Hi everyone, thank you for coming. And just before we begin, just kind of wanted to just also thank Dr. Wasser and Dr. Peale for being with us today and joining me in this webinar. This is generally an open discussion where if you have any questions about the course, if you've taken it, if you've registered for it but not taken it yet, that's fine as well. It's pretty much open to any questions you might have about forensics. We generally design the course to be something where there are folks that might have some interest in forensic psychiatry but perhaps aren't interested in doing a full fellowship or they're just in a role where forensic issues of some sort come up. And we just kind of want to bridge the gap a little bit between folks that are practicing clinical psychiatry in different settings that have, you know, a certain percentage of forensic involvement, especially those who are required to go to court and things like that. And then I just put up my email in the chat, just because the course itself is open for my understanding is it goes through the 22nd of September. And so some folks may be taking it later and obviously can't join the Q&A today. But I'll certainly do my best to answer any questions that might come up later on. I can feel free to email me. And that's my general opening statement. And I'll certainly hand it over to Dr. Peale and Dr. Wasser to see if they wanted to mention a few things too. I just wanted to say thank you for those who have hopped on and joined today. And certainly a special thank you to my co-presenters, Dr. Annis in particular for organizing this and then also Dr. Wasser. And I too am available for questions, you know, after today. If you do send an email to Dr. Annis and it happens to be in an area that maybe I'm more suited to answering, it can likely be sent to me and I'm happy to respond. I don't think I have anything else to add. Happy to be here today. Happy to have some of you guys here and happy to answer any questions folks have. You know, we have a pretty small group here today. So if participants are happy to talk, it would be great to just get to know you a little bit. Maybe say your name, where you're physically located, the type of practice that you're doing. And if you've had any, you know, legal matters come up or if there's any legal matters that you're particularly interested in, maybe we can start with that. So I'm Amit Pradhan, I am, oh, I'm so sorry, Dr. Amani is in front. OK. OK, so I'm Amit Pradhan, I'm a consultant psychiatrist working at the county hospitals, which is now ValleyWise in Phoenix. And I have worked in various settings before, inpatient, outpatient, CL, ECTs. And currently, so we do petition patients and do the affidavits and stuff. I think this is a different thing for Arizona. I'm not sure if it is. It's a little different where I was in New York and Virginia and Maryland and stuff. So this is a little different. But yeah, so we do have and we also get quite a few patients from the Arizona jail, which is the Phoenix County Jail, which is right behind us, as also the prison complex. So there are some interesting cases, foreign body ingestions, especially, which come quite a lot. And I actually have a question about foreign body ingestions, which is from my inpatient days, but I'll wait till everybody else has introduced themselves. Thank you so much for that overview. And one of the things you raised was the fact that you're working in Arizona and there can be some differences between states. So we certainly want to highlight that that's jurisdictional differences in law can really affect your practice. So Amani, I think, had her hand up initially. So maybe you can go next. Yes, I'm Tweety Amani, I'm a psychiatric resident in the forensic department in Hospital Razi in Tunisia. Hospital Razi is a psychiatric hospital and I was affected to have my trainee in for six months in the forensic department. So it was interesting for me to see other aspects of forensic psychiatry elsewhere. Wonderful, thanks so much for joining us today. Well, it's great to have some international folks. Yes. Yeah. Hi, everybody. I'm Lorraine Copley. I am coming to you from Columbus, Ohio. Dr. Peel, when you turned on your thing, I had the exact same art in my other office. I'm actually in my home office today. You have very good taste. Thank you. I appreciate that. I appreciate that. So I worked for years, so I'm a child psychiatrist and a general psychiatrist, and I'm board certified in addiction medicine as well. And my background, I was a pharmacist before I went to med school. And so my current role is I'm a medical director for a very large private practice in Columbus, Ohio, and have interacted with courts, police, all the weird questions come to you as a medical director when any of my team is not sure what to do. On the side of that, I have started my own consulting business because just got really out of hand. I was getting asked to do all sorts of things that weren't medical director things. And I have done some consulting around reading charts where there's a concern for malpractice. And is this the standard of care? Like, it's just as a practicing psychiatrist, is this what you would have done? You know, and answering questions and trying to educate around that. And I've done some consulting work for my own medical board around medical marijuana and around physicians or other providers where there's a concern about care. So I have lots of questions, but I'm going to hold those. And I appreciate the course. Thank you, because I'm getting into this a little too. I feel like a little late in my career to say, hey, I'm just going to just hang on everybody for a year. I'm going to go get a forensics fellowship and do that. That feels really not feasible, although I have these moments when it seems feasible. So I'm very interested in those things, too. Wonderful. Sounds like we have a lot of different experiences among participants here today, and that's really great. Well, if there are questions, we want to make sure that we have time to address them. So why don't we just start? Anybody who has a question, maybe present it and everyone can chime in. So I have a question and there's a forensic aspect as also the medical legal aspect. So we had a patient, luckily I didn't have him, but there was a patient when I was in New York who had a compulsion of these repeated foreign body ingestions and he used to swallow toothbrushes. So. He once was admitted to one of the units and at one point