I thought I would start the new year out with a post that looks at the factual basis of physician accountability and satisfaction with care provided by psychiatrists. Apart from the usual irrational and conflict of interest derived criticism of psychiatry – there appears to be a significant number of people promulgating the myth that there are many people with complaints about psychiatrists. One of them suggested that the numbers were in the millions. That number sounds large, but if there are roughly 40,000 psychiatrists treating 1,000 patients a year that is 40M people. I did ask for that reference but there apparently was none.
I have written about this issue many times on this
blog. My position could not be clearer,
but to restate it – I have no doubt that problems arise during clinical care in
medicine that result in suboptimal care, dissatisfied patients, and in the
extreme angry, offended, concerned, or injured patients. I do not think that happens more often in
psychiatry than any other specialty and have recorded a few examples of my
experience with specialty care that was clearly suboptimal. I do not think that complaining about these
incidents in social media, suggesting that all psychiatrists learn from
isolated incidents that they were not involved in, or criticizing the entire
field based on these anecdotes is either productive or useful. What is useful
is presenting these problems as soon as they occur to the various entities
charged with monitoring physician professional standards, behavior, and
qualifications.
My opinion on this matter goes beyond my personal clinical
experience. I was a physician reviewer
for all Medicare hospitalizations in the states of Minnesota and Wisconsin for
about 15 years. My job was to perform
top level reviews on both quality and utilization issues that were flagged by
standardized criteria. As an example,
one of the many quality markers was any death that occurred on a psychiatric
unit. My job was to review all the available documentation and give an opinion
on whether the care was substandard.
Reimbursement for the work was trivial and that was intentional so that
no reviewer could make a living doing the reviews. Another requirement for the position was that
reviewers had to be employed full time as practicing clinicians in the states
where the reviews were occurring. The program was eventually shut down because
not enough problems in inpatient care were identified to justify the cost of
the program. That alone is a statement
about the general quality of care provided based on standardized criteria.
At about the same time, a billing and coding system was
introduced. It did not take long for the
federal government to decide that it could be used for fraud investigations
based on documentation and coding mismatches.
In other words, if there was not enough documentation or specific bullet
points were missed the physician or clinic could be fined or worse. They could be barred from billing government
insurers (Medicaid or Medicare). In the
worst-case scenario, they could be charged with mail fraud (since the billing
was mailed) or RICO (Racketeer Influenced and Corrupt Organizations Act)
violations. I was in an employer seminar where it was suggested that physicians could end up in federal prison if the documentation did not match the billing code! The FBI conducted many of
these investigations and large fines were levied against clinics and in some
cases teaching hospitals. Some of those rulings had to do with attending
physicians countersigning resident notes rather than writing separate
notes. The resulted in a period when
attending physicians had to write notes that were redundant with the resident
documentation. That had a significant
effect on morale and teaching.
Eventually both the policing of the billing and coding and
the quality reviews were turned over to health care organizations. That led to a different kind of
accountability. The review process was no longer conducted by independent
reviewers carefully screened for conflict of interest or law enforcement. Now the reviewers were employees of health
care companies who could profit from their decisions. That has resulted in a rationed but semi
standardized approach to health care. It is harder to see a physician or see
them for any length of time, but since most physicians are employees it is
easier to report them up the administrative ladder.
These days the opportunity for filing these reports
generally starts early in the process.
You attend a clinic and as part of the paperwork you are given a patient
bill of rights. It explains how you should expect to be treated in health
care settings and what the complaint process looks like if that fails. Specific
contact numbers are usually given for filing complaints. I have noticed that
this process can be selective. For
example, in my experience with emergency departments, some departments of
surgery, and some departments of cardiology there was no explicit complaint or
feedback process. I worked in 4 different psychiatry departments and that was
not the case. Patient feedback was always part of the annual review. My speculation is that high revenue producing
centers may be less likely to solicit feedback or complaints. Either way the process is not foolproof, but
there are avenues for filing complaints outside of the medical institution
where the incident occurred.
The diagram at the top of this post shows all the feedback
loops available for reporting or critiquing physicians. The complaints can be
spontaneous or solicited. Several levels
also report to other levels independent of any patient complaint. For example –
several of the entities (State Licensing, DEA, Privileging, Law Enforcement)
report to the National Practitioner Database.
