Legal responsibilities to a patient?

[uhmocksuhsillen]

I will begin moonlighting as a PGY4 at a detoxification center. I will be a 1099 employee. My role will be to see the patient for an initial psychiatric evaluation. They will have already been seen by the medical director (non psychiatrist) for all tapers and associated meds.

My questions are..

1. What responsibility do I have to these patients once they discharge?
2. If a psychiatric medication is indicated, am I responsible for ensuring they will have adequate follow up for refills/labs/etc?
3. In this sort of scenario would you hold off on starting a medication and simply making recommendations to whomever they follow up with?

Thank you for your feedback.

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[comp1]

These are excellent questions for the medical director of the facility. They're likely going to be pretty specific to the system and they should have policies in place for each item you list. If they don't...don't take the job,

 

[Bartelby]

I agree with the above, the medical director should be able to provide you a clear answer. Based on my experience:

1- they should be connected with an outpatient provider. Depending on your program's policies, you may serve as a point of contact while they await intake with their new prescriber.

2- yes, at least while they are in the program. Longer-term follow-up should occur with the outpatient prescriber, but if monitoring is needed before they make their intake I personally would feel very uncomfortable with just sitting back and thinking of it as not my problem. If there is a bad outcome because of insufficient monitoring related to a medication you started (and they have not yet seen any outpatient providers) a plaintiff's attorney would likely at least name you in the suit.

3- not likely. If you identify a need for psychiatric treatment for your patient, the expectation will likely be that you initiate that treatment and then hand it off to the outpatient team. Again if there is a bad outcome because you did not start appropriate treatment you may face liability. And ultimately just seeing patients and then saying they should go see a psychiatrist (without ever starting any treatment) sounds like a relatively useless role.

 

[nexus73]

3- not likely. If you identify a need for psychiatric treatment for your patient, the expectation will likely be that you initiate that treatment and then hand it off to the outpatient team. Again if there is a bad outcome because you did not start appropriate treatment you may face liability. And ultimately just seeing patients and then saying they should go see a psychiatrist (without ever starting any treatment) sounds like a relatively useless role.

This job could be prelude to a position in hospital administration.

 

[uhmocksuhsillen]

I agree with the above, the medical director should be able to provide you a clear answer. Based on my experience:

1- they should be connected with an outpatient provider. Depending on your program's policies, you may serve as a point of contact while they await intake with their new prescriber.

2- yes, at least while they are in the program. Longer-term follow-up should occur with the outpatient prescriber, but if monitoring is needed before they make their intake I personally would feel very uncomfortable with just sitting back and thinking of it as not my problem. If there is a bad outcome because of insufficient monitoring related to a medication you started (and they have not yet seen any outpatient providers) a plaintiff's attorney would likely at least name you in the suit.

3- not likely. If you identify a need for psychiatric treatment for your patient, the expectation will likely be that you initiate that treatment and then hand it off to the outpatient team. Again if there is a bad outcome because you did not start appropriate treatment you may face liability. And ultimately just seeing patients and then saying they should go see a psychiatrist (without ever starting any treatment) sounds like a relatively useless role.

Thank you (and comp) for your replies.

So essentially if the detox can schedule a follow up appointment with a provider I should be okay to start meds and send them out with a refill to get them to that appt as well as clear instructions for labs if indicated?

Ive been told by other pp doc's at my program that a one-off appt does not necessarily mean you've formed a doctor patient relationship. They've told me that you can opt to discontinue seeing a patient. So as long as I'm prescribing meds I have no responsibility either. would that be true?

Also how is this different from me seeing a patient in the er, maybe giving them a Rx of a home med they've said they've run out of, and telling them to follow up with the local community mental health clinic with no appt booked or anything.

 

[Bartelby]

A one-off appointment does not have to form a doctor-patient relationship. You can do a consultation in which it is clear to everyone involved that you will provide recommendations to the patient's current providers and will not be seeing the patient again. You can also frame a first meeting as a consultation in which you will determine the patient's treatment needs and, if you are not a good fit for their treatment needs, refer them on to other treatment. That is not likely to apply here, because the goal of evaluating the patient as part of detox is (I presume) to identify and treat psychiatric comorbidity. If you prescribe for the patient, you have clearly established a doctor-patient relationship. That does not mean you have to treat them forever, you can certainly refer them on to an outpatient provider, but you have for sure established a doctor-patient relationship that can then be ended by referring them on.

I presume this detox is an inpatient or residential program? If so, you should look into local requirements for followup. Typically it is not considered acceptable to have a hospital inpatient leave with nothing more than a printout listing local resources (unless it is, for instance, a rapid AMA discharge). There is usually an expectation that you will help arrange adequate followup. In the ER the goal is to assess and stabilize an emergency condition, and finding a full aftercare program for each evaluation is not a realistic expectation.

 

[jbomba]

A one-off appointment does not have to form a doctor-patient relationship. You can do a consultation in which it is clear to everyone involved that you will provide recommendations to the patient's current providers and will not be seeing the patient again. You can also frame a first meeting as a consultation in which you will determine the patient's treatment needs and, if you are not a good fit for their treatment needs, refer them on to other treatment. That is not likely to apply here, because the goal of evaluating the patient as part of detox is (I presume) to identify and treat psychiatric comorbidity. If you prescribe for the patient, you have clearly established a doctor-patient relationship. That does not mean you have to treat them forever, you can certainly refer them on to an outpatient provider, but you have for sure established a doctor-patient relationship that can then be ended by referring them on.

I presume this detox is an inpatient or residential program? If so, you should look into local requirements for followup. Typically it is not considered acceptable to have a hospital inpatient leave with nothing more than a printout listing local resources (unless it is, for instance, a rapid AMA discharge). There is usually an expectation that you will help arrange adequate followup. In the ER the goal is to assess and stabilize an emergency condition, and finding a full aftercare program for each evaluation is not a realistic expectation.

This is helpful, particularly to residents who might not have this real world experience yet. In my clinic, our policies are such that we need to go through tons of hoops to sever a relationship with a patient - and this is only after they've not made appointments for a period of time.

In the above example let's say op starts a medication. Can the relationship be severed when they discharge and they refer them on to another provider? Does op have to ensure they have an appointment booked or is it reasonable to provide a list of providers with openings? I'm guessing if one fired a private practice patient they wouldn't have to physically call around and book an appointment for this patient, right?

 

[nexus73]

I think a one time visit still creates a doctor patient relationship for the services provided at that specific time. But if it’s made clear it will only be one visit and no meds or other treatments are ordered that should be the end of it. Form a med mail standpoint the doctor is still responsible for proper diagnosis and proper risk assessment. An obvious example is someone with imminent SI risk. You have to try to get them to a hospital or make a safe plan somehow. You can’t say there’s no doctor patient relationship there, even if it’s just one visit. I agree this should be in policy and patients sign a consent including this information.