of time, he was given by the nurses, they hand out these little packets for brushing their teeth and stuff to all inpatients. He happened to get one and of course, he ingested it. And then he filed a lawsuit saying that he had been harmed. So I'm just curious to know how would, you know. Is there really a basis for a complaint like this and B, would a generalist get involved in something like this? Because right now when I'm working on CL, we do have people who come in and then most recently in COVID, they would take out the wires of the mask and swallow them. So we have had people who have swallowed things two days in a row and have gone down to get them scoped three days in a row. So that's one question that I have. I'm definitely going to defer to Dr. Peel for the bulk of this answer, but just a brief thing I wanted to mention was that I don't you know, when it comes to malpractice suits, there are there can be a lot that get to the point of, you know, beginning where you're like the case gets started, it gets to a certain point and that that are not very meritorious, I guess. So the first step is not that surprising that someone might try this. But basically, one of the big things is that there needs to be damages. So if he ingested whatever they gave him, that would be, you know, there would have to be something other than him just going through another scope or something like that. So if if there wasn't something significant, I don't I don't see much of a basis there. And then another thing is, I mean, I guess if he wasn't supervised and he was giving that, given that, but I think there is a there's also a little bit of a minimal and this is just me throwing it up, throwing this out there. You know, there are certainly minimal human rights, things people have right to, including certain things involved in hygiene. So the act of actually giving him that would not really seem to be malpractice. The other the other question might be if he should have been supervised with everything he could ingest. But I'm not I'm going to defer to Dr. Peel for the for the main answer. That was just kind of my comments. Perfect comments there. I mean, was there was there anything that you did in particular that or this case when you were thinking about it that struck you or you think that you would likely do if you were in the same situation? Oh, I mean, the way I talk about this, I don't know how the hospital settled it, but I guess it would only be through documentation in which one would be able to say that the patient is basically highly prone to ingesting things and. The risk can be minimized or not minimized, reduced by having a strict observation policy or stuff. I mean, to convey in certain ways that there will always be a risk. Yeah, I think you're thinking about it in a very nice way. First of all, anybody can file a lawsuit, a complaint. And so really, when we're thinking about malpractice and medical negligence, most of time we're thinking about can those complaints be substantiated? And if they were to move forward, what kind of evidence would be protective of the medical provider? So here I would encourage you to think about the foreseeability of harm. This is a person who likely who has engaged in foreign body ingestion before, so likely the clinicians are on notice. But perhaps already in that hospital course, they've been doing fine when they're given hygiene materials or other materials. So having those observations can be really useful. And then knowing that the person might be at elevated risk for doing this, were the actions on the part of the clinician reasonable? Most likely, the clinicians are not going to be able to stand next to the patient consistently and probably over time, they'll want to have spaced out intervals where the patient is not directly observed. But you're going to want to get that data and then demonstrate whether those clinicians did what was reasonable under the circumstances or whether no prudent clinician would do what they did. In which case, if that occurred and damages occurred, then they could be liable for negligence. On a related note, frequently what happens in hospitals is that nursing staff, nursing short staff, and they're frequently like they don't have enough one to ones. How would you deal with that in terms of, you know, theoretically, everybody who is suicidal should be on a one to one, but that is. Then you get the kind of suggestions that is he suicidal right now, has he said something about being suicidal right now and those kind of things. So in your experience, how do you square that with, you know. Things like this. Good question, that's a scenario that I think comes up quite a bit, and I'm curious from other people's experiences, how has that been addressed maybe where you work? I will tell you, when I was on the unit more, I don't, I do all outpatient work now. There was lots of pressure to take people one to one because of staffing concerns. And this was also true in I worked in a juvenile detention that was both civil and forensic. Hospitals, I worked in a juvenile detention, and there was a lot of pressure like on a unit that was for folks who were civilly or or not committed. And there were there would be all sorts of people on the mental health team who would, like perhaps a social worker would walk in and say, well, I asked him if he was suicidal and he says, no. So you need to you need to sign Dr. Cathlete to take him off of his one to one or his eyes on or his arm's length. And I would be like, you know, that 14 year old just found out that the kid he accidentally shot died. He's going to go up for capital, whatever. Like, no. How about now? And so then it became like this. It was this, you know, it was this all day long and twice on Sunday between staffing needs in the hospital and clinical needs of an individual person. And at the end, it was it was very difficult just because it all came down to I'd be the one who signed it, you know, and I couldn't I didn't feel like I was going to be able to say to somebody who after a bad thing happened. Well, you know, the nursing staff wanted me to sign it. I didn't feel like I was going to get to say that. I didn't feel like I felt like I had to take responsibility for that. And so I wasn't anyone's favorite. And it was really hard. It was very, very hard. It was like a constant battle. And it came down to systems of do you have adequate staffing? Do you have adequate care? Do you have adequate safety? Here is no. It's very hard. And the