Lee H. Haller, M.D.

Here is a question for you: for whom do you work? “That’s an easy one,” you say. “I work for myself” (if you are in private practice), or “I work for XYZ company” (if you are employed by someone else). Here is question number two: as a physician aren’t you supposed to be working for your patient? Obviously, the answer to this question is “yes” as well. So what happens when the two interests collide? For example, suppose you are performing an evaluation of a child when, towards the end of the session, the child voices suicidal ideation. What do you do? Example number two: you are doing a medication management session with a child while someone else is doing the psychotherapy. You have scheduled a fifteen minute appointment for checking progress on medication. However, a problem arises that cannot be managed within that time frame. You do not have another patient waiting, but you have authorization from the insurance company for payment only for medication checks. How do you proceed?

In both of these incidents, as in every case you evaluate, your first duty is to the patient. This is true because you are a physician and, as such, your ethical duty to treat your patient must supersede your own personal needs. Therefore, you must determine what action to take based on that premise. To do otherwise leaves you open to charges of an ethics violation and/or a medical malpractice charge.

I am not implying that you must give more time to any given patient at that immediate time. Such may not be clinically necessary nor even what is in the patient’s best interest. For example, in case one above, the suicidal threat may have been uttered for a reason other than true suicidality and, as such, represents an acting out of conflict or transference. What is required of you is that you assess the patient for safety before ending the session. If a critical or urgent situation exists, it is incumbent upon you to take the appropriate steps to remediate the problem. If the patient requires immediate attention because of imminent suicidality, your duty is to act to obviate such. This may require spending more time with the patient and/or parent in order to further asses the situation and initiate a course of action.

If you are going to keep other patients waiting by taking this action, it is also incumbent on you to make sure that they can wait that day, be rescheduled, or referred to another provider. In other words, appropriate arrangements need to be made for their care as well.

In case number two, if you are concerned about being paid for your time, which is reasonable, you can have your secretary or administrative assistant place a call to the insurance company.

Once you have a reviewer on the line, you can explain what is taking place and request to get authorization for payment for a more comprehensive visit. If the individual representing the insurance company refuses further payment, however, you are not relieved of your duty to see that the patient gets care. However, once the patient is out of acute danger, you can then decide whether to withdraw from providing care. You are not obligated to continue to provide uncompensated care. However, you are obligated to see that the patient gets cared for acutely, as well as to remain available for a reasonable period of time until the patient can make other arrangements for psychiatric follow up.

These are but two examples of many that will arise in your practice. You, as a child and adolescent psychiatrist, will be confronted frequently with having to make decisions about options for care. It is important that you first keep in mind the best interest of the patient. It is also important that you keep in mind your own physical limitations and ethics. For example, if an employer wants you to do eight hours per day of only fifteen minute medication checks, you may decide this is beyond your ability to practice in a concentrated fashion. You also may wish to reassess whether you want to work for that individual or company. Not all patients can be handled in fifteen minutes.

Thinking of the patient first, but also adhering to what you believe is clinically and ethically correct, should lead you down the path of providing carefully considered quality psychiatric care.