The rationale for that database was to prevent any state disciplinary
action from being hidden by relicensing in another state.
Apart from the mechanics in the diagram there are additional
approaches to the problem of accountability.
Ikkos, et al (1) discuss both the physician patient relationship and the
formulation as being central to the work of psychiatry. Professionalism is
described as the contract of the profession with society. That includes the fact that complaint
procedures are necessary to maintain professionalism. Some complaints are accurate and others are
not. The authors in this case look at
the psychodynamic and systemic factors that may affect complaints and their
accuracy. Although this paper is form
the UK, very similar mechanisms in the US through the medical practice boards
of each state. Those boards are political
rather than medical agencies and they enforce state medical practice statutes including
relicensing.
Another indirect indicator of physician complaints is
malpractice cases. Ideally malpractice
in the US is a marker of negligence but the reality is that it is a much more
complicated dimension. In any year a significant number of physicians face a malpractice
action but only about ¼ result in a payment.
One study (3) documented that 7.4%
of physicians across 25 specialties had a malpractice action in one year and 78% did not
result in a financial award. The rate of
malpractice actions varied significantly across specialties with surgical specialties
at the top and primary care specialties having the lowest risk. Psychiatry ranked 25th out of the
25 specialties in terms of malpractice risk.
Specialties were also analyzed by the 5 highest and lowest risk
(includes psychiatry) for cumulative risk of a malpractice action by age 65 and
those numbers were 71% and 19% respectively. Additionally, psychiatry used to
have a two-tiered malpractice premium system in the US that was modified to one
premium because of the low incidence of malpractice cases among the psychiatrists doing electroconvulsive therapy.
What do I hope people have learned from this post? First – the first line of approach can
a direct discussion of the problem with your physician. Misunderstandings,
disagreements, systems problems, and bad days are common and they do not have
to be catastrophic. Psychiatrists should be more attentive to the relationship
aspects of encounters making that discussion easier. Second - if you have a complaint
against a psychiatrist or any other physician there is an option to take it to
one of the many channels in place to hear and act on those complaints. Posting on social media and attempting to
create the impression that your problem is widespread will not address it. If you are really interested in a solution
follow the designated channels. This suggestion does not diminish the problem
you are experiencing at all – it is focused on an effective solution. Third
– do not expect that all psychiatrists or physicians that you complain to will
accept your suggestion that the problem is common or that they need to change
based on your problem. Most physicians
practicing get constant feedback from all these accountability measures and
none of their work is flagged. Further –
in some cases these same mechanisms are used by administrators to get
physicians to do what they want. There
are also cases where complaints are made to harass physicians using these same
mechanisms. Fourth – in acute
care psychiatric settings it is common to encounter patients who resent,
complain about, or threaten psychiatrists on sight. In other words – even if they are meeting a
psychiatrist for the very first time, they exhibit aggressive behavior. It is
the nature of some forms of severe psychopathology and in some cases, it can
persist and form the basis of a complaint about that physician. Fifth - much of the unfounded criticism from both
outside and inside the field is based on the assumptions that there is massive
wrongdoing, error-making, ignorance, malfeasance, etc on the part of
psychiatrists. There is absolutely
nothing to back that position up. Many of those critics seem to be making a
career out of criticizing the psychiatrists who are doing the work and have
limited to no knowledge of how those psychiatrists work or the stressors they
are under.
If you have finally seen a psychiatrist, and there is a
problem with the interaction or treatment – use your judgment and try one of
the many ways to address that problem. Don’t hesitate to get a second
opinion.
George Dawson, MD, DFAPA
References:
1: Ikkos G, McQueen
D, St. John-Smith P. Psychiatry’s
contract with society: what is expected?
Acta Psychiatr Scand 2011: 124: 1–3
2: Ikkos G, Barbenel
D. Complaints against psychiatrists: Potential abuses, Psychoanalytic
Psychotherapy 2000, 14:1, 49-62, DOI: 10.1080/02668730000700051
3: Jena AB, Seabury
S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty.
N Engl J Med. 2011 Aug 18;365(7):629-36. doi: 10.1056/NEJMsa1012370. PMID:
21848463; PMCID: PMC3204310.
Graphic:
Done by me using Microsoft Visio. Click directly on the graphic to enlarge and see a clearer graphic.
