All right. Well, why don't we start? Welcome to a session on psychiatric malpractice. My name is Steve Nofsinger. And for those of you that don't have the QR code, and I'll put this up here several times during the presentation, you can scan this, and this will take you to the PDF file of our handouts here. There's a couple of seats up front, so feel free to come up towards the front here. So our faculty this morning is Dr. Megan Shedd. To my far right is currently a fellow in our Forensic Psychiatry Fellowship at Case Western Reserve. And Dr. Alexis Glomsky, to my immediate right, who's also a fellow. And I'm Steve Nofsinger. I'm the program director of the Forensic Fellowship in Cleveland. And I have some experience with malpractice through my forensic private practice, which I've had for the past 30 years, and have had a chance to evaluate probably a couple hundred of malpractice cases and testify in them, both on behalf of plaintiffs and defendants. Here is our learning objectives to define the concepts of the standard of care and the four components of a malpractice claim. That'll be accomplished by Dr. Shedd. Actually, Dr. Glomsky's doing that, right? You're doing that, OK. Next, to understand the major areas of psychiatric practice that are often subject to malpractice claims. And finally, to learn actionable steps you can take to minimize your malpractice liability and how to respond to a claim. So we have no disclosures. So we'll start to talk here. So most people feel like this when they think about the topic of malpractice. It's foreign to them, shocking. But our job here is to give you some knowledge, because knowledge is power. If you have knowledge of the specific areas that can lead to a malpractice claim, this will give you the ability to proactively and preemptively take steps to protect yourself. I've got a few kind of teaser questions here, maybe to preview the presentation here. And just think to yourself what you think is the correct answer here. So what kind of event is most commonly linked with a psychiatric malpractice claim? Adverse drug reaction, creating a drug dependence, suicide, improper hospital discharge, or tardive dyskinesia? The answer is suicide. On average, what percentage of psychiatrists are sued for malpractice in a given year? 1%, 3%, 5%, 7%, or 10%? Think about that for a second. It's actually 3%. So psychiatrists, as you'll hear later, are one of the lowest frequency subjects of a malpractice claim. But still, when it happens to you, it doesn't really matter if you're an N of 1. There's a couple of seats up front, so come on down if you so inclined. At a malpractice trial, what kind of evidence is most powerful? Injured patients slash plaintiff's testimony, testimony of the defendant physician, the medical record, the expert witness testimony, or the attorney closing arguments? And you'll see, yes, it's the medical record documentation. So we'll talk about how to develop that if you have an area where you can anticipate a potential bad outcome in some claim. Practitioners sometimes do not thoroughly document in their medical record because insufficient time, they're unaware of the potential implications. They're aware but in denial. Who knows? All of the above, right. It's all of the above. The next two slides are some data from PRMS, which is a major malpractice insurance company. So this is claims over a 38-year period from 1986 to 2023. They looked at claims filed in all states. Suicide was the number one claim, followed by incorrect treatment and a confidentiality breach. More recently, this was the past 10 years, from 2014 through 2023, a little bit different. So the top three were incorrect treatment, medication errors, and then suicide. It's interesting that the frequency of the claim being filed does not always equate with the amount of payouts. So for example, incorrect treatment represented 21% of the claims filed, but 27% of dollars paid out. Medication errors, strikingly, were 8% of claims, but 22% of dollars being paid out. Suicide, not surprisingly, was the topic of 28% of claims, but only 13% of payouts. So while suicide is one of the top frequency claims being filed, it doesn't result in a correspondingly proportionate amount of payouts. All right, I'm going to set the stage here with a malpractice example, and then we'll come back to it later and talk about it. So this was a 48-year-old man with a history of depression and anxiety. And he informs his outpatient psychiatrist that he has suicidal ideation, an intent, and a plan. So he belongs to an HMO, so he's hospitalized, appropriately. And it's a different psychiatrist who's the provider on the inpatient side. He's there for a 10-day length of stay. And during the 10 days, suicidal ideation, plan, and intent were not discussed. You know, that was the reason for the admission. He received trials of many different types of medications almost on a daily basis. But he complained of side effects. He had poor tolerance to the medication. I think at one point, the psychiatrist expressed their frustration with him in the medical record, writing, this patient is a pain in the ass. So, yeah. Diagnosis of major depression, discharged home on no medications. And then there was a suicide within two days of discharge. So you can think about that, where you think the problems might be at. And again, for those of you who came in late, here is the QR code. And I'll give you 30 seconds, then we'll turn things over to Dr. Shedd. When you say not discussed, most EMRs have a checkbox. There's a suicide, meaning it wasn't in the care. We'll come back to it later. But the question is about, was this a checkbox in EMR? This was pre-EMR. This was a checkbox in the EMR. This was an older case, back in the days of handwritten notes. OK. Can everyone hear me OK? All right. I'm going to go ahead and jump into it. So there are a few areas I'm going to discuss with you. First, I want to answer the question, how often do psychiatrists get sued? And how successful are suits when they do occur? I want to briefly touch on the forces present in the practice of psychiatry and in the health care system that increase our exposure to malpractice. And then I want to get into some of the legal elements of malpractice claims. So malpractice is a very common issue that physicians will have to face likely in their career. It's estimated that 7.4% of all physicians are sued annually. A survey conducted in 2020 found that 41% of psychiatrists reported being sued at least once in their career. Of course, the longer that you practice and do clinical work and the more encounters that you have, the more exposure that you have to malpractice risk. And then interestingly, men are more likely to be sued than women. So which specialties get sued the most? Well, fortunately, psychiatrists are less likely to get sued compared to other specialties. This is a chart from the New England Journal of Medicine. This was a survey of all claims in 2011. And you can see that psychiatry is at the very bottom of the list. Surgical subspecialties like neurosurgery, cardiothoracic surgery, general surgery have the highest risk of getting sued each year. You can see they range from 15% to 19% annual risk. Primary care specialties like family medicine and pediatrics are pretty low on the list. And psychiatry is the lowest at 2.6% annual risk, according to this New England Journal of Medicine study. Now, having a claim brought against you does not mean it will be successful. In fact, only 1.6% of physicians are successfully sued every year, and 78% of these claims do not result in any payout to the plaintiff. So this figure shows the amount of malpractice payments either by settlements or jury awards, according to the specialty. In psychiatry, the average payout per claim is $190,000. And the median payout per claim is $50,000. So generally, your carrier will be able to cover that type of claim. Now, if you're in the unfortunate position of getting sued for malpractice, then there's about a 7% chance that you'll have to go to trial. And nobody wants to go to trial. So that means that 93% of the time, the claim will either be dismissed by the plaintiff, which is the person suing the physician, it will be settled pretrial for monetary damages, or the court will grant summary judgment. And what that means is that the judge will review the case, and they'll decide based on the evidence that it's compelling in one direction, and they'll make a ruling rather than send it for jury review. Now, if you have to go to trial, then juries typically view physicians favorably. Approximately 80% of the time, there is a verdict for the defendant physician. Generally, if a claim is very obvious, then your attorney will advise you to settle early. Attorneys are not going to try a case where there is obvious error and obvious harm to the plaintiff. The cases