Going outside your area of expertise: How far is too far?
Dear Dr. Mossman:
I am an adult psychiatrist practicing in a geographically isolated area. I am working with the family of 10-year-old “Bobby” who is struggling with attention problems. Top notch neuropsychologic testing recommends a stimulant trial, but the local pediatrician is too busy to give Bobby adequate follow-up and attention.
I am an experienced psychopharmacologist but have not prescribed medication to children since residency. My relationship with the family is excellent, and the local pediatrician said that she would supervise me. If I choose to treat Bobby, what are the possible liability issues I should be aware of, and how can I address them?—Submitted by “Dr. F”
Dr. F’s question raises issues that come up whenever patients need treatment for conditions outside the few with which you are highly familiar. Although you can’t be an expert on every aspect of every patient’s treatment, psychiatrists shouldn’t practice outside their area of competence.
Thus, the main liability-related issue that Dr. F should ask herself is, “Can I treat Bobby competently?” Of course, whenever you decide to treat any patient, you should be able to answer “yes” to this question. When thinking about potential liability related to treating Bobby, Dr. F might also ask, “If a lawsuit occurred, how would my treatment of Bobby appear?” This article discusses key issues that arise when general psychiatrists treat children and the steps general psychiatrists can take to show that they are practicing prudently.
Problem: Not enough clinicians
Child and adolescent psychiatrists (CAPs) are in short supply.1,2 In 2001 the United States had 8.67 CAPs per 100,000 youths and 1.6 CAPs for every 1,000 youths with severe mental disorders. 1 Studies suggest that the United States needs nearly twice that many CAPs.3 The shortage is especially severe in rural areas, but approximately one-half of metropolitan counties with populations of >250,000 have no CAPs.1 In much of the nation, finding CAPs who are accepting new patients is difficult, and child and adolescent psychiatric treatment often is delivered by pediatricians, family practitioners, psychiatric nurse practitioners, and general adult psychiatrists.
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Children’s special medical issues
General psychiatrists know that children aren’t just little adults. CAPs develop skills and thinking styles during their 2 years of subspecialty fellowship training that are quite different from those used by their general psychiatric colleagues.
Communication. Children and adolescents who need psychiatric care often have limited verbal abilities. Working and communicating with these patients requires a different interactive style.
Information sources. CAPs learn to seek and assimilate clinically important information from many settings—especially a child’s home—where their patients interact with others.
Caution. Only a small subset of psychotropic medications that adult psychiatrists prescribe are FDA-approved for use in children (Table 1).4 Because we don’t know how psychotropic drugs affect brain development, CAPs sometimes are leery of giving kids the same medications that adult psychiatrists readily prescribe.
FDA-approved drugs and dosages for ADHD in children and adults
Dosing forms (mg)
5, 7.5, 10, 12.5, 15, 20, 30
5 to 40 mg
3 to 18 years
5, 10, 15, 20, 25, 30
5 to 30 mg
3 years to adult
18, 27, 36, 54
18 to 72 mg
6 years to adult
10, 15, 20, 30 (patch)
10 to 30 mg
6 to 18 years
2.5, 5, 10
2.5 to 10 mg bid
6 to 17 years
5, 10, 15, 20
5 to 20 mg
6 years to adult
10, 20, 30, 50, 60
10 to 60 mg
6 to 18 years
5, 10, 20
5 to 20 mg bid or tid
6 to 18 years
10, 20, 30, 40
10 to 60 mg
6 to 18 years
10, 18, 25, 40, 60, 80, 100
10 to 100 mg
6 years to adult
ER stimulant (precursor)
30, 50, 70
30 to 70 mg
6 years to adult
LA: long acting; CD: controlled delivery; ER, XR: extended release; IR: immediate release; SNRI: selective norepinephrine reuptake inhibitor
Different drugs. Some medications commonly taken by children are not often prescribed for adults, although this is changing as attention-deficit/hyperactivity disorder (ADHD) is better recognized in adults.5,6
Dosages. Dosing psychotropics in adults is fairly standardized, but in children and adolescents dosages vary with age, body weight, and physical maturity.
