By Bruce Hershfield, MD
[Winter 2006; Vol. 32, No. 2; Pg 8]
I was covering for a colleague who was out of the country and I told one of his patients that I would not renew her prescription for a benzodiazepine without at least briefly meeting her. I explained that I’ve had this policy for many years. She was not pleased. “Does Dr. X know that that’s your policy?” she asked me.
How much treatment IS enough to fulfill my obligations to my colleagues and their patients and my profession?
Because I don’t know of any formal guidelines to follow when I’m covering for other psychiatrists, I’ve tried to make up my own. I would like to hear from others. We do need to help our colleagues who are away (sometimes, suddenly), while protecting ourselves from criticism (or worse).
One common situation arises when a pharmacist asks me to renew a prescription. I always ask to speak with that patient on the phone. If the prescription is not for a controlled substance, I’m willing to renew it if the patient says that there are no side effects. However, I’m only willing to renew it until around the time that the doctor returns–-never for “90 days” even if that’s what the “pharmacy plan” calls for. I write a note for my own records, but I don’t feel comfortable writing to the doctor for whom I’m covering unless I at least get verbal authorization to do that. Frequently, it IS for a controlled substance; in that case, I tell the patients that it’s necessary to meet with me for a brief session. If they’re not willing to do that, I suggest they call their family physician. I am concerned that they are not legitimately patients of the doctor who is away and that somehow they have heard that he or she is out of town.
But when I do see them, what should I charge for a brief evaluation, since it rarely lasts for more than 15 or 20 minutes? I’ve decided not to charge for it at all, since it’s easier that way. The brief visit is not long enough for me to get answers to the questions required for a routine evaluation, so I can’t use that code. I don’t feel comfortable charging for a follow-up visit without having done an initial evaluation. Furthermore, it’s hard for the patients to get reimbursed, since I am not credentialed by the managed care companies that handle their bills. Charging a different fee than the patient’s treating psychiatrist can also lead to problems. When I see the patient I get an authorization to send a copy of the note or a brief letter to the doctor for whom I’m covering.
Sometimes it is hard to make a decision without having access to the treating psychiatrist’s records–including lab results. A few minutes of phone conversation can help me find out if the patients are having any side effects, but that’s not the same as knowing if their serum lithium is in a dangerous range. Access to electronic records could eventually help solve this problem.
Suicidal threats occasionally arise. I think that offering to see the patient, plus making it clear that I am available by phone until the psychiatrist returns, is usually sufficient. If it looks like that is not enough, it is probably better to recommend a visit to the emergency room, where a thorough evaluation can be done.
I think that it is a good idea to ask a colleague who is going away to send a pre-vacation note about any anticipated problems.
I am concerned about the potential
liability that I incur when I take responsibility for treating a person I‘ve
never met. Although I’ve never heard of any psychiatrist getting in
trouble because of covering for another, it’s easy to imagine it happening. I
think that it’s wise to take the time to evaluate the situation–-at least,
by talking to the patient on the phone–-and to document what we do and why we
decided to do it.