that are likely to go to trial are those where there's a very close call, or there's a significant disagreement in the amount of monetary damages that the plaintiff believes they're entitled to. So this is data from the National Practitioner Data Bank. This is a federal system that tracks all malpractice payments. So the malpractice carrier reports any payments to this federal system. And so it kind of stays with you for life, and they report to medical boards. And it showed that in 2022, there were about 7,900 payouts by physicians, totaling $3.5 billion, while all other health care professionals combined had about 3,000 payouts in 2022, totaling $700 million. So this entire industry cost $4.2 billion. And this number is pretty consistent year to year. This also highlights that physicians are sued more frequently than all other health care specialties combined. And because of this staggering number, malpractice has become a very lucrative medical specialty, or medical legal industry composed of attorneys who specialize in malpractice, insurance carriers, courts, and expert witnesses. The first recorded malpractice claim occurred in England in 1374. A patient named Stratton, he sued his surgeon, who operated on his traumatic hand injury. And he was left with a deformed hand. And he argued that his surgeon, Dr. Swanlin, had guaranteed him a cure, and that he did not deliver that cure. So what did the courts do in this situation? The court found in favor of the surgeon, and they set a standard that is still prevailing in malpractice. That is that a physician should only be held liable for poor care. They should not be held liable for a bad outcome as long as they exercise due care. The court recognizes that bad outcomes are a part of the practice of medicine. Even competent physicians have bad outcomes. As long as you exercise reasonable care, then you theoretically should not be held liable. The word malpractice is derived from the Latin term malapraxis, which means bad or unskillful practice by a physician or midwife. And it was coined by Sir William Blackstone in 1765 in his commentaries on the laws of England. So malpractice law is a type of tort law, which has its origins in the English common law. So now I want to turn to some of the forces that are operating in our health care system and in psychiatric practice that increase our risk to malpractice exposure. So let's talk about some of those things. There are systemic issues that we face. So we're expected to see more patients in less time with less support staff. We work in a very fragmented health care system with barriers to communications across systems and less community support for patients. And in this backdrop, it really creates problems in the accuracy of psychiatric evaluations and the effectiveness of our management. So we have to often over-rely on self-report, and sometimes patients' reports are not accurate. There are barriers to obtaining collateral medical records, communicating with other treating clinicians. We work in a mental health care system where there is a shortage of hospital beds, and the average length of hospital stay is declining, so that our patients are more acutely ill in the community, and it's more difficult to hospitalize patients. Telepsychiatry is becoming more commonplace, and there are concerns about its reliability. And the legal standards for telepsychiatry practice are still evolving, being developed, and haven't yet been fully established. So there's often situations, especially in outpatient psychiatry practice, where the physician is siloed. It's difficult to obtain informal consultation from colleagues if you're not sure about a specific question. It can be difficult to refer patients who are treatment refractory to subspecialists. And you may have limited or no access to psychological testing, which can improve diagnostic accuracy. If you work in a rural setting, then you may be forced to work beyond your comfort zone, or even work out of your, beyond your scope of practice, which can increase risk of errors. And then by virtue of working on an inpatient unit, or in a psychiatric emergency service, then there's increased risk of exposure. You work with more ill patient populations, you work with higher risk patients who may be acutely suicidal, or have increased risk of violence. And if there's a bad outcome in a setting where there's this expectation for extensive supervision and environmental monitoring, for example, if there's a suicide on the inpatient unit, then those outcomes are gonna be highly scrutinized in court. And then many successful malpractice claims are the result of general psychiatrists being unfamiliar with many of these core forensic topics. And so that's what we wanna discuss today and empower you with some knowledge. We wanna talk about violence risk assessment, suicide risk assessment, duty to protect third parties, and a few more other concepts. So let's get into some of the legal aspects of malpractice claims, the four Ds of malpractice. What are they? So we have duty, dereliction of duty, damages, and direct relationship. And the plaintiff, that's the person suing the physician, is required to prove by preponderance of the evidence that all four of these elements are present in a malpractice claim. So what does that mean? Preponderance of the evidence means greater weight of the evidence or more likely than not. So it's a lower standard than criminal court, but it's not the lowest standard, but it's still pretty concerning. Then there's duty. So there are many different types of duties. A moral duty arises from your conscience. It's your sense of right or wrong. An ethical duty is an accepted standard for social or professional behavior. So as physicians, we have ethical guidelines proposed by the APA or the AMA, for example. And then a legal duty is recognized by the Department of Justice. For example, and then a legal duty is recognized by law rather than equity. If you breach a legal duty, you can be sued in a court of law. If you breach an ethical duty, you might get sanctioned by the APA. So how is a duty how is a legal duty established? Well there's a general rule in the law that one person does not owe a duty to another person. So as a citizen if I'm walking down the street and I see a child drowning and you know my neighbor's backyard I do not have a legal obligation to intervene in that situation. I may have a moral or ethical duty but I can't be sued by failing to intervene. There is of course an exception to this rule and that's if there is a special relationship. So the law recognizes in certain special relationships that there are duties of behavior from one or two of the parties one or more of the parties. So the law recognizes many types of special relationships that lead to certain duties. The host-guest relationship is one where the host has a duty to provide a reasonably safe environment free of foreseeable risky conditions for example fall risk or an aggressive animal. You have the business operator-customer relationship where the business owner has some duty to have a safe business place for their customers. The parent- child relationship the employer-employee where the employer has some duty to the employee. Correctional staff and prisoner, guardian and ward and then of course doctor-patient. So the law imposes many duties on physicians by virtue of the doctor-patient relationship. So we have a duty to keep a patient's medical information secret. We also have a duty to violate our patient's confidentiality in the interest of public safety for certain circumstances for instance child abuse, gunshot wounds, infectious diseases. We have a limited duty as psychiatrists to protect third parties from our patients violence and then of course we have a duty to assess and treat patients within the standard of care. So what are some of the instances where we establish a doctor-patient relationship? In some instances it's very obvious to us that we've established a doctor-patient relationship. For instance working in the emergency department, seeing a patient in the emergency department, in your office in the hospital. But there are some special cases that are less obvious to us where courts have found a duty might exist. So for instance if you call in a prescription to a friend or co-worker you know just a one-off prescription, courts have recognized that there is a duty that's formed there. And how is this duty terminated or discharged? So the duty ends when the relationship ends and it's very important to have a formal termination in the relationship. So you need to give the person notice that this formal relationship has ended in the same way that we recognize that the relationship begins in a formal way we need to end it in a formal way. And of course there's another exception to this. As physicians there is a duty to former patients to