In meetings before and after Cedar Brook officially opened, the five of us worked on a set of principles to serve as a more formal ethical and operative foundation to our collaborative practice. Among these principles, which have served as an informal partnership agreement, are these:
- The associates of Cedar Brook agree to adhere to the ethical and clinical standards of their individual professional organizations.
- If Cedar Brook, as a collection of its partners, decides to enter into contracts as a single entity ("Cedar Brook"), then this decision must be unanimous, and all revenues will be dispersed back to the partners (that is, Cedar Brook itself would keep no money.)
- Associates who wish to leave Cedar Brook shall not be restrained from doing so. Cedar Brook will not put any conditions--competitive or otherwise--on associates who wish to leaveAssociateswill place no restrictions on any clinician in regards to taking clients and patients with them upon leaving Cedar Brook Associates.
How has my practice changed as a result of being a member of a merged multidisciplinary group? The biggest clinical change is that the various roles I have played as psychiatrist within the clinical mental health community of Burlington are now more consolidated among people with whom I have a close, daily working relationship. Nearly 20 years ago, the American Psychiatric Association delineated three types of clinical relationships that psychiatrists typically enter into with other, nonmedical, practitioners. In consultative relationships, the psychiatrist offers clinical advice and opinion without assuming direct care of the patient. In collaborative relationships, the psychiatrist assumes the medical role in a patient's care--i.e., making or verifying initial diagnosis, prescribing and monitoring appropriate medication and keeping an eye on general medical status--while psychotherapy treatment is provided by someone else independently. In supervisory relationships, the psychiatrist directly assesses and helps guide the work and goals of the therapist.
Before Cedar Brook, I had consultative and collaborative relationships with about a dozen therapists in the area, none of whom worked in my building and some of whom I barely knew before their initial call for help. Now, most of my case-sharing is with my Cedar Brook partners. This arrangement creates ample opportunity to keep each other updated and informed, and it also has allowed me to develop a truer, more complete sense of how the clinicians with whom I share cases function and think. I feel the liability risk to me in case sharing is lessened. As a final and vital benefit, of course, this closer collaboration is a better arrangement for the patients as well, as they feel more reassured about the working relationships between the clinicians in their care.
As the psychiatrist in a mixed group practice, I agreed to assume supervisory responsibility for Medicaid and Medicare billing for three of my colleagues, and with each of them I have a different supervision arrangement. I decided not to accept money for my supervision time, nor for signing off on their bills, because I felt that could have undermined the nonhierarchical environment that Cedar Brook was attempting to foster. I chose to believe that overall we would end up being mutually supervisory. Besides, the occasional appointments I had with my colleagues' Medicaid and Medicare patients filled in gaps in my weekly schedule that might otherwise have gone unfilled, creating an indirect financial benefit.