answer is no. Many times. That's a really good point. One of the things I just wanted to add just on to that is that you're I mean, your instincts are exactly correct. There are times where there's systems issues. You know, there aren't enough staff for one to ones. And and then ask someone to ask you to take someone off a one to one. And I mean, it really is. They're asking you, obviously, you know, they're asking you to sign this because you're the one responsible. And so if, you know, if they, you know, I mean, I just a little example. I was at a state hospital and I had a guy in one to one, and I certainly want to keep him on there. And the nurses called a bunch of people looking for coverage to get this. And they said, can we take them off a one to one because we can't have coverage. I'm like, you can't find coverage. That's on you. I'm like, do your best. But I'm not going to say I'm taking them off the one for the other. So even though some cases aren't that obvious, you know, sometimes we can be put in a position where there's pressure and things like that, you know, just definitely my advice would be to stress is that you're working in a system, but you're not you're not there to make it run better in that sense. You're not going to make it up because there's less coverage. If that's the case, whatever happens on the administration and on their end are going to be the people that have to deal with that. Let them let them do that. I agree with all those comments, you know, so often in these malpractice cases, particularly where it is a bad event that occurs on an inpatient unit. One of the things the court will look at as establishing the standard of care is whether there were actual hospital policies on the issue in place and then whether they were followed. So important, you know, in cases like this to look to see if there are hospital policies, in addition to helping you with the hospital policies, helping you with your care management, sometimes relying on those hospital policies to go up through the team of administrative staff to try to push for more funding or staffing can also be useful. So just being familiar, you know, with the policies at the area that you practice can often help in many different ways. I have a question that came up as I was watching the videos that you guys put out. So in Ohio, we have a we call it a pink slip. We have a 72 hour hold, basically. And the criteria are this person suffers from a mental illness. This person is an imminent risk to self or others or because of their mental illness, cannot care for themselves. And that's what allows any physician, peace officer, psychologist or nurse practitioner in my in my in my town, in my state, to be able to have a person transported to the hospital and evaluated emergently. So one of the things we've really struggled with is in this age of covid and telehealth, our laws imply that the patient has to be evaluated in person. And so when we are seeing a person on telehealth and in the moment, one of our patients is not is pink slipable, if you will, like if they were in my office, I would be pink slipping them. We've really struggled because they are at home on their computer and our general policy and just what we do locally. It's not just my practice. It's across the board is we call the police and have the police go pick them up for a wellness check. But there's this phenomenon where the police come. And even though I've called the police and said, this is Joe Blow, he's my patient. I've broken confidentiality because I think it's an emergency. I'm fine with that. I'd rather defend that than the guy being dead in my house. You know, hey, I'm really worried about him. He's not okay. Please, please, please take him. If he were in front of me, I would be signing a pink slip. The officers can sign a pink slip and they don't, they won't. The police have a different kind of standard. Basically, you have to be standing in front of the police officer screaming that you're going to harm yourself or somebody else. They don't have any nuance around that. And so then the many times we'll go out and do a wellness check and say, hey, I think that dude's okay. And then we never hear anything about it again. And that makes me very, very uncomfortable as a medical director, because it happens frequently when you're taking, I'm watching a team of people practice. So I'm interested in if there have been, I'm interested in how we can do that well as practitioners. I'm interested in how, if there has been, has this come into court systems yet? Or is this come, what do we do? I don't know what to do. I don't know what to do. David, it looked like you were going to say something. I'm sorry, me? Yeah, were you going to say something? No, I mean, it's a brief thing. It's a special, that issue has come up a lot, at least in my experience. I'm sure each of us have some experience like that. Not specifically the telehealth issue, but asking for a pickup order when you have the authority to do so. Like if you're seeing a patient and you're not actually there, but a family member calls or you talk to the patient on the phone or something, you get a lot of really good info that the person needs to be seen for an ED. And you file, there's a different number of motions in New York and probably somewhat similar in Ohio. There are times where the police will take it upon themselves to decide if a person needs to go in or not without kind of understanding that this is a very, this is a clinical decision that's being made even from afar, which we do have skill and importance in doing this and authority. There are times when we have people on assisted outpatient treatment in New York, which means they've already been court ordered to take medications. It technically means that if they refuse medications, they can be taken straight to the ED. As a practical matter, that doesn't happen. Usually people who refuse medications on a court order will, I mean, the teams will do the best they can. And then unless they really start decommissating or something, then we'll use the pickup order kind of as a last resort. But the bar is really low for someone on AOT to get a pickup order. There are times where the police will like knock on someone's door and they won't answer like, well, we're not gonna go any further than that. We're not gonna open the door. So the answer to this, I don't know if there is a good answer to this is, there's some multidisciplinary or collaborative efforts between education, between