not engage in any romantic or sexual relationships with them. So that's a lifelong duty that we have. So what are some instances where a doctor-patient relationship is not formed? Well it's very obvious if you if you decline to evaluate a person so maybe they call to try to make an appointment and you decline them or if you are working on a CL service and you get consulted and you decline to see them then there's no doctor-patient relationship. In independent medical examinations like we do in the forensic setting this is not a typical doctor-patient relationship. There are some other places where the law has recognized that even if you're not seeing the patient a doctor-patient relationship may exist so there may be some duty formed. For instance if your colleague consults you curbside for an informal consultation a duty may exist in that situation. If you're giving medical advice in a non-clinical setting so if you're at a cocktail party and you present yourself as a doctor and you you know tell give a friend some medical advice courts have recognized that a duty exists in that situation. So we have to be very careful even in social settings whenever we're talking about medicine. If you supervise trainees without seeing the patient yourself but you discuss their care then there is likely a duty. And then we're going to talk about dereliction of duty also known as negligence. And this is an act of omission or commission that falls below the standard of care. So act of omission means that you failed to do something. Maybe you prescribed clozapine to a patient and you fail to recognize a bowel obstruction. And then act of commission is whenever you make an error you do something and make an error. So maybe you prescribe a medication and it causes a side effect. Standard of care is an important concept whenever we're thinking about dereliction of duty. What is it? Well it's not we kind of know what it's not. It's not perfect care. It's not optimal care. It's just ordinary care. It's also not what you personally would do or would not do. You really have to ask yourself what would a reasonable doctor do in this situation? So standard of care is the lowest level of care that any competent physician practicing in the same specialty would have provided given the same circumstances. And the benchmark for standard of care is set by the profession. So it's derived from the DSM 5 textbooks scientific literature APA practice guidelines continuing medical education material even like this talk. So all of this literature they draw upon to establish a standard of care. There is an exception that duty to protect third parties from our patients violence is the standard of care is set by the actual state statute. So how do courts establish standard of care? They're not medical professionals. They're not reading the DSM. They rely on expert witnesses in the field. This means that a psychiatrist typically working in the same practice area as you or working in the same content area as the outcome. So if there's a suicide they might be an expert and suicide risk management will review the records and they will give an opinion to the court that you did or did not deviate from the standard of care. Damages are the actual harm caused to the patient. And so to be clear you might make an error but if it doesn't cause harm then you don't have a malpractice claim. So the purposes of tort are to remedy damages by compensating the injured party. So the court does this by awarding different types of damages. Actual damages are lost wages or medical bills that arise from the harm that you cause. So if someone has a side effect like tardive dyskinesia and they can't work they're entitled to lost wages. Compensatory damages are intended to compensate the injured party for their pain and suffering and that can be physical pain and psychological suffering and it goes beyond the actual damages. And then punitive damages are intended to punish the wrongdoer. And these types of damages are typically reserved for intentional tort. So this would be the case if a physician knowingly caused harm to a patient by exploiting them or engaging in a sexual relationship with them the court could award punitive damages where they want to punish the wrongdoer. And then the most important of the four D's is direct relationship. So this requires that there be a direct relationship between the damages so the harm caused to the patient and the deviation from the standard of care. And this is often the most difficult for a plaintiff to prove. So just to kind of recap malpractice claim requires at a doctor patient relationship be established that there some dereliction of duty meaning that there was a deviation from the standard of care and due to that deviation from the standard of care direct harm was caused to the patient. OK. Let me turn it over to Dr. Gonski. All right. So this is the portion of the talk where we're going to scare you just a little bit. So I'm going to go through all the different areas where risks for malpractice comes in play for a psychiatrist. So just looking in general we'll talk about suicide harm to third parties misdiagnosis improper medication use improper discharges mismanaged medical conditions improper use of psychotherapy boundary violations abandonment lack of informed consent false imprisonment and breach of privacy. Starting off I'm going to talk about suicide which as we've already discussed is the most common area for malpractice for psychiatrists. First is going to be a failure to screen for suicide risk. So this is why we all write denies suicide in all of our notes. This isn't a full risk assessment. Just simply did you screen for it. Did you ask if they were suicidal. Did you see if they had any overt risk factors. Next would be a failure to conduct a suicide risk assessment when it is indicated. So if something comes up on that suicide screen you need to complete a full and thorough risk assessment. Next would be failure to conduct ongoing monitoring of suicidality. And this is an area a lot of psychiatrists will have trouble with because let's say someone is admitted to a hospital. Initially you do a thorough suicide risk assessment you document it and then for the rest of the hospitalization another thorough risk assessment is never completed. So you need to keep documenting on the suicidality and the ongoing risk of that suicidality. And then next would be an inaccurate or incomplete suicide risk assessment. This could be a failure to obtain accurate information not obtaining enough information or an improper assessment of the information that you did obtain in the risk assessment. Relying solely on patients denial of risk factors. We all know that patients do not always tell us accurate information whether they are not a good historian or whether they are doing it intentionally. We need to pay attention to other objective data that does not just come from our patient. And then ignoring risk factors. So is there past suicide attempts. Is there psychosis. Is there hopelessness. And so did you pay attention to those. Did you address those risk factors or were they completely ignored in your risk assessment. And then when it comes to treatment of suicidal patients one area would be acknowledging that there is a suicide risk but then not taking any sort of appropriate precautions to address that risk which folds into the next point of a failure to address any suicide risk factors in your treatment plan. And you know this goes for even patients that you're not seeing specifically for having suicidal thoughts. If there are still risks you need to pay attention to those and address those. Failure to evaluate safety of the environment. This is where the other thing we always do is do they have access to firearms because we need to pay attention to what is in their environment that puts them at higher risk to be in a dangerous position and thus more likely to commit suicide. Failure to develop a safety plan when your patient is suicidal or does have a high risk for suicide. This is part of creating a thorough treatment plan. How are you going to address it and creating a safety plan with your patient really rounds out your overall treatment of their suicidality and then failure to involve the family in a safety plan. Again if indicated there are certainly situations where you may not need to do this but let's say if somebody is being discharged home with their family it would be very important to make sure you have discussed with the family you know the plans for this patient risk factors what to do if there are concerning signs that they're becoming suicidal. Other risks related to suicide. So this is kind of a repeat that we already talked about but relying solely on the patient's report. This could be either during your initial suicide risk assessment during their hospitalization and this is where