a local emergency room or clinic for evaluation. Longer-term treatment via telephone with a patient who is out of state brings up questions of whether you may be practicing medicine without a license in another state. Contact the state medical-licensing board in the state where you are licensed and the state where the patient is located to learn their positions on this issue.

• Be aware of patient confidentiality concerns when using the telephone.

Make sure that your end of a telephone call involving confidential information cannot be overheard by other patients, uninvolved staff, or other individuals (for example, cleaning staff, fellow movie goers). When leaving messages on patients’ answering machines, include only your name (without “doctor”), a request to call you, and your number. Make sure that messages left on the office answering machine and messages retrieved from it cannot be overheard by individuals in the waiting room, the maintenance staff after hours, or anyone who does not have a need to know confidential patient information.

If using cellular and cordless phones to discuss sensitive patient information, even if you are using the more secure digital cell phone, do you know whether the person on the other end of the line is using a digital phone or a less secure phone such as an analog cell or cordless phone? ▪

Ms. Melonas is vice president of risk management for Professional Risk Management Services Inc., the manager of the Psychiatrists’ Program, the APA-endorsed professional liability insurance program.