mental health practitioners and law enforcement. A lot of them that I've seen or been somewhat aware of or seem to be more to do with people training officers so they understand a little more about mental health and maybe finding ways that they can deal better with some of the folks without necessarily worrying about them all being dangerous, which is kind of something that people think about as well, but not as much about these practical issues or what happens when there is really a legal method that's being followed, the process is being followed correctly. And then for some reason, the person on the other end, at the end of the line, an officer will say, no, I'm not gonna do that. That can be a big issue too. So the only thing I can think is better kind of collaboration between law enforcement and mental health leaders in the community, like yourself, like medical directors and things like that. I think you brought up so many... Oh, Amit, were you gonna say something? Yeah, I have a question for Dr. Anas that you spoke about the forensic psychiatry fellowship. And I mean, I'm CL certified, but it would be great to have a better experience or a better working knowledge. One of the ways to do it is, of course, to attend sessions like these, but what would be a good way in which to get more familiar with... I think I'm frozen. I don't know if anybody else is. Yeah, I'm getting into office. I think I might not have caught the very end of that, but the beginning when you mentioned, what are some ways of someone that has a good basis of some with clinical work, but can't really feasibly take the time to do a year of fellowship and do all that. And what are the best things to do? So I think one of the best things that I would recommend would be to... I would probably, and this is actually when Dr. Popley was talking, I was thinking of this as well, about the kind of like the best way to be as skilled as you can without necessarily going through a fellowship. I would recommend American Academy of Psychiatry in the Law Review course, which is given annually. And I believe it's three days. It's a pretty intensive course. And it wouldn't be like, oh, when you're done with this, you're a forensic psychiatrist and obviously not that. But if there's a way, I think that's probably a good way to get a good sense or at least a sense of a little of everything around forensics. And I think you could pick up a lot of issues that could be very helpful. It also would be helpful for those who work in correctional settings that aren't gonna get necessarily a forensic fellowship training, but what are some of the unique aspects of treatment in that setting versus other things like that? And then being involved in different organizations like American Academy of Psychiatry and the Law, American Academy of Forensic Sciences. There are a lot of those annual meetings and things like that that I think allow people to do a lot of collaborative work and learn from each other. Are there any specific resources in which you are able to see forensic write-ups or say competency evaluations? Resources to learn more about those? Actually see a couple of them written out. Like observe like the whole evaluation and everything? Yeah. Yeah. I mean, that is a good question. I know that there are some folks that have put up some videos or every once in a while if they have consent from the person that they use for educational purposes. I don't know if I know of any specifically. I don't know that Dr. Peele or Dr. Wasser. So I was just gonna mention, I mean, one, I would echo what Dr. Anna said about the review course. It's really a wonderful crash course in forensic psychiatry. But if you're looking for specifically resources or references about report writing or competency report writing, so I'm just putting a link in the chat here. So Dr. Mike Norco and Alec Buchanan were the co-editors of this book that won the Guttmacher Award, which is like a award given by the APA and Apple annually for the best writings of forensic psychiatry in that year. So it won this several years ago, but it goes through report writing principles across a number of different kinds of forensic psychiatry reports, including competency to stand trial. So that would be a pretty good resource that if you were interested in learning more about, you could reference. I echo those as well. There are also several centers that focus on forensic mental health or psychiatry and the law that often offer periodic trainings. So the University of Virginia often has trainings. My center at the University of Washington, the Center for Mental Health Policy and the Law, we offer trainings. There are just a handful of times during the year, but they're open to anyone. And oftentimes we do share things like example reports or video clips and go through how you might do an interview of a particular case scenario. And the book seems like a really nice resource and we look out for the courses and the crash course. Yeah, the Apple review course is very nice as a good introduction to a lot of issues in forensic mental health. And typically there are examples of at least abbreviated reports that are shown during those courses. So that might be a good way to get a flavor. And in forensics, like since we get these patients from the jail to some of them are under investigation for a crime and they have a couple of police officers sitting in with them in the room. So it will be, how does one go about asking? I mean, if it is necessary about the details of the crime and B, for an example, I had somebody who was a psychotic and a paranoid and he made some odd comments about being sorry for what he had done. And he said, you know, sorry for what he had done or something along those lines. And as part of the interview, I would have gone into more detail, but since there were the cops there, I did not go into that part of that interview. And of course I later Googled it. And I found that he had run over a couple of people because he was delusional. But what is the position of the psychiatrist in terms of interviewing somebody for treatment when they are under, you know, in custody or if your findings are going to be problematic for them in general? At least I would say, I think those sorts of things do come up all the time in different settings and jail settings and emergency room settings. I think you have to remember our obligation to first do no harm. And so I think you have to be really careful about what you're asking somebody when potentially