it comes into play with the patients who maybe they're admitted for suicidal thoughts and two days later they magically feel better and they're no longer having suicidal thoughts. If you simply rely on that that can put you at a high risk for some sort of malpractice incident happening. Failure to recognize that the suicidal patient views you the psychiatrist or therapist as an adversary. So most prominent in a hospital setting if they're hospitalized for suicidality they don't want to be in the hospital. They're not going to view you as being on their side because you're keeping them in the hospital. So that's important to keep in mind when you're thinking about what the patient tells you and how the patient behaves with you. And again why we want to incorporate objective data other observations reports from you know other health care providers maybe nurses on your unit things like that. Harm to third parties. So this is harm by your patient to a separate individual. First is going to be failure to conduct a violence risk assessment. Again this is if it's indicated. So if there's some sort of risk factor that arises that makes you concerned they could be at a higher risk for harming somebody else. You need to complete a full violence risk assessment. And along with that risk would be if you don't complete an accurate or full violence risk assessment. Same as with the suicide risk assessments not obtaining accurate data not obtaining enough data or not making you know appropriate assessments of the data you've obtained and somebody is identified as having a high risk for violence again similar to suicide you need to address those risk factors in your treatment plan. It's not enough to just say they're at high risk and leave it at that. You need to address what you're going to do what sort of treatment interventions are going to be used and how that would help reduce their violence risk failure to comply with duty to protect statutes. And I'll talk a little bit more about that on the next slide and then improper discharge. So if somebody is identified as being at risk for violence and you discharge them without addressing those risk factors or why you think those risk factors are mitigated to a point where they're safe for discharge that can put you at risk for malpractice. So the case of Tarasoff this is that duty to protect that I was talking about. Briefly the woman on the left there is Tatiana Tarasoff and the man on the right is Mr. Podar. So they were students and they developed a friendly relationship. Miss Tarasoff was not interested in anything romantic. However Mr. Podar interpreted as a romantic relationship. He made various like cultural actions that to him signified they were very serious. They would get married and she was not. That was not her thoughts. So he became kind of obsessed with her in a way began stalking her. And at one point she was actually out of the country for a little while and he got involved in therapy with a doctor more. And during his course of treatment with Dr. Moore he had expressed a desire to kill Tatiana. Dr. Moore took steps. He told you know the campus police about it what he was concerned about. Mr. Podar was briefly detained and questioned about this but ultimately was let go and it was determined there was nothing that they could do further with that information. As you can guess if you don't know the case already Mr. Podar did in the end murder Tatiana. So her parents filed this suit and this case is what developed these duty to protect laws where a mental health professional does have a duty to warn third of a risk of harm to third parties even if it does break that confidentiality within the relationship. And the duty to protect laws it varies across the different states. It's based on state statute. So it's important to know what that statute is specifically for your state. It will tell you exactly what situations require you to take action and then what actions you have to take to then discharge your duty. OK. The next category is misdiagnosis and improper treatment. So misdiagnosis arises if you don't complete a thorough evaluation. Don't ask enough questions, don't get enough information, don't get collateral if you need to get collateral to help you understand what's going on. If you misapply the diagnostic criteria, so make sure you know your DSM and you're using that diagnostic criteria. And as we can all guess, a wrong diagnosis can lead to wrong treatment, which again further puts you at additional risks of malpractice. Risks regarding hospitalization. If you fail to hospitalize a patient that is at increased risk for suicide or for violence and then they go out and they act on those risk factors, that puts you at a significant increase for malpractice claims. False imprisonment. This is one that a lot of times we don't think about. You cannot just hospitalize people just because, right. It is violating their rights. So know your laws for civil commitment. Again it's going to depend on your state and what your laws are there. But make sure you're following the appropriate criteria for civilly committing a patient. And along with that, once somebody no longer meets that civil commitment criteria you have to discharge them. If you continue holding them that is considered false imprisonment. Medication use. So if you prescribe somebody an improper class of medication, think of for example if somebody needs something for anxiety and you prescribe an antipsychotic, which is not necessarily uncommon. Some places do do that. But that is not an indication for that medication. If you use an inappropriate dose of medication, either far too much or even too low doses. Failure to inquire about allergies. If you don't ask, you don't know and you prescribe them something and they have a bad reaction, that's going to be on you. If you prescribe medications that are contraindicated. So this could be a combination of medications that are contraindicated. Also remember your medical conditions. There's going to be certain medications that you don't use in certain medical conditions. And just because you're not a medical doctor doesn't mean you don't need to be aware of those contraindications. Polypharmacy. We'll use antipsychotics for example again. If you are using three different antipsychotics and you're not justifying it, that's going to put you at risk for malpractice claims. Using medications off-label without specific informed consent. So if you go back to using antipsychotics for anxiety, not that you can't do that, but make sure your patient knows that's not why the medication is made for and you're indicating all of the risks that come with that. And if they give you appropriate informed consent you can go forward but you need to document that as well. Failure to prescribe when it's indicated. This comes from a case, Osharoff v. Chestnut Lodge. So this patient was actually a nephrologist. And he had had some depression and anxiety symptoms in the past, treated with a TCA and responded very well. His symptoms were worse at one point and so he was admitted to this hospital, Chestnut Lodge, which was considered one of the nice fancy hospitals in the area. And they chose to treat him with psychotherapy alone. His symptoms were not getting better, they were actually getting worse. And they continued to only treat him with psychotherapy. His family did help get him out of the hospital. They got him to a new doctor. He was again prescribed a TCA and responded very well. So they brought forth this suit because he didn't receive adequate treatment. He was only getting psychotherapy. In the end the suit settled out of court so you don't have any sort of final court decision on it. But it raised a big discussion about this need to be given medications and given appropriate indicated treatment. If you prescribe lethal medications to suicidal patients, not that you can't do it at all, but you need to be careful when you do. So think about for example, a TCA or lithium in a suicidal patient. You can prescribe it but document your risk of the high suicidality and what steps you're going to take to mitigate that. So don't give them for example, a 90-day supply at one time, give them shorter supplies. Failure to monitor side effects of medications and failure to order blood levels to make sure they're not toxic or too high. And creating drug dependence. And this mostly is going to be without the appropriate informed consent. So think about a benzodiazepine. You want to tell your patient about the risk of becoming dependent on that type of medication and document that they are aware of that risk before starting a prescription for it. Issues with long-term treatment. So failure to adjust your diagnosis or your treatment plan, sticking with the status quo. Sometimes that is what happens. But a lot of times things change if you're seeing somebody over