Risk Management Resolutions For the New Year

A psychiatrist owes certain legal and ethical duties to patients. To know to whom those duties are owed, it must be absolutely clear to the psychiatrist and to all relevant parties exactly who is and who is not a patient. Clarity in this area will reduce the risk of allegations of abandonment and malpractice.

• Follow up with “no-show” patients. The most frequently encountered area of uncertainty is the “no-show” patient. The psychiatrist should follow up on missed appointments to ascertain the patient’s intention with regard to continuing treatment. In some instances, a follow-up letter might be sent. This advice applies to initial appointments as well, particularly if the new patient seemed to have an urgent reason for making the appointment. It may seem onerous or even counterintuitive to take such steps in light of the patient’s no-show, but if an allegation of abandonment or malpractice were to be made, the psychiatrist likely will be on solid ground having documented the steps taken to ascertain the patient’s intent (that is, having attempted to meet the patient’s clinical needs).

• It is risky to terminate treatment with a patient who is in crisis. It can be extremely risky to terminate treatment with an outpatient who is in crisis. Ideally, the psychiatrist should continue treating until the crisis is resolved. If the patient’s condition requires hospitalization, the psychiatrist may terminate safely while the patient is hospitalized; the psychiatrist should inform the patient and the inpatient clinicians that he or she is no longer the patient’s psychiatrist and will not be available upon discharge. Participants of the Psychiatrists’ Program, the APA-endorsed Psychiatrists’ Professional Liability Insurance Program, who wish or need to terminate with patients who are in crisis should contact the Risk Management Consultation Service to discuss questions and concerns.

• Do not assume you have been “fired.” When a patient “fires” his or her psychiatrist, the psychiatrist should assess whether the patient is in crisis. If the patient is not, a formal termination letter should be sent to the patient confirming that the psychiatrist-patient relationship has been terminated and that the psychiatrist is no longer available to the patient. If the patient is in crisis, the psychiatrist may need to remain involved until further action has been taken to assess and resolve the situation. Program participants in this situation should call the Risk Management Consultation Service to discuss questions and concerns.

Boundary violations are stereotypically thought to refer only to sexual activity with a current or former patient. In fact, boundary violations occur in varied and subtle forms. Furthermore, not all boundary violations are created equal; some violations are more serious and potentially damaging than others. Program participants should contact the Risk Management Consultation Service if with any question about potential boundary violations.

• Do not undertake any course of action that would tend to exploit or hinder the psychiatrist-patient relationship. This means that, for example, the psychiatrist must not enter into a nontreatment business relationship with a patient, must not enter into an employment relationship with the patient, must not loan money to or borrow from a patient, and must not develop a social relationship with the patient outside of treatment. Exceptions may apply in rare circumstances.

• Do not barter services for treatment. If the patient if unable to meet the financial obligations of treatment, the psychiatrist must either structure a workable payment schedule or refer the patient to other resources.

• Be mindful of the potential for boundary issues to arise in any setting. Not all boundary violations appear obvious from the outset. Indeed, many situations begin quite innocuously. Psychiatrists should remain mindful that boundary violations have the potential to appear in any setting.

An amazing number of lawsuits arise simply because a patient becomes angry with his or her psychiatrist. Basic politeness and a good “bedside manner” on the part of the psychiatrist can go a long way toward reducing potential liability risk.

• Engage in communication and informed consent. A significant part of being nice includes communicating relevant information promptly and effectively to the patient and seeking the patient’s informed consent to treatment. Psychiatrists should remember that informed consent is a process. As a patient’s situation or treatment alternatives change, the patient should be consulted and consent renewed. The informed consent process also helps prevent unrealistic patient expectations, a major source of liability risk.

• Be honest. The act of formally apologizing when a potential error comes to light is a highly controversial issue, not just in psychiatry but in medicine in general. Expressing heartfelt empathy about a particular outcome may reduce risk for the psychiatrist by strengthening the psychiatrist-patient relationship. However, it is not clear whether the additional acts of accepting blame or admitting error further these goals. Program participants who are facing an adverse event should contact PRMS and ask to speak to the claims examiner or litigation specialist for their state.

• Practice a good “bedside manner.” Even during a turbulent period, such as terminating with an especially difficult patient, the psychiatrist should try to project a bedside manner that makes clear that the patient’s care comes first.

The full version of this article and related multimedia presentation are available online to participants of the Psychiatrists’ Program in the “For Participants Only” section at www.psychprogram.com. If you are not insured with the Program, a complimentary copy of this article can be obtained by calling (800) 245-3333, ext. 389 or e-mailing [email protected].