either what you document about that could ultimately end up in some sort of legal proceeding or certainly if they're in the presence of police officers and they've been Mirandized and told everything they say, you know, could be used against them. So I think you have to be very ginger, very careful. And just as you experienced in that instance you're describing, you probably have to hold back from diving more deeply into something that you might in a different context that didn't have legal or potential legal implications. So I think you need to make sure you've gotten enough information in order to conduct a sufficient clinical evaluation, make sure that they're safe, make sure they're getting appropriate treatment interventions. But you may need to know that they're feeling sorrow or you may need to understand that they're having delusions but you wanna really steer clear of asking anything that might lead them to divulge information that could potentially be more harmful to them. Particularly if they're in a state of illness where they may not have the decision-making capacity to really appreciate what they're doing and what the ramifications of that sharing might be. I don't know what my colleagues think but that's what I typically advise people in similar circumstances. Yeah. I want to share my experience in the emergency. When I see a patient, a psychotic patient who is here to be examinated in order to see if he needs hospitalization or he needs treatment and he has committed a crime, we can, as a doctor, ask the co-op to leave the room, the examination room, so that we can have a good therapeutic relation with the patient. He is more confident, he can express his symptoms, his emotions, and unless the patient is dangerous and I need the presence of the co-op with me in the emergency. And we are not asked after the examination to leave any details about what the patient has said or even details about the crime that he has committed. So I think that the presence of the co-op in the examination is not something that is necessary but it's about something that I think when as a therapist in my relation with my patients. I don't know. I'm sorry, go ahead please. What's the question? I thought you were going to say something. I'm sorry. I was speaking and I thought I interrupted you. No, I'm not getting your question. No, I thought you were saying something. I thought I interrupted you. Did I? Are you finished? No, I have something. Okay, good, yeah. And I just want to make one quick, just a brief comment of it, which is related to kind of what you brought up. There are certainly situations where some type of security, whether it's an forensic hospital or if it's in a jail or prison or someone has to be taken out of the prison or jail setting for a higher level of care and it goes to an acute hospital where security is, where it is dangerous to be alone with a person, individual. There are situations like that. In general, I would say in those situations, those people are so acute that they're really not going to be amenable to therapy. So I wouldn't worry that much about really trying to connect with them on that level. It would be more about stabilization at that point. There are situations where if somebody is like a pretrial detainee, they haven't, they were in jail and then they get brought in. If the person, the person might end up confessing in a psychotic state or something like that and they may not realize that, but no officer hears that, the option might testify. I don't know exactly, every jurisdiction might be a little bit different. I would say that in situations where this is not exactly the same thing, but it was someone had to be on a one-to-one and I was doing a confidence to stand trial evaluation, which is not exactly a confidential evaluation. And we have to explain that in extreme detail or at least as clear as we can. And the person, the hospital said they had to have somebody there as one-to-one. And so I basically had said to the person, I want you to understand that you can't repeat anything you hear in this meeting when you go to your team meetings and stuff like that and everything like that. And he said, that's fine. And I guess that's one way we sort of navigated past that, but it's certainly a very tricky issue. I'm certainly would like to hear about how other people have tried to deal with those types of issues. Yeah, I would say, so for Amani, I think your point is a good one. And I think what you described is the ideal, if the officers will comply with that request. And I think part of the challenge is we don't control what the officers will do or willing to do. And so I think you're making a really good point that your first request should be, are you willing, if it's safe, if you as a clinically think it's safe to ask the officers, can they excuse you? Can they give you private space? And sometimes you're able to do that, but at least in the emergency room where I work, sometimes that privacy is behind a thin sheet. And so it's sort of a farce of privacy. And so I think that is the ideal, but recognize we don't always control these dynamics. And particularly if you're working in a correctional environment, you quite literally, it's not your domain, you're a service that's being provided in a correctional setting. And so you often won't be able to dictate the circumstances of the evaluation. But I think you're right to point out that that ought to be our first attempted intervention as psychiatrists. And then if that's not able to happen, then you accommodate based on the circumstances. I just wanted to go back to Dr. Copley, your question from earlier about dealing with a complicated situation about police not taking seriously your concerns about somebody's safety, or at least conducting their own assessment. I think in some ways there's similar parallels here, just in that obviously you can't control what the police are going to do, and they're gonna conduct the assessment however they're trained to do that. I don't know if they have CIT training where you are for the officers. So certainly that would be, go ahead. I was gonna say, we oftentimes will request that a CIT officer be sent. I've done some of that training of police many, many years ago, and they're still doing it in our community. And that's not always available. So they will do it if there's an officer available to go do that at the time, but it's not always the case. And so we will request it. We document that we requested it. I document who I