an extended period of time and you need to make sure you update that information. Insufficient treatment encounters, not seeing your patient often enough. The wrong type of treatment. Failure to refer to other areas, therapy, primary care, neurology, any other sort of specialist that is indicated. And a failure to coordinate care with these other individuals. Dismanaged medical conditions. Again you're not held to the standard of a medical doctor, but you are a doctor. You need to be aware. Medical problems exist and can sometimes present themselves as psychiatric conditions. So you need to pay attention to that. Not mistake a medical condition for a mental disorder. Be aware of any sort of evolving medical problems and address those problems appropriately, whether it's through you or most likely a referral to their PCP or a specialist. Failure to order lab tests or imaging to follow-up and make sure there's not evolving medical conditions. And then practicing outside of your scope of expertise. So again, you're held to the standard of a psychiatrist. You're not a medical doctor. Don't try to manage things that you're not trained to manage. Informed consent. There's three elements to informed consent. So this is going to be telling your patient about the benefits, indications, risks, side effects and alternatives to whatever treatment you are trying to prescribe for them. Competence. Are they able to make a decision to agree to the treatment? So they need to be able to communicate their choice about the treatment. They need to understand the information that's relevant to making a decision. They need to appreciate the situation at hand and the consequences of the current situation. May that be consequences of the potential treatment or consequences of not receiving the treatment. And is their decision-making rational? You don't have to agree with it, but it needs to be rational in some way. And then voluntariness. So they can't be coerced into the decision under like duress or distress in obviously no sort of fraudulent situations. Areas where psychiatrists can be at malpractice risk related to the informed consent would be not informing patients of side effects. So a big one would be think of our antipsychotics, not informing of the risk of metabolic syndrome, not informing the risk of tardive dyskinesia. Failure to advise the patient of this balance between the risks and benefits. A lot of times we tell the patient the risks, but what are the benefits? Why are you giving it to them? They need to know that too. And then the risk of discontinuing treatment. If we use for example something like a benzodiazepine, because they can have this dependence they need to know the risk of just abruptly discontinuing it. And there's this concept of the reasonable person versus the reasonable practitioner standards for the courts to make decisions about whether or not a person was given the appropriate information to make an informed decision. And you have to know, it's based on the state, about 50% of the states use this reasonable person. So was the patient given information that would be necessary for a reasonable person to make a decision that they would find relevant? And then the other half of states use this reasonable practitioner where it's more of the physician making the decision of what they think is relevant for the patient to know. And so you just have to know what's the standard in your state. Improper discharge, discharging too soon, if they're discharged to an inappropriate placement or level of care, or an insufficient outpatient treatment plan. The first visit being too far out in time, not enough visits, no sort of safety plan, or the wrong type of outpatient treatment. Maybe they need an IOP-type program and you're just sending them to a clinic to follow-up once every 3 months. Psychotherapies, there's tons of different psychotherapies. And to be honest, most of the time this isn't going to be an area of high malpractice risk. Most of these cases don't really go anywhere. It's mostly just very large, egregious type of errors that would be subject to malpractice. Boundary violations, as we've already mentioned. Absolutely no sexual or romantic relationships with your patients or former patients. This is really not at all defendable in court. And malpractice carriers don't usually cover this sort of claim. Any sort of improper social relationships, employing patients or exploiting a patient, so don't see your front office worker. That would be considered probably an inappropriate relationship. Abandonment, if you just discontinue your treatment abruptly and you don't have that formal closure of the treatment relationship, that puts you at malpractice risk. If you don't help with their transfer of care, so getting them to a new provider or providing referrals and resources for them to get a new provider. And failure to address any emergencies. So if you are discharging someone from your practice and they tell you they're suicidal, you still need to address that and make sure that you take the appropriate steps to keep that person safe. Breach of privacy. This one I think we're all pretty familiar with. It's pretty straightforward. With HIPAA rules, you can't share your patient information, right. You have to have appropriate consents to release information to specific parties. And it will tell you based on that consent what information you can release. All right. Now I'm going to turn it over to Dr. Nofsinger and he's going to give you some recommendations to avoid the risks I just told you about. All right. Let's talk about some of the things we can do to avoid malpractice claims and some of these high risk issues that we've heard about from Dr. Glomsky. So first obviously is to screen for suicide risk in any mental status examination. We learned about this in medical school, but you'd be surprised how some cases there's a bad outcome and there's no screening for suicide risk at the evaluation. Conduct a comprehensive suicide risk assessment when indicated. And so you might ask yourself, well, what kind of thing should trigger a comprehensive suicide risk assessment? Well, if a patient does on screening endorse recent or current suicidal ideation or passive death wish, if there's been a recent attempt at suicide or self-injurious behavior, or other kind of high risk symptoms for suicide such as severe hopelessness or psychotic depression. And then incorporate the risk that are identified or the risk factors that you find in the comprehensive suicide risk assessment, incorporate that into the treatment plan. And we see people who do the risk assessment, they acknowledge the presence of the risk factors, and then have no treatment intervention. So for example, they acknowledge someone's at high risk but then fail to hospitalize or acknowledge a high risk diagnosis and then fail to treat it. This gets back to the example I gave you early on of the man with the 10-day admission spurred on because he informed his outpatient provider of a plan and intent to commit suicide that was not addressed during the 10-day inpatient stay and was discharged home on no medication for a diagnosis of major depression. So the two areas of fault in this case were no comprehensive suicide risk assessment done during the hospital stay, and obviously no medication treatment for his depression and his anxiety. So that case was a slam dunk for the plaintiff's attorneys. Do not rely solely on a patient's denial of suicidal ideation or intent, and again, recognize the patient will view you as an adversary. And so look for objective signs, especially on the inpatient side. So improving signs would include better sleep, less anxiety, better appetite, better participation, more appropriate affect. For patients being discharged either from the inpatient service or from the ED, develop a workable, accessible safety plan. We see sometimes people get in trouble in this area here. This doesn't have to be detailed, just what to do if your condition worsens. Call 911. Come back to the ED. Call the inpatient service. Call the outpatient provider. But just give the person specific instructions on what to do. And if feasible, end with the patient's authorization to involve the family so the family knows what to do if they see their loved one begin to decompensate. Carefully be alert to especially ominous suicide risk factors, so global anxiety, psychotic depression, severe hopelessness, global insomnia, and a recent attempt. Use DSM-5 criteria in your medical record documentation to justify diagnosis. So you'd be surprised. In fact, we have an example later on in which a man received an antipsychotic for maintenance therapy for bipolar disorder, later had a bad outcome, and then he claimed all the while he was never bipolar. And so it would have been important and helpful for that psychiatrist to have justified that