1. If you hold licenses in more than one state, have you familiarized yourself with all regulations regarding the practice of medicine (including CME and reporting requirements) in each state?

Licensees are expected to be familiar with - and abide by – laws and regulations regarding the practice of medicine within states where they treat patients. Individual states may have very different rules regarding such things as documentation of medical records, record retention, informed consent, reporting requirements, CME requirements, and termination of treatment - just to name a few. Failure to abide by these various requirements may make you the subject of a licensing board action, and ignorance of the rules will not be a defense.

2. Do you regularly look at your list of patients to see whether any patients have fallen out of treatment and do you contact those patients to determine whether they plan to continue with treatment?

No one wants to receive the call from the patient in crisis who hasn’t been seen in a year but whose file is still active.  Reach out to patients who have fallen out of treatment and let them know that you will be closing their file unless they contact you to set up an appointment within a specified period of time.  If you have open files on patients whom you are not following, you could find yourself being accused of negligence for failure to appropriately monitor your patient should harm befall them. Click here for our article on termination, including model letters.  

3. If working part-time in a clinic or other facility, do you ensure that you have a written agreement in place that not only outlines your duties during the term of the contract but sets forth the duties and obligations of each party once the contract has been terminated?

Many psychiatrists take jobs as independent contractors at clinics and other facilities as a means to supplement their regular income. Even though you may be spending just a few hours a week in these positions you must still approach them as you would a full-time job when it comes to understanding your duties and obligations.  Insist that there be a written agreement so that these terms are clear to all parties.  Of particular importance will be how much notice you must give prior to terminating your agreement, whose duty it will be to notify patients and provide for their care upon your departure, and who will maintain possession of patient records and how you will be able to access them in needed in the future, such as to defend an action brought against you. 

4. If you receive a request for records from someone who claims to hold a Power of Attorney on your patient, do you ask to review the document before providing them with any information?

Commonly POAs are created to allow someone to assist with another’s business and financial affairs and often have absolutely nothing to do with making medical decisions or accessing treatment information. If someone claiming to hold a Power of Attorney requests medical information regarding one of your patients, insist on seeing a copy of the document and reviewing it to determine whether it grants the authority to request information and whether it has taken effect or is contingent upon a future event such as your patient’s incapacity.   

5. If you are seeing a patient in a split treatment relationship, are you acquainted with the patient’s therapist and is there regular communication between the two of you regarding the patient’s status?

Split treatment works best when two professionals work together as opposed to operating in silos.  Your patient likely sees their therapist much more frequently than they do you, thus the therapist can be invaluable in making you aware of such things as effects of medication or an increase in the patient’s risk level.  Because physicians are thought to have greater knowledge (and thus a greater duty to patients) you should also recognize that engaging in a split-treatment relationship with a therapist whose skills you are not comfortable with may cause you to be drawn into any lawsuit stemming from their care of your mutual patient.  Click here for our article on split treatment and suicidal patients. 

6. If you are contemplating changes to your practice – such as branching out into new treatment methods or expanding your services – have you contacted your malpractice carrier to ensure that you will have coverage for these activities?

Do not presume that just because you see other psychiatrists engaging in different types of treatment and activities that it is accepted as standard practice and will automatically be covered by your malpractice policy. Particularly if new treatment modalities are not yet mainstream, carriers may place limitations upon your coverage or elect not to cover you for them at all.  The same may be true of non-medical activities such as coaching; your carrier may decide that these do not fall under the practice of psychiatry and thus you may not be insured for these activities.  Always check with your carrier when contemplating expanding your services.

7. Have you developed a contingency plan to allow someone to either take over your practice during your unexpected absence or shut it down completely in the event you were not able to return?

We frequently receive calls from family members, office staff, or even estate attorneys trying to figure out how to close down a practice and find care for patients following a psychiatrist’s death or sudden incapacity. It’s a tragic situation made more so by the fact that the psychiatrist oftentimes has not provided any instructions, thus leaving it to the office staff or family members (who are dealing with their own worry and grief) to try to figure out what the psychiatrist would have wanted and how best to manage patients.  Plan now to ensure such a situation doesn’t happen to your staff, family, and patients. Think of it as an “advance directive” for your medical practice and let someone—be it your spouse, office manager, or another physician covering for you—know of its existence and where to find it. Click here for our article and here for our contingency plan template. 

8. When patients let you know of their intent to move out of the state(s) in which you hold a license, do you make them aware of the need to terminate treatment and close their files?

Especially with the rise in the use of treatment via telepsychiatry, patients may not understand that you cannot treat them wherever they may be located. If a patient is moving out the area and you are not able to continue the treatment relationship, you should make it clear to your patient that the relationship will end once they leave the area.  You do not want to find yourself in the situation where a patient calls you in crisis from across the country and you have the dilemma of having to choose between practicing illegally and ignoring a patient in need.

9. Do you tell patients that their first visit is an evaluation only after which you will both decide whether a treatment relationship should be established?

Particularly because patients may have to wait several days or weeks before their first appointment, it is important they understand you will not necessarily be accepting them as patients and that treatment will not begin until you have determined you can help the patient and there is at least an initial agreement as to the treatment plan. If this is made clear and it turns out a prospective patient is not a good fit for your practice, then you have no further obligation to that individual.  If, on the other hand, the prospective patient believes treatment will start at the first appointment and thus foregoes the opportunity to begin treatment with someone else, you may be forced to provide care until you can formally terminate the treatment relationship.

10. If you are approached by a patient or their attorney and asked to write a letter on their behalf in conjunction with any type of legal matter, do you contact your malpractice carrier to discuss this first?

Psychiatrists are quite frequently asked to write letters to support patients in legal matters.  In attempting to help a patient by honoring what appears to be a simple request, a psychiatrist may find that they have inadvertently taken on a dual role acting as both a treating and forensic psychiatrist. This may then have a negative impact upon the treatment relationship if the patient’s legal goals are not achieved or if the psychiatrist finds him or herself spending great quantities of time preparing documents or speaking to attorneys in addition to rendering care.  Other requests may expose the psychiatrist to liability risk such as when asked to attest to the patient’s safety to own a gun.  Before agreeing to your patients’ requests for letters, reports, testimony, etc., always discuss it with your carrier first.  Click here for our article on dual roles.