Phone management pitfalls
Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.6 APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.
The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:
- Telephone assessments tend to be rushed and not as systematic as an office evaluation.
- Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.7 In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.8
Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.
In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.
Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.
Telephone protocol for your practice
Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.
Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.
During the phone call, have the patient repeat any instructions you give.9 This will minimize the risk for error.5
Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.2
Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:
- the date and time of the call
- the patient’s name
- the chief complaint and his or her disposition
- your assessment and any advice given
- necessary follow-up action
- requests for prescription refills
- and any symptoms that indicate that the patient should call back.7
How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.
Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.
Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.
Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.6
Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.2