talked to at the police department in my note and say, here's what I told them. I told them how concerned I was, blah, blah, blah, right? And then I will give my cell phone number and say, please call me, blah, blah, blah. That may or may not happen. So we're trying to document that we're doing the best that we can. I feel like that's all we can do. And sometimes it's really not, it's not very satisfying. I'm sure you all say that all the time. Yeah, well, I agree. And I was gonna validate, it does sound like you are doing all that one can do in that circumstance. And so it's a question of legally protecting yourself versus what's best for the patients. And so, I think obviously it sounds like you're doing as much as could be done to legally protect yourselves. As far as what's best for the patient, well, the only other things I could imagine, one would be if you aren't satisfied or if you're particularly concerned, you could also ask to speak to the person supervisor and see whether that's possible and try to get a better understanding of how did you reach this conclusion, given that I am a board certified trained psychiatrist and I'm really worried, how did you come to a different conclusion? The other thoughts I have are not really clinical legal, but more advocacy related. So thinking about other avenues that you might have to try to achieve the outcomes that Dr. Annas was talking about. So one would be potentially, I don't know how to go to local district branch of the APA, but that might be another avenue to consider because ultimately they usually have legislative liaisons. And that might be a way to try to think about, is there any way of trying to either actually adapt the laws in our county or state to better address this issue and keep up with what's going on, or at least try to see if they can help you liaise with the relevant like state senators or representatives who might be able to have impact over the police to try to get better responses. The other thought I had, and I don't know the county system that well in Ohio, but reaching out to the local mental health authority, you know, Department of Mental Health or whatever the acronym is, and trying to see if, because they also will likely have through state or county channels, some way of accessing the police leadership. And obviously you're not part of that system, you're a private practice entity, but I think ultimately they ought to be interested in how their constituents are being cared for. And if this is something that you are running into, my guess is they're also running into it in their spheres. So those are just a couple other more action oriented thoughts I had about how you might try to address it, not on the individual level, but more on the broader level. And much appreciated. It had not occurred to me to call my local APA and say, gosh, are you seeing any even, are you seeing any practices that do this well even? And can we not only try to advocate with the decision makers at the police level and lawmakers, but what are you recommending in the meantime? That's kind of like, Dr. Ernst is talking about the local standard of care. What's the local way that we do this? So I appreciate those ideas. Thank you. I have a question to Dr. Coakley. How do you request the intervention of the police officer? Sure. There's a non-emergency number that we call. Identify myself. There's a mental health worker at times, sometimes yes, sometimes no. If you're able to get a hold of a mental health worker, sometimes we have social workers that work for the police that will go out with the officer and those outcomes usually go better just because it's a mental health provider. It's like what we would call a probate pre-screener in our area, right? So somebody who's willing, not necessarily able to pink slip a patient, but able to impact the police's decision because they work on the police team. But if not, it could be just a single officer going out who may or may not be CIT trained. In my daily practice, when I have a patient that he need help or he need hospitalization against his consultant, it's one of my supervisors who writes a medical certificate to a public prosecutor's office. And the public prosecutor office indicates an emergency examination or sometimes compulsory hospitalization. So it's somehow complicated, but at the end, the patient get the suitable treatment because we did not deal directly with the police office, but with their supervisors. So, and it's through a medical certification. So it's complicated, but at least the patient get what he needs. Yeah, we do that too. We call it a pink slip. And the issue becomes when the patient and I are not in the same place. And so that's the tricky part that happens. One thing we notice where I practice is oftentimes we don't know when it is the police are gonna go out and try to make that contact. It could be immediately or sometimes it's days depending on the severity of other things going on in the city at the time. One thing I found helpful is, if you can get a sense. So typically if it's gonna be immediate, they're able to tell you that and I'll stay on the phone with my patient until the police arrive. And oftentimes my patient will give consent and I can pass on my concerns and observations directly to law enforcement, much higher chances than that the person's gonna be taken immediately to the ED. But oftentimes they are not able to give me a timeframe, in which case I tell my patient, you need to call me back in an hour and I'll just keep doing that with my patient. You can't do it indefinitely, but it does provide some ongoing connection between you and the patient. So you can continue to assess some risks and it gives you some sense of whether the police have made contact or not. And if they haven't in a reasonable time to follow up. I'm interested in your comment. I get consent from the patient because when I called the police, I'm identifying them as my patient and I recognize that I'm breaking confidentiality and my reason for doing that is an emergency. And so I'm interested in if that, if just even calling for a well check creates a potential problem. I mean, certainly we would document why we were doing that. We think this person is posing a risk, but you're breaking confidentiality. Yeah, usually if there's a serious and imminent risk, you do not need to get consent. You'll be protected by the language of HIPAA and state privacy laws. You wanna know exactly the laws in your jurisdiction, but typically if that's the