diagnosis in the medical record using DSM-5 criteria. Hospitalization. A failure to hospitalize is a frequently raised claim in malpractice cases. So when there's a clinical need, obviously, based on risk, then admit the person to the hospital and be familiar with your jurisdiction's criteria for emergency commitment. And know it and use it. As for situations when you recommend admission but the patient is not so certain and you believe that they don't fit the criteria for an emergency admission, document that you offered a voluntary admission. Document then the patient's response and if they declined it, document how they don't meet the criteria for emergency commitment. On the flip side, we see cases of false imprisonment. So do not commit people when you know that they don't meet the commitment criteria. With respect to hospital discharge, people get into trouble with an early discharge and then there's a bad outcome. So a patient commits suicide or violence after a few days. I had a case recently out of West Virginia where a woman was discharged. Within 36 hours, she murdered her stepmother, stabbed her on the phone, stabbed her while the stepmother was on the phone with 911. And so there was obviously a bad outcome and there was a lawsuit filed over that. Likewise, a faulty hospital pass, it actually should be absent with leave, not AWOL. But granting someone a pass from the hospital when it's not indicated can be a recipe for problems. On the flip side, people get into trouble by patients asking for their release and the psychiatrist not granting the discharge all the while knowing that they are not committable. So another example of a false imprisonment. So the remedy for this is to use professional judgment, that courts and juries are very forgiving for errors in judgment as long as the risk assessment is completed and documented. Where people get into hot water is if they fail to do the assessment whatsoever and there's a bad outcome. So with respect to discharges, to do the analysis in their records and to document that can be very protective. With respect to violence, this parallels some of the pointers about suicide risk. So always screen for homicidal ideation in any initial mental status and conduct a comprehensive violence risk assessment when warranted. And I'll show you some triggering events that should result in a comprehensive violence risk assessment. And also then incorporate the results of that violence risk assessment into the treatment plan. So, for example, if you in the course of your risk assessment encounter let's say paranoid psychosis or severe substance use, or noncompliance with treatment, those should all be then addressed in your treatment plan to reduce future violence. And here are some triggers that should result in a comprehensive risk assessment. So current homicidal ideation intent or plans, a recent threat, a recent violent act, paranoia, or hallucinations should all trigger a risk assessment. You heard from Dr. Glomsky about the Tarasoff statute. So about 38 or 40 states have addressed and adopted a Tarasoff duty, either through statutes or case law. So know your state's Tarasoff statute and use it. I had a case recently where an outpatient male going through a divorce murdered his estranged wife's adult stepson from a prior relationship. So harm to a third party, the murder of the stepson, and the governing statute then was our jurisdiction's Tarasoff statute. And we heard the story about Tatyana Tarasoff and Prosangent Podar. Medication, these next 10 pointers point towards medication use and or areas of claims. So obviously select the appropriate class of medication. Don't give an anti-anxiety agent to a patient who's overtly psychotic in lieu of an antipsychotic. Conform to dosing guidelines. Don't prescribe a toxic dose that will cause side effects. Likewise, don't prescribe a minuscule dose that will lead to no improvement in symptoms. Avoid prescribing contraindicated medications. The classic example is Demerol with a MAOI. Monitor for adverse drug reactions. So for example, if you're prescribing Tegretol, monitor for Stevens-Johnson's syndrome, and order blood levels when appropriate. This all seems kind of obvious, but you'd be surprised where people get into hot water. Avoid polypharmacy. So avoid multiple sedatives or multiple antipsychotics, or if you do prescribe them, justify your rationale in the medical record. Don't prescribe lethal doses of medications to people at risk for suicide, such as given a, this is back from the 80s, I guess, give a 90-day supply of a tricyclic antidepressant in someone who's at risk for suicide. Prescribing off-label. Happens all the time, right? And it's perfectly appropriate, but you need to document your rationale and get informed consent to tell your patient, this is off-label. So if you're prescribing, for example, Prazisin for PTSD nightmares, or Gabapentin for alcohol dependence or anxiety, fine. Just inform the person this is not an FDA indication. Get their authorization. Prescribe when indicated. We heard a story from Dr. Glomsky about the Osheroff versus Chestnut Lodge. So obviously you can't just prescribe what you happen to specialize in or like, but you have to prescribe standard treatments for disorders. Here's an example. 38-year-old female who had had numerous past admissions for bipolar disorder. And the last seven years was treated in an outpatient practice with a Suprazidone and had maintained her remissions from symptoms for those seven years. Gradually her dose was increased from 80 milligrams once a day to 80 milligrams twice a day, up to 160 milligrams twice a day. Husband comes home, finds his wife dead in bed, autopsy showed she died from myocarditis. Blood doubles were taken post-mortem. It showed her Suprazidone level was in the low therapeutic range. And they actually found bottles full of Suprazidone in the medicine cabinet. So thoughts about this. Was there a deviation from the standard of care? See some heads nodding. What was the deviation? The dosage, right. The max dosage of Suprazidone is 160 per day. She got double that. So we had a deviation from the standard of care. But the real question here was causation because we don't think she was taking it. We have full prescription bottles. We have cause of death of myocarditis. Now the attorney handling this said he wanted to settle this because he never wanted to take a case to a jury on the sole issue of causation. That if there is an overt deviation from the standard of care, which there was, he wanted to settle this. So it seems reasonable. Long-term treatment. Obviously update the person's diagnosis and treatment plan as you gather more data over the course of your ongoing treatment. And if you gather more data that would justify a change in diagnosis or treatment plan, obviously, then that's appropriate. See the patient with sufficient frequency. People get into hot water with seeing high-risk patients every three months. Remember when appropriate to a specialist, seems kind of obvious here, be alert with respect to medical conditions to evolving or new diagnoses and rule out underlying diagnosis. This comes up often in inpatient settings. You have a person with, let's say, a subdural hematoma that's evolving. Person's getting more cognitively impaired and delirious. And it's ascribed to, well, they're just more depressed and we're not going to address this. I've had a couple cases as well where people had a recent colonoscopy where they had a ruptured colon developing peritonitis that was mismanaged or not even recognized. And so then there was a bad outcome. Informed consent. So always inform your patient. We heard about from Dr. Glomsky about information that you must convey to get informed consent. So advise the patient of the risk and benefits of treatment. But also advise them of the risk of stopping treatment. And there's a famous case here. Our defendant, Wendell Williamson, on the left there, he successfully sued his treating psychiatrist because he stopped taking his antipsychotic medication, became psychotic, opened fire on some police officers and bystanders downtown Chapel Hill, North Carolina, was ultimately found not guilty by reason of insanity for the murder, but then sued his treating psychiatrist unsuccessfully for malpractice, claiming that he was not advised that if he stopped his antipsychotic that his psychosis would return and he would become at increased risk for violence. So this was a big case in the mid-1990s. Boundary violations. Obviously, do not employ your patient or exploit your patient and observe professional boundaries. With respect to abandonment, do not stop treatment abruptly, but rather make a referral and transfer their care, and in the meantime, deal with emergencies. And some of this, again, is pretty overt or pretty obvious, but maintain confidentiality and