Thursday, January 04, 2007

Coverage & Standards of Care: by Guest Blogger CoveringDoc

First you need to read my post from yesterday: Covering Your...
So, CoveringDoc sent me his comments by way of the back door. They felt important enough to be a stand alone post, and so, with permission:

I guess that you succumbed to the temptation to tell the psychiatrist who insisted on seeing your patient that he could read about it on the blog.
It only applies for controlled substances. I think that it would be a res ipsa loquitor--"the facts speak for themselves"-- case of negligence if something went wrong and a controlled substance was involved and the prescribing physician hadn't ever set eyes on the patient. I'd rather be obsessive than negligent, if I have to choose.
The code of ethics for the AMA, with special annotations for psychiatrists, says that psychiatrists should be available to their patients for emergencies. This has been interpreted to mean WITHIN 30 MINUTES. So, I'd either make myself available in the middle of the night or not mention that I didn't have such an arrangement. (You can guess which one I decided to do.) It was when I read of that decision that I started carrying a beeper around.
I have never understood why the APA doesn't make that booklet available to all of its members, on a regular basis, or at least have frequent articles about it in the Psychiatric News.

The 30 minute interpretation was made by the Ethics Committee of the APA; it's listed in a compendium of its decisions.
I knew a psychiatrist who had his license suspended because he prescribed an analgesic for a patent.(He did it more than once, even after someone warned him.) He was a good psychiatrist , in my opinion. As a result of losing his license, he also lost his administrative job.

I've had 20 more years than you have had to hear these stories and to worry. I'm getting better(at worrying) than I used to be.
I still think that the APA and/or the MPS should tell its members more frequently what the standard of care is, particularly if it changes. The only time I''ve studied this subject since I left my training in 1974 was when I was preparing to take the Administrative Psychiatry Boards in 1986.

So thanks, CoveringDoc . Just to be clear on my last post: Every patient I see is given a written statement of how to contact me, it includes my cell phone number and my home number with instructions to call my home number if an emergency occurs during the night. I check my messages between sessions, and while I don't generally answer the phone if I'm not somewhere I can talk privately, I generally do listen to every voicemail message to be sure it's not an emergency, but I may not return non-emergent phone calls for a few hours. I generally return all my calls the same day and no one has ever complained about my lack of responsiveness or unavailability. Still not a beeper or a cell phone that rings during sessions, so I am not instantly available always.

The 30 minute standard is one I've never heard before, and one I think few physicians could uphold on an absolute basis. What if the psychiatrist has thick hair (with lots of chemicals) that takes a long time to blow dry and a cell phone or beeper can't be heard over the sound of the dryer? What if the psychiatrist gets constipated? Likes long showers? Is somewhere cellular coverage can't reach?

I'm also left, still, with the question of What's An Emergency? While we'd all agree that the guy about to jump from the bridge is an emergency, what about the distressed patient in the midst of a panic attack? My personal favorite: repeated emergency calls from a patient the Sunday I was returning from vacation-- yes, I had coverage, but she wanted me--- she realized her insurance was going to expire in a few weeks and she'd have to pay for her own benzodiazepines.

Finally, I'm left with the thought that many psychiatrists I know do cover for themselves by checking their messages-- if I go on vacation, am I responsible to insist that the covering doc promise me he'll be available around the clock and within 30 minutes to any patient of mine having an emergency?

To the patients out there reading this blog, can I ask a favor? If you have an emergency, if your shrink is away and you need to talk to the covering psychiatrist, please, please, and I can't say this loudly enough: Leave a Phone Number where you can be reached!