scenario, you'll be protected. But you may be surprised in how often your patient will give consent. So if you're able to get consent, then you're not breaching their confidentiality and you can reveal more information that might be able to aid law enforcement and your patient in getting access to care in a timely manner. Sure. I'm wondering if we have time for another question. I'm running full of the time in general. So when you are evaluating standard of care, say you're reading, I read charts, I say, gosh, there may not be something, that might not have been something I would have done, but does that really fall below standard of care? One of the things that I've struggled with is many times you have providers from different disciplines. So I am a stickler, I guess, I don't know. So in my world, there's a standard of care, say for depression treatment in the hospital or risk assessment in the hospital or outpatient. There's a standard of care of certain things, but it's that provider that provided the care is not a physician. Is there a different standard of care? Like I would always go to APA guidelines, I would go to the research, I would go to professional organizations, but there are people providing care that are not physicians, but they're providing the same care. They're prescribing- There often is a different standard of care. And in fact, in many jurisdictions, only the discipline of the individual involved, meaning if it's a psychiatrist that is alleged to have reached the standard of care, only a psychiatric expert could weigh in. Similarly, if it's an internal medicine doctor that's alleged to reach the standard of care, then internal medicine doctor would weigh in. Now, oftentimes we do have some latitude in related disciplines. So maybe a psychiatric nurse practitioner or a psychiatric PA, but that will be up to the discretion of the court. And so certainly if you're retained as an expert, you wanna have those discussions early. It may be more prudent for that retaining attorney to get somebody of the discipline that's been alleged to have reached the standard of care. Got it. No, I appreciate that conversation. The patient would receive the same care. So the particular scenarios that I see a lot are mid-level providers, which in Ohio are supervised by physicians. So if you're supervised by a physician, does a mid-level provider have to provide the same standard of care that the physician would provide? Not necessarily. So if it's a nurse practitioner, for example, you will wanna look at things like guidelines issued by their discipline. Every once in a while, the laws can be different based on the discipline. So there might be a statute that requires a social worker to do something different than a physician where you're practicing. There could be even internal policies at the site that you work that break it down by discipline. So you do wanna gather that information. It may be that it's almost the same as being a practicing psychiatrist, but in some cases there could be differences. One thing I just wanted to add to that is that I know, and again, this is usually more local jurisdiction in the sense that what defines, what language defines a standard of care and things like that. But one of the general rules that we think about are that you are liable for the level where you're practicing. So in the example that we're usually used on, used is that if let's say we're seeing a patient as a psychiatrist and the person also has a seizure disorder but they stopped seeing a neurologist and you decide, well, you know what? I'm gonna, you know, they don't have a problem with affect liability, but you know, you start prescribing, you know, the seizure medications or something and something happens and then, you know, the person has some adverse reaction. You can't then step back and say, well, I'm just a psychiatrist. So you only have to hold me at the standard of a psychiatrist practicing as, you know, that decided to do neurology. In a sense, you're sort of putting yourself forward as someone who is now will be held at the standard of a neurologist. And so it's, I don't know how the courts have dealt with mid-levels in that sense, but at least the independently practicing mid-levels that are practicing in the psychiatric field, it would seem to me that there's certainly an argument to be made that they should be held at the standard of a psychiatrist, even though we know that they're not at that level because they are practicing higher than what their level is. Being under supervision adds a whole other complexity to it, of course. And so I think that, you know, that depends on how close the supervision is and also, you know, how much that really means that other than someone signing off on everything that the person does. And then just one other comment I wanted to make was that one of the reasons I think, you know, as much as not everybody can do a full forensic fellowship is that when you're doing, when you start getting into situations where you're consulting and doing forensic evaluations for the court, it does take a lot. I mean, and sometimes I didn't appreciate this until I finished fellowship or went through it, but it's not easy to, let me put it this way, it's easy without the training to get yourself in trouble. I don't mean that as far as getting yourself in trouble, like losing your license or anything like that, but I just mean that without knowing how you're supposed to act as an expert witness, there are a lot of rules, a lot of ethical rules to it that, you know, some folks will, without training will come in and then they'll just like say, oh, well, I think my job is to help the lawyer that hired me or something and not realize that, you know, when courts, you know, certainly when there's trials and things like that, the trier of fact really, which will be the judge or the jury really needs to understand and believe that an expert witness is trying to be as objective as possible in every situation. And so I think it's very hard sometimes for people who haven't gone through a lot of, some sort of training to really understand about the standard of care. Now the courts actually define the standard of care with the existence of expert witnesses, but most of the language is general, is almost like average practice or a reasonable person in that situation. So when you go to like guidelines and say, did they follow the guidelines? I mean, that's usually more of a gold standard than a standard of care. And so sometimes