Going outside your area of expertise: How far is too far?

Dosages. Dosing psychotropics in adults is fairly standardized, but in children and adolescents dosages vary with age, body weight, and physical maturity.

Adverse effects. The side effects kids experience and the way they report them can differ markedly from adults and will vary with age and developmental maturity. Some issues related to monitoring children—such as appropriate cardiac screening before starting stimulants—are controversial and remain unsettled.^7,8

Consider alternatives

Dr. F may be tempted to treat Bobby because of her preexisting, positive relationship with the child’s family and a laudable desire to help. But Dr. F needs to ask, “Is there really no other workable alternative for Bobby?” Some possibilities include:

• Refer Bobby to a CAP in another community for initiation of treatment. Dr. F or Bobby’s pediatrician might safely continue care once a CAP establishes an effective treatment regimen.
• Find another pediatrician who might have more time to provide the follow-up that Dr. F feels is necessary.
• Decline to treat Bobby. Before doing this, Dr. F should consider what effect this refusal might have on her relationship with the family and the consequences for Bobby if his problems go untreated.
• Consult a CAP from another community, describing the situation and clinical factors in detail without naming or identifying the patient, and then ask, “Is this really the best thing to do?”

From a liability standpoint, this last point may be crucial. If the CAP answers “yes,” Dr. F can document the alternatives she has considered and her consultation and discussion with the CAP colleague as evidence of prudent practice. Dr. F can also document any advice that she has received and her plans to follow it.

If you choose to treat

Presumably, Dr. F would not perform thoracic surgery or provide any treatment that is far outside a general psychiatrist’s competence except under the most dire circumstances. General psychiatrists receive child psychiatry training during residency, and treating children is within their scope of practice. Similarly, most elderly patients are treated by general psychiatrists, rather than graduates of geropsychiatry fellowships. Prescribing medication for Bobby is not grossly different from Dr. F’s other duties, and she might provide services that a pediatrician might not.

Ask yourself 4 questions to determine if you are competent to provide medical treatment outside your usual area of expertise (Table 2). In Bobby’s case, Dr. F can consider these additional questions:

• Am I comfortable doing this? Would I be comfortable with this scenario if Bobby were my child?
• How extensive was my general residency training in child psychiatry?
• How long ago was my last CAP experience?
• Have I treated ADHD in adults, and am I familiar with stimulant medications?
• What kind of supervision could I arrange, such as regular phone consultation with a CAP or pediatrician?
• How helpful are other information sources, such as recent texts, journals, and medical Web sites?
• What is my relationship with the family, and how would treating Bobby affect it?

Table 2

Should you provide treatment? 4 questions to ask yourself

Advantages and benefits

So far, we’ve emphasized cautions, but Dr. F also should remember that she may offer patients services that general psychiatrists provide but that pediatricians might not do routinely. Among the possibilities:

• Performing a diagnostic assessment that incorporates biopsychosocial factors.
• Taking time to foster a strong doctor-patient relationship with the family.
• Reserving time for medication-related psychoeducation.
• Scheduling longer visits to discuss a child’s psychiatric problems and explore solutions.
• Utilizing knowledge of and existing relationships with nonphysician therapists who could provide additional psychotherapy.