February 3, 2009
Psychiatric Times.
No. 2
Practice Management
Practice Management: Managing Risks When Practicing in Three-Party Care Settings
Helping Your Patients While Minimizing Your Risks
Robindra K. Paul, MD, DPH, MBA, Christopher Lockey, MD, Ryan C. W. Hall, MD, and Harold J. Bursztajn, MD
Dr Paul is a forensic psychiatrist in practice in San Diego. He is board-certified in psychiatry. He completed a fellowship in forensic psychiatry at Case Western Reserve University and is a past GlaxoSmithKline and Rappeport Fellow.
Dr Lockey is assistant professor of psychiatry at Oregon Health and Science University in Portland. He completed a fellowship in forensic psychiatry at Case Western Reserve University.
Dr Hall is an affiliated instructor of psychiatry at the University of South Florida and a past Rappeport Fellow of the American Academy of Psychiatry and the Law.
Dr Bursztajn is cofounder of the Program in Psychiatry and the Law at Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, Boston. He has an active clinical and forensic neuropsychiatric practice. He has been a consulting and testifying expert for attorneys representing physicians, patients, and third-party organizations, and he is a consultant for independent peer-review organizations. He is a recipient of the Clifford A. Barger Excellence in Mentoring Award from Harvard Medical School.
Summary
In third-party, resource-administered, time-limited environments it is vital to be mindful of fundamental principles, particularly in the midst of the stress of decision making under conditions of uncertainty.7 This includes recognizing that clinical decision making in real time contains elements of uncertainty, and thus shared responsibility expressed as a respect for patients’ autonomy is crucial. When clinical time or resources are limited, it is vital to distinguish between patients who want to take responsibility and pseudopatients who are not interested in treatment by reason of character or motive. The psychiatrist who respects a patient’s autonomy is in the best position to provide wise, effective, nondefensive clinical care while also being able to manage the risks for the practice in resource-constrained third-party treatment environments.
References
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Evidence-Based References
Bursztajn HJ, Paul RK, Reiss DM, Hamm RM. Forensic psychiatric evaluation of workers’ compensation claims in a managed-care context. J Am Acad Psychiatry Law. 2003;31:117-119. http://www.jaapl.org/ cgi/reprint/31/1/117.pdf. January 22, 2009.
Perlin ML, Bursztajn H, Gledhill K, Szeli E. UNESCO Chair in Bioethics. Psychiatric ethics and the rights of persons with mental disabilities in institutions and the community. 2008. http://medlaw.haifa.ac.il/index/ main/4/psychethicsperlin.pdf. Accessed January 22, 2009.