people may not have followed what the APA would consider the guidelines or something like that. But even if they fall below that standard, that doesn't necessarily mean we should be applying that and go ahead with the standard of care. And it can certainly be very complex, but I just wanted to make that point too. No, much. This is something that in doing not, obviously I haven't done a fellowship, but I certainly have sought out additional training and tried to learn as much as possible about this. So I recognize difficulties around that. And I think it's obviously a really hard thing. Being really open with anyone retaining me has been in my mind, the key to that, not I'm trying to represent the data that was collected. So appreciate it. Thank you. It looks like we have just a few more minutes if there's maybe one more question. Okay. And just to make another little brief comment, of course, as I said before, please feel free to email me if questions come up later or if there's any other things that you might be interested in, or just something that, or if your colleagues have to take this course after today and you can pass on my email. I mean, I give it in the talk, but I also mentioning that it was for this, in a sense for this Q&A, but I hope people understand that they can just email me. But if not, we'll certainly do our best to respond to as many questions as you might have as best we can. I just have a question to those who have been practicing in forensic department for years, because I think that's so challenging and maybe in few years, I will be university assistant in the forensic psychiatric department. How do you evaluate your personal experience? I think there's so many different ways to answer that. I can tell you what I do in terms of my report writing. I set an anniversary date every year and I make sure that I review all the reports that I've written in that year. I wanna get a sense of who it is that retained me and am I largely taking cases from either the defense or the plaintiff, just reminding myself what that year was like. I like to go back through the reports when I've had a little bit of distance from them to see if what I wrote sounds clear to me at the time. And occasionally I will ask one of my colleagues to review one of my reports just for independent feedback. And I think that's been a really useful supplement to my ongoing education. Thank you. That's so thorough, Jen, that you review. I don't know that I've ever been thoughtful enough to go back and look at my older reports, but now you've inspired me to go back and do that. So I do keep a running log of all the cases that I've been retained on and whether or not I report, what side they were on, what were the circumstances? Was it a civil case, a criminal case? If it was criminal, what were the charges? Things like that. If you do this kind of work, it's important to have that kind of a log because you will be asked. And in federal court, there are actually a requirement that you have to not only say the cases, but how many times you've been called to testify in court. So you need a list of all these things. The other thing that I've done maybe similar-ish, but much less intense than what Jen's describing is I stay connected to the department where I did my training. And so periodically, I'd say at least once or twice a year as part of that group, I present cases that I'm working on to get peer feedback on the kind of work I'm doing and to try to check myself a little bit to make sure that I'm trying to be somewhat within our own professional standards. So those are the mechanisms I use. I think it's particularly important if you end up being an expert in several cases where there's not an opposing expert. The opposing expert in many cases will be a great source of ongoing feedback for you. But oftentimes, you don't see that report or you might not get that feedback. So having another source is useful. Yeah, those are all really good things. And I just wanted to also mention, this device just mentioned that too. Yeah, I mean, that's a great thing. The anniversary and going back and reading, I think that's a really, really great idea. And even if you're not going to do federal work or you don't have something where you're required to give every list of things that you've done, it's good just to keep a log of it yourself. When it comes to these cases, you all often hear, oh, you work more for the prosecution or defense or whatever when you get into forensic work. But often it really comes down to more how much you can stay objective regardless of who you're with. So even if you, let's say you work, you just end up starting to do forensic work and you do a lot of work for VA's office. The question is more, how many times have you said, kind of went on there? Truthfully, I've never been pressured by an attorney to give an opinion one way or the other, but attorneys often will ask you how many, well, have you done defense malpractice cases or do you do the other malpractice case? Do you do the plaintiffs? Do you do this? And it's, a lot of folks get referred to by the attorneys that they work for. And then they're usually around the same type of field. And so sometimes that ends up how people get work and things like that. But also in general, as far as just overall, how you look back on your career and stuff like that, I would say some people think about it going into forensics and they're a little, oh, it's all criminals. It's gonna be all depressing. It's gonna be all awful. I would definitely say that's not the case. We always have challenging cases, but I mean, I think I've had more clinical direct care cases that have depressed me or made me feel that more so than forensics. But there certainly are some things where you might encounter some shocking things, but it's the same idea. You just do the same things that we all do and try to relax and let go and keep trying to stay healthy and stuff like that. Thank you. It was so nice to meet everyone and to see everyone here and I'll just echo, feel free to reach out if you do have questions. Thank you so much for joining us. Really appreciate that. It's great to see some faces for some folks that are interested in our course. I really appreciate you taking it and joining us today. Thank you for offering it. Thank you for the discussion.

forensic psychiatry

webinar

open discussion

standard of care

supervision

human rights

one-to-one care

collaboration

mental health practitioners

evaluating standard of care