treat patients and their families with respect. Patients and families are very forgiving whenever there's a bad outcome, but what really puts them over the edge to file a claim is that they feel disrespected or not heard. Some states have apology laws that bar from admission into evidence at malpractice trials if a physician apologizes to the patient, and so know your jurisdiction's law on that, because often an apology can be construed by a plaintiff's attorney as an admission of malpractice, but some states have protections on that where you can express some empathy and an apology for the bad outcome. It doesn't mean you're apologizing for an error. And the final 10 points are actually all on one topic here, which is documentation, because it's so important. Kind of like the Titanic and the iceberg, medical records and medical malpractice claims are on a collision course. What's in the medical record collides, sometimes violently, with the patient's claims of malpractice. So what's in the medical record has a huge impact on the outcome of the malpractice claim. Likewise, what's not in the record, what's missing from the record, also can have a huge impact on the outcome. So the big question here is, how is the medical record actually used in a malpractice trial? And this is the timeline of a malpractice claim here. So the complaint is filed by the plaintiff's attorney that will specify probably 15, 20 different alleged errors. They want to make sure and cover all the bases. And it will be accompanied by an affidavit of merit from an expert in the field who will say, yes, I've reviewed the file, and I think that there was a deviation from the standard of care. Later, the plaintiff's expert will probably issue a report. Jurisdictions require an expert report saying exactly how they believed the defendant doctor erred. So a discovery then begins, and that medical record is exchanged. It's looked at by everybody. And what is in or missing from that medical record has a huge impact on the outcome. The medical record information is of high volume because it's written as the facts unfold, as the events unfold. So it's not tainted by later knowledge of a bad outcome or a doctor documenting defensively, knowing there's a bad outcome. It's written in the moment. So juries place a lot of weight on that contemporaneous documentation. So that's why it's very important that you are able to document proactively and preemptively whenever you think you're having a high-risk situation here. The medical record is looked at very closely by everyone involved in the lawsuit, plaintiff and defense attorneys, the paralegals, the malpractice insurance company, the experts, and ultimately the jury. Some plaintiff's attorneys go by this, if it wasn't written down, it didn't happen. And I would disagree with that. There's a lot that happens that's not written down. It certainly helps if it's written down, and if it's not written down, you can hope to remedy that by testimony at a deposition or at trial. Then the issue becomes then, well, the credibility of that testimony. And it's obviously very helpful if it's written down. This is a high-profile plaintiff's attorney in Cleveland. I put him in there, says, I'll make you pay, is his saying here. So when you're in the moment, when you're discharging that high-risk patient or you're stopping suicide precautions, anticipate that this is an area of potential liability, and then document proactively. Think to yourself, what if there's a bad outcome and I'm sued, I'm in a malpractice trial, what would I want to have in the medical record to protect me? And so then put it in in the moment. So medical records should follow a SOAP note format. We're all trained in this, but also it happens to be highly valuable, and it complies with the standard of documentation as well. So medical records should be thorough, honest, non-prejudicial, don't write bad things about your patient like that one example I gave you, appropriate to your discipline and timely. If you wait to do the discharge summary a month after discharge and the patient kills himself two weeks post-discharge, that discharge summary is going to be worthless in your defense, so it's no longer contemporaneous. So in your records you should avoid making conclusions, but instead explain your rationale. So don't, for example, say patient is malingering and end there, but instead give the evidence for it. Also if you document, you know, patient is at low risk for suicide, don't end there, but give your rationale. Explain your rationale for your diagnoses, for your treatment decisions, for your critical decisions around stopping suicide precautions, granting a pass from the hospital, and granting a hospital discharge, and illustrate the use of professional judgment. This statute here is called the kiss of death, and I put it in here for a reason. Because what's the kiss of death in a medical malpractice claim? Modifying or destroying records. In fact, in the Tarasov case, Dr. Moore was told by his supervisor to destroy Podar's medical record. He was concerned that they had breached Podar's confidentiality by calling the police. And obviously it's always a major mistake to modify or destroy medical records. It's an admission of wrongdoing. It's a slam dunk for the plaintiff's attorney. So most people when they're sued, they're unhappy, they're surprised, they're shocked, but instead remain calm. All your insurance company, don't discuss the case with other people because you'll be asked under oath, did you discuss it with other people? And if you say yes, then the plaintiff's attorney will go depose those other people and see what you said about it. Don't over personalize it, realize this is the cost of doing business, 3% of us get sued every year for malpractice, and be patient because these claims take about two years on average to come to a conclusion. So don't feel dumped on, don't feel inadequate, but instead just realize this is in the course of business. So with that, I'm going to turn it over to Dr. Shedd, who's going to give you a detailed vignette. And as you hear this, I want you to think about was this malpractice or not. So the fun part now. So we have a 22-year-old male with new onset psychosis. He's having command hallucinations from God. He stabs himself in the chest and tries to enucleate his eye. He's evaluated in an emergency department and appropriately admitted to the ICU. And this is 5 p.m. on Saturday. And he admits he's trying to sacrifice himself for God. So fast forward to the next day. He's in the ICU. This is Sunday. Mike is consulted at 9 a.m. and then again at noon. I guess they're busy, you know, seeing patients in the morning. But they finally get around to evaluating him at 3 p.m. He says he was trying to sacrifice himself to God to obtain a better life. He denies SI and denies HI. He's diagnosed with major depression with rule-outs of major depression with psychosis and rule-out schizophrenia. And the recommendations are to transfer to psych inpatient when he's medically cleared. And if he agrees to transfer, it can be voluntary. If not, then he should be civilly committed. So this is still Sunday in the ICU. This is 4 p.m. He expresses distaste regarding the idea of being in a locked unit because he doesn't want to lose his freedom. And he feels like the psychiatrist is trying to control him. At 5 p.m., he's observed standing naked at bedside and he's trying to pull out his IV. So at 6 p.m., begrudgingly I'm assuming, the psychiatrist returns to the ICU and he sees that the patient is anxious and agitated and he gives an immediate verbal order he needs to be transferred quickly to the psychiatric inpatient service. So that's... So that was at 6 p.m. Now fast-forward to 7 p.m. He arrives to the psychiatric inpatient service. And routinely, the nurses meet with him and they start their assessment process. And they place him on Q15-minute checks. He gets on the unit. He's calm. He starts eating food and he's watching TV. And the admission orders have yet to be called in. There's no psychotropic medications prescribed at this point at 7 p.m. One hour later at 8 p.m., he bolts wildly into the dining hall. He's knocking over three tables. The nurse pushes the emergency call button. The nurse attempts to verbally corral him into sort of a special care area, probably like a seclusion area. The tech attempts to physically corral him now into a seclusion area. He runs down the hallway and he hits the locked door with full frontal force, causing the door to be open. Then he runs towards the nurse's station. He takes a sharp left, runs full speed, and he breaks out of the psych unit, runs through a window, and falls down several stories to his death. So what a nightmare. Okay. Let me get a show of hands. Who says this was malpractice? Raise your hand. Raise them up high so I can see. So a lot