Adverse effects. The side effects kids experience and the way they report them can differ markedly from adults and will vary with age and developmental maturity. Some issues related to monitoring children—such as appropriate cardiac screening before starting stimulants—are controversial and remain unsettled.7,8
Dr. F may be tempted to treat Bobby because of her preexisting, positive relationship with the child’s family and a laudable desire to help. But Dr. F needs to ask, “Is there really no other workable alternative for Bobby?” Some possibilities include:
- Refer Bobby to a CAP in another community for initiation of treatment. Dr. F or Bobby’s pediatrician might safely continue care once a CAP establishes an effective treatment regimen.
- Find another pediatrician who might have more time to provide the follow-up that Dr. F feels is necessary.
- Decline to treat Bobby. Before doing this, Dr. F should consider what effect this refusal might have on her relationship with the family and the consequences for Bobby if his problems go untreated.
- Consult a CAP from another community, describing the situation and clinical factors in detail without naming or identifying the patient, and then ask, “Is this really the best thing to do?”
From a liability standpoint, this last point may be crucial. If the CAP answers “yes,” Dr. F can document the alternatives she has considered and her consultation and discussion with the CAP colleague as evidence of prudent practice. Dr. F can also document any advice that she has received and her plans to follow it.
If you choose to treat
Presumably, Dr. F would not perform thoracic surgery or provide any treatment that is far outside a general psychiatrist’s competence except under the most dire circumstances. General psychiatrists receive child psychiatry training during residency, and treating children is within their scope of practice. Similarly, most elderly patients are treated by general psychiatrists, rather than graduates of geropsychiatry fellowships. Prescribing medication for Bobby is not grossly different from Dr. F’s other duties, and she might provide services that a pediatrician might not.
Ask yourself 4 questions to determine if you are competent to provide medical treatment outside your usual area of expertise (Table 2). In Bobby’s case, Dr. F can consider these additional questions:
- Am I comfortable doing this? Would I be comfortable with this scenario if Bobby were my child?
- How extensive was my general residency training in child psychiatry?
- How long ago was my last CAP experience?
- Have I treated ADHD in adults, and am I familiar with stimulant medications?
- What kind of supervision could I arrange, such as regular phone consultation with a CAP or pediatrician?
- How helpful are other information sources, such as recent texts, journals, and medical Web sites?
- What is my relationship with the family, and how would treating Bobby affect it?
Should you provide treatment? 4 questions to ask yourself
How sure am I that I know what I don’t know?
How will I know when I should ask for help?
Do I have colleagues readily available for consultation if I need help?
Do I have a good track record for seeking consultation when I need it?
Advantages and benefits
So far, we’ve emphasized cautions, but Dr. F also should remember that she may offer patients services that general psychiatrists provide but that pediatricians might not do routinely. Among the possibilities:
- Performing a diagnostic assessment that incorporates biopsychosocial factors.
- Taking time to foster a strong doctor-patient relationship with the family.
- Reserving time for medication-related psychoeducation.
- Scheduling longer visits to discuss a child’s psychiatric problems and explore solutions.
- Utilizing knowledge of and existing relationships with nonphysician therapists who could provide additional psychotherapy.
1. Thomas CR, Holzer CE, III. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry 2006;45:1023-31.
2. U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: National Institute of Mental Health; 1999. Available at: http://www.surgeongeneral.gov/library/mentalhealth/home.html. Accessed August 20, 2008.
3. Levin A. Rural counties suffer from child psychiatry shortage. Psychiatr News 2006;42(14):4-41.
4. National Institute of Mental Health. Treatment of children with mental disorders. 2004. Available at: http://www.nimh.nih.gov/publicat/childqa.cfm. Accessed August 2, 2008.
5. Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annu Rev Med 2002;53:113-31.
6. Greenhill LL, Pliszka S, Dulcan MK, et al. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41(2 suppl):26S-49S.
7. Perrin JM, Friedman RA, Knilans TK. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics 2008;122:451-3.
8. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder: A scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 2008;117:2407-23.