Splitting treatment: How to limit liability risk when you share a patient’s care
Check them out. Before agreeing to split care, find out if the potential collaborator is credentialed, and respectfully inquire about his or her training and clinical approaches.8 Because unlicensed or uncredentialed therapists might not be held to the same practice standards as physicians and often have little or no malpractice insurance, psychiatrists who work with them may be assuming most of the clinical and legal liability.9 If a court is looking for a way to compensate an injured patient, it may hold the psychiatrist accountable for not knowing the therapist’s qualifications, failing to supervise the therapist, or failing to inform the patient of the therapist’s lack of qualifications.7,10
Establish the collaboration. Psychiatrists have a duty to ensure that their patients receive good care. Split treatment can help patients—who get 2 pairs of eyes monitoring them, plus 2 clinicians’ combined areas of skill—if the clinicians work together satisfactorily. Some psychiatrists recommend using initial consultation forms8 or contracts to spell out mutual expectations and establish important components of the relationship (Table 2).11,12 Other psychiatrists are comfortable with brief discussions with potential collaborators that cover:
- how the clinicians will divide treatment responsibilities
- circumstances when they will communicate
- patient coverage during each other’s vacations
- availability to patients during crises
- types of problems that would prompt the patient to contact the psychiatrist or therapist first.
Table 2
7 C’s of effective collaborative treatment
| Clarity about the relationship (collaborative, supervisory) and what each provider will do |
| Contract. A written agreement about duties and roles may help to dispel an assumption that the psychiatrist had supervisory responsibilities |
| Communication that occurs routinely between caregivers, even when treatment is going well |
| Consent by the patient, which requires that the patient knows, understands, and accepts each provider’s role |
| Comprehensive review of what’s happened in therapy, especially if the psychiatrist sees the patient infrequently |
| Credentialing. If the parties don’t know each other well, they should check out each other’s background |
| Consultation. Seek when problems arise in treatment or with the above arrangements |
| Source: References 11,12 |
Be sure to document these discussions as well as written consent for initial and ongoing communication in the patient’s medical record. Major treatment advances or setbacks, nonadherence, or termination of treatment by/with one clinician should prompt contact with the other clinician. Collaborating clinicians should communicate regularly even when treatment is going well, not only when big changes occur.8
Back to Dr. B
What should you do if a patient seeks pharmacotherapy and the therapist hasn’t contacted you? First, you probably should speak with your patient about the absence of interclinician communication, explain that it is important, and get the patient’s written permission to initiate contact. After contacting the therapist, you will be in a better position to determine how often you should see the patient and how often you need to share information with the therapist.
If you are uncomfortable sharing care with some or all nonphysician therapists, tell your patients. You might refer prospective patients to psychotherapists with whom you’re comfortable providing collaborative care or to other psychiatrists who accept split relationships.
Ideally, get patients’ written consent to share confidential information before you agree to participate in a shared treatment relationship. If patients refuse, you will not have access to all treatment information. This may adversely affect the quality of care and increase your liability risk.
In some cases, your discomfort with a split-treatment situation may make you decide to decline or terminate the treatment relationship. This is permissible if you give the patient proper notice, suggest other psychiatrists who might see the patient, and remain available for urgent matters for a reasonable time—usually 30 to 60 days—to allow the patient to contact another psychiatrist.10 When you discuss potential providers, explain that you don’t know these clinicians (if that’s the case) or whether they will agree to treat the patient.12
