Challenges of Private Practice: Working With Health Care Colleagues

The rewards of private psychiatric practice are many. As your own boss, you have the flexibility to determine when and how to practice, set policies in line with your values, and choose the patient population for whom to provide care. However, it also comes with significant practical and ethics challenges.

An immediate challenge involves working with colleagues from other disciplines such as social workers, psychologists, nurses, other therapists, and so on. If they are employees, the responsibility for oversight of the services they provide rests solely on the psychiatrist owner. That means that adequate time must be carved out to supervise the care provided in the practice. The mode of supervision can vary from regularly scheduled joint meetings to individual supervision for challenging cases or situations. The psychiatrist owner can be held liable or deemed to be practicing unethically when care provided by employed staff members falls below standard.

To avoid this liability, some psychiatrists hire mental health colleagues as independent contractors. In these arrangements, the psychiatrist owner should be alert to the danger of fee splitting, which is unethical. This occurs when a contracted staff member pays the psychiatrist a percentage of the revenue generated from his or her independent patient care activities. To avoid fee splitting, a psychiatrist can charge only a flat fee for the use of office space and set clear arrangements for payment of utilities.

The 2015 APA Commentary on Ethics in Practice (Topic 3.3.2) acknowledges the potential ethical tension in such collaborations “regarding the extent of responsibility of the psychiatrist for treatment decisions.” It recommends, “When collaboration occurs between independent practitioners (as in split psychotherapy/psychopharmacology treatment), psychiatrists should coordinate care with their colleagues and should be aware that they are assuming shared responsibility for the overall treatment but are still solely responsible for the medical aspects of treatment. The psychiatrist and the collaborating clinician must communicate to their common patient the unique roles of each.”

Collaborating with mental health colleagues outside of a psychiatrist’s private practice comes with a specific set of challenges. If the psychiatrist is providing only medication administration to a patient who is also receiving psychotherapy from a therapist in the community, adequate coordination of care requires the psychiatrist to speak with the therapist, not just once, but as often as necessary. Without such connection, the psychiatrist may be clueless about important issues that come up in therapy that could impact the care provided. Conversely, the therapist could make inappropriate medication recommendations that differ from the psychiatrist’s plan, thereby leaving the confused patient in the uncomfortable middle of a turf battle.

Having to communicate with other therapists is not easy and can be overwhelming for the psychiatrist who has the added burden of documentation requirements; medication approval calls; insurance company paperwork; consultation with pharmacy, family members, or colleagues; and so on. If not carefully managed, the psychiatrist’s mounting frustration could explode as anger toward patients or outbursts to their therapist colleagues, either of which would be unfortunate.

Challenges can also arise when working with nonpsychiatrist physicians. Coordinating care with patients who have an established relationship with a primary care physician (PCP) can be useful. However, it can also present difficulties. On occasion, a PCP or other specialist may order psychotropic medications that could complicate the psychiatrist’s treatment plan. Examples include prescriptions of zolpidem, trazodone, or a benzodiazepine for sleep as well as anti-epileptic or pain management medications. Unfortunately, it is not always easy to collaborate with these physicians—some physicians do not appreciate the seriousness of tinkering with a stable patient’s medications and believe that the patient’s medical care is paramount.

A psychiatrist prescribing medications that have the potential to cause monitorable side effects must be up to date on the indices to be monitored. The results of laboratory and other pertinent tests ordered by the PCP should be available for the psychiatrist’s review. The onus is on the psychiatrist to order necessary investigations that the PCP failed to order. As physicians, psychiatrists are expected to respond to abnormal results including alerting the patient’s PCP or medical specialist as necessary. Failure to do so could be considered unethical.

Another area of practice that deserves careful attention is working with a patient with a complicated psychiatric presentation or refractory illness. To enhance ethical practice, the psychiatrist should consult with a senior colleague or specialist with the patient’s or patient conservator’s permission and document the outcome of the consultation. Topic 3.3.1 of the APA commentary encourages psychiatrist to “carefully consider the need for consultation with colleagues and/or supervisors, especially when patients are not doing well. Professional competence entails recognizing the limits of one’s clinical skills. Consultation in the analysis of ethical dilemmas is also sound practice.”

Working with colleagues can be fruitful and mutually beneficial, but it can also be challenging, onerous, and exhausting, more so for psychiatrists in solo private practice. In addition to paying careful attention to the potential pitfalls described earlier, it is crucial that psychiatrists treat their colleagues with respect and dignity, even when there are major differences of opinion on how to improve a patient’s treatment. This is essential to strengthening our common goal of providing quality care for our patients, as adequate coordination of care is key. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also an associate professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.