Since most psychiatrists will add a forensic psychiatric practice to a treatment practice, they should analyze carefully how to balance the two endeavors. It is critical to maintain dynamic stability in both practices as they develop in a parallel fashion. Many well-honed clinical skills will apply directly to the practice of forensic psychiatry. Nevertheless, certain business tactics can enhance the incorporation of a forensic practice into a treatment practice.
Customer orientation. Forensic psychiatrists should maintain a customer orientation that may differ from that of their clinical practice. In forensic psychiatric practice, one has clients rather than patients; therefore, the complex interactions and communications necessary in forensic psychiatry best lend themselves to having someone available to answer calls and provide information to potential clients rather than using answering services or telephone voicemail systems. Loss of business in a forensic psychiatric practice can be substantial as a result of using voicemail or other mechanical or electronic answering systems. The individual who answers the phone for the forensic psychiatrist should be trained to provide as much information as possible to the caller or prospective client. This enhancement of information transfer can be improved by the use of Web sites for the benefit of the prospective client. In forensic psychiatric practice, most juries are highly familiar with Web sites and will not find this to be an unusual practice.
Evidence-based models. Evidence-based medical models are becoming increasingly utilized in the practice of psychiatry. Forensic psychiatrists should adhere to DSM diagnostic categories and evidence-based medical models. Use of idiosyncratic diagnoses or failure to provide scientific evidence to support conclusions may render testimony inadmissible under the legal criteria that govern the admissibility of expert evidence (Daubert v Merrell Dow Pharmaceuticals, Inc., 1993). In addition, mental evaluations should be standardized and based on acceptable mental measurements. While the face-to-face mental status examination is required within the psychiatric examination, triers of fact usually assume that a portion of certain types of forensic examinations will be quantified. Therefore, the forensic psychiatrist should develop a relationship with a psychologist who can provide measurements of:
- Reading skill
- Intellectual capacity
- Neuropsychological assessment
Laboratory tests. The use of structural and functional brain imaging and appropriate laboratory tests should be included in the examination when appropriate. If the psychiatrist does not perform neurological examinations when evaluating claims of cognitive disorders or brain injury, this should be provided by other practitioners.
Technology. A successful forensic psychiatry practice depends upon judicious use of efficient and productive technology. Use of word processing technology, dictation services, templates and computer scheduling can increase efficiency and reduce time demands. Conducting weekly staff meetings, wherein cases are discussed and examination strategies completed before the examinee arrives, can enhance productivity further.
Financial affairs. The success or failure of a forensic psychiatry practice often revolves around fee issues. Financial arrangements between treatment and forensic psychiatry differ markedly. In forensic psychiatric practice, psychiatrists should have clear, written contracts with their clients; this prevents professional or ethical lapses. Obtaining a retainer fee prior to examination is advisable, ethical and customary in forensic psychiatry. Prepayment of the fee prior to the examination ensures that no perception of contingency fee arrangements exists, and it facilitates honesty and objectivity in the examination process. Acceptance by the client of the retainer fee seals the contractual arrangement and thus allows the psychiatrist unlimited objective latitude within the course of the examination. This will become particularly important when the psychiatrist's opinion is not helpful to the client or entity who retained the psychiatrist's services.
Communication. Communication skills can make or break a developing forensic psychiatry practice. Psychiatrists practicing in forensic arenas who cannot communicate effectively by oral and written methods are at a distinct disadvantage. Regardless of one's academic credentials and clinical skills, an inability to communicate effectively will reduce the likelihood of further forensic referrals. The role of the forensic psychiatrist is to educate the trier of fact. Testimony is a method of teaching and providing information to those who must make decisions about the legal matters at hand. Forensic psychiatrists should strive to teach clearly their opinions; plain language should be used at all times.
The quality of written reports is fundamental to a successful forensic psychiatry practice. In many instances, the report may stand on its own merits and a case may be settled without requiring the psychiatrist's oral testimony. Reports that are poorly written, digress, contain poor logic and do not answer specifically the retaining party's questions will reduce the effectiveness and success of the practice.
Clinical skills. Lastly, lack of clinical skills may severely limit practice opportunities for a novice forensic psychiatrist. The clinical practice of psychiatry on a daily basis--while also practicing forensic psychiatry--has a twofold purpose: 1) It maintains the forensic psychiatrist's clinical skills at a high level and assists in the maintenance and development of current information in clinical psychiatry; and 2) Triers of fact are often suspicious of psychiatrists testifying as an expert if they do not actively treat patients. In some jurisdictions, this can limit the type of referrals psychiatrists receive in a forensic practice, as they may require that at least 50% of practice time be devoted to treatment and medical consultation before the psychiatrist can testify in a medical malpractice action or other types of legal actions. The most effective forensic psychiatrists maintain psychiatric and medical skills at the highest level possible (Granacher, 2004). Table 2 provides practice guidelines that, if followed, should considerably enhance the ability of a treatment psychiatrist to establish and maintain a forensic psychiatric practice.Summary
The practice of forensic psychiatry is an intellectually challenging and extremely gratifying experience for most psychiatrists. Marketing and advertising are not needed, as every report generated by the psychiatrist, every testimony provided by the psychiatrist and every interaction with prospective clients produces an effect that markets the psychiatrist's forensic skills in an ethical and professionally acceptable manner. The most critical factors for success in forensic arenas are the psychiatrist's clinical skills and integrity.