of people. Interesting. Okay. Can someone in the front just kind of yell out what are the reasons why you think it's malpractice? What are some of the... Okay. Working diagnosis, major depression sounds off. Okay. What else? Emergency medications aren't prescribed. Okay. Anything else? Lack of orders. Okay. Okay. Drug screen is... I don't think there's any information about that at this point. Yeah. Okay. Raise your hand if you think this was not malpractice. Raise your hand. Really? Can you tell us why? Right, right. Very good. So this is so interesting. So this was actually, this went to a jury trial and the jury found in favor of the defendant physician. So this was not malpractice. For a lot of the reasons that you mentioned, this is, it's, we're not talking about optimal care. I mean, there's a lot of things that could have been done better, but this is ordinary care. He was there calm in the unit. He was waiting for the doctor to come evaluate him. This is a Sunday. So there, you know, maybe they're coming from home. You know, there's so, it takes some time to get things started. It's not unusual to not start medications right away. So so yeah, that was the outcome. And we have another case, Dr. Glomsky, and we'll go over. Well, just a question for the group. So what do you think was the compelling reason to give him medications prior to when eight o'clock came when he broke down the door? So you think that would result in an emergency medication? You would? Okay. Interesting. Okay. We've actually showed this case to law students and they all agree that it, you know, they thought it was malpractice, but the jury disagreed. So they had a good case. All right. We'll move on to the next one. So this is a 64-year-old attorney with a self-reported history of bipolar disorder. He self-reports prior manic episodes. Five years ago he described euphoria, irritability, decreased need for sleep and racing thoughts. Two prior psychiatrists had diagnosed him with bipolar disorder. He had been treated with antidepressants, mood stabilizers, low-dose antipsychotics for the prior three years. In treatment with the psychiatrist Dr. A for five years, he was prescribed Zyprexa 20 milligrams daily for remission of his bipolar disorder. He also received stimulant medications for ADHD. His bipolar disorder remained in remission during the treatment period with Dr. A. He gradually developed intermittent very mild tardive dyskinesia, wasn't very obvious on exam. Then suddenly the tardive dyskinesia worsened. It became disfiguring and impacted his ability to do his work. He then self-discontinues the olanzapine. He criticizes Dr. A for prescribing the medication and states he never had bipolar disorder and olanzapine was an error. He files a malpractice lawsuit and claims olanzapine was below the standard of care. He refutes the diagnosis of bipolar disorder. And he claimed a lack of informed consent for the olanzapine. So same thing, raise your hand if you think it was malpractice. Do you want to share why? Yeah, and the case did not specify that part, so you're correct on that. Okay, so then who thinks it is not malpractice? »» Yeah. There's definitely, as with most malpractice cases, a lot more details that would be helpful. But this case also went to a jury and it was bound in favor of the defendant so it was not malpractice for the reasons you said. It was clear history of bipolar disorder. The physician documented the symptoms that met the criteria, the DSM criteria for bipolar disorder. And Olanzapine was an appropriate medication for that. Okay. So what questions does anybody have? Yeah. »» So I have a burning question with the sort of ‑‑ »» Could you use the microphone? »» Oh, yeah. »» Hi. So I have a burning question. With the disclaimer that I'm a child psychiatrist working in community mental health in Philly. I think one of the big challenges that I face all the time is that I can't force people to do what I think that they should do. And one of the things that jumps out in these cases is people maybe not wanting medication when we think ‑‑ I work in the outpatient setting. I can't give people medication if they don't want it. So I think shared decision‑making I guess is one framework. But I don't know if that's really defensible and how do we kind of practice perfectly in a less than perfect kind of setting where people have a lot of maybe bias or bad experiences with psychiatry. They might be skeptical about treatment. But then there's a lot of things we can't control. Thank you. »» So I guess I would say I think that goes into the informed consent part where they can make a decision you don't necessarily have to agree with. So just really providing the education, trying to get on their level and understand their concerns of course. But then if they're still denying it or declining the medication, really just documenting you provided information on it, you described the risk benefits of it and they chose no treatment and really just saying they did it, understanding all that information and for a rational reason. »» Just keep in mind that competent patients can refuse even life‑saving treatments. So as long as there's not a question about is this an incompetent refusal and no issue with respect to the need for guardianship, then you've complied with the standard of care. You just have a patient who's not willing to accept your recommendations. »» Hi. I'm a psychiatrist in private practice and my question is pertaining to release of information of records. Of course, we all do the standard HIPAA consent before we release information to, for example, a forensic psychiatrist that is involved for an evaluation for custody. In those cases, when we are releasing records for our patients to a third party, a forensic psychiatrist, what do we need to be careful about? Do we release the full records? Do we hold records? What's the general advice on that? Or is there any potential for any malpractice lawsuit if you do release the records? »» I think the important part is to get your patient's consent for the release. »» After that, is there anything that needs to be ‑‑ »» I thought you were going to say that you got a subpoena from a lawyer for the records and what do you do in that situation when the patient hasn't authorized it? I think the response to that is even if you get a subpoena from a lawyer, don't release it until you've got your patient's authorization because lawyers can subpoena things left and right and it doesn't mean it's appropriate release. And in that situation, maybe consult with your attorney or if you're in a hospital with risk management. But with respect to if you have a patient who fully authorizes their release, then I think you're done. They've given you authorization. So what concern would you have that they're unhappy about something that's in the medical record or the way it's used? »» With what's in the medical record, how that can potentially damage the custody case, for example, one. »» Well, that's not your interest, though. What happens with this patient's custody case is separate from your treatment of them. »» Okay. That framing helps. Thank you. »» Okay. »» It's almost 3 o'clock so we'll take one more. But then any remaining questions we'll be happy to answer. »» I'm also from the other end of the state of Ohio. So good to see you all. I'm in my first year practicing as an attending psychiatrist. So obviously malpractice is definitely something in the back of my mind since I have no one watching over me. My question is, so for different medications, do you advise that I specifically, because I've been doing this for all the medications I've described, do you advise, I include, that I discuss these specific side effects? Or should we just do risks, benefits, and side effects were discussed with the above medications? Like a more generic versus a specific for each medication, like on Epic? »» Right, yeah. And so in Ohio, we adopt the materiality of the information standard on how much information you have to disclose to the patient in order to get informed consent. So the question is then what would a reasonable patient think is material information to consider before they agree or refuse the proffered treatment? So I think I would certainly hit the highlights. So I think it's fine to say we discussed the major risks and benefits of the medication or whatever it happens to be you're offering. But then if you know there's something especially risky, I would document that specifically. »» So like for example, like with Lamotrigine, you know, the risk of rash or trazodone, pre-epism. »» Right. »» Okay. »» Right. »» Thank you. »» Yeah, I mean that can only protect you. »» Okay. Thank you. »» I'm going to put up, oh yeah, there you go, the QR code. »» All right. »» Yeah, we'll be up here. Any other questions?

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