Split treatment raises concerns about ethical risks for psychiatrists and other mental health care professionals entering into such relationships without appropriate safeguards and policies. The increasing pressures of managed systems of care have pushed the formation of such relationships without adequate oversight, planning, or scientifically valid research into outcome, efficacy, and cost-efficiency Systems continue to promote split treatment, adding administrative cost and often increasing the complexity of treatment. Clearly, there are groups of patients for whom the team approach provides excellent care. When such treatment is the treatment of choice, there is no ethical problem. When such treatment is provided primarily for cost consideration, however, there are often formidable ethical problems.
The American Medical Association1 and the American Psychiatric Association (APA)2 have recognized the importance of physicians collaborating with other health care and mental health care professionals. Section 5 of the American Medical Association's principles states: "A physician shall continue to study apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated." The APA has also published guidelines for psychiatrists in consultative, supervisory, or collaborative relationships with nonphysician clinicians.3
There are many areas of potential ethical conflict when psychiatrists and other mental health care professionals enter into split treatment relationships, including state licensing laws, competency questions, being used as a figurehead, delegation of medical judgment, and financial arrangements. The following case vignettes illustrate these conflicts.
STATE LICENSING LAWS
A psychiatrist working in a busy public psychiatric clinic was encouraged by the administrator of the clinic to leave signed prescriptions at the clinic that could be filled in by other mental health care workers and given to patients. Because of the considerable cost constraints in the clinic and the psychiatrist's belief in the abilities of the other mental health care workers, he allowed this to occur for some time. He subsequently had an action taken against his medical license when the licensing board became aware of this practice and also had an ethics sanction by his APA district branch.
Psychiatrists in public systems are often confronted with limited budgets and inadequate resources for patient care. Whenever a psychiatrist is called on to sacrifice quality of care for the sake of convenience or expethency, he or she should protest and attempt to resolve the problem in favor of better patient care. Each psychiatrist must decide how far treatment can be compromised. Professional and patient advocacy organizations can assist in advocacy for adequate funding to resolve these types of problems.
A psychiatrist contracting with a health maintenance organization worked closely with several psychologists by providing medication management for the patients whom the psychologists were treating with psychotherapy The psychiatrist had a contract with the health maintenance organization in which he agreed to provide the same standard of care to patients in the health maintenance organization as he provided to patients covered by other payers. In time, the psychiatrist trusted the work of the psychologists and began to assess the patients who were referred more rapidly. He often would take the recommendations of the psychologists for psychotropic medications, and because the patients were receiving regular psychotherapy, he would see them personally only when they complained to the psychologists of problems. After awhile, when the psychologists would call him about patients, the psychiatrist would call in prescriptions for the recommended medications without evaluating the patients himself.
One of the patients was a middle-aged man with severe depression. He was treated by one of the psychologists with psychotherapy and was seen once by the psychiatrist, who prescribed nortriptyline until a therapeutic blood level was reached. The psychiatrist then only called in prescriptions and did not see the patient for 2 years. When the patient committed suicide with an overdose of nortriptyline, the psychiatrist was sued for malpractice and an ethics complaint was filed. It was determined that the psychiatrist would see many other patients with a similar diagnosis and medication at least once every 1 to 2 months. His treatment of thi9 patient was found to be below the standard of care and a substantial judgment was made to the patient's widow. In addition, the ethics committee of his APA district branch concluded that the psychiatrist's care of the patient was incompetent because he had not regularly assessed the patient in a manner similar to other patients and that he may have been in a position to evaluate the patient/ s suicidality.
Psychiatrists must consider the recommendations of other mental health care professionals but ultimately make independent decisions about medications based on a personal assessment of patients. In general, assessments should be done in conformance with the overall practice pattern of the psychiatrist.
A psychiatrist contracting with a managed care company provided medication management for patients who were also receiving treatment from nonphysician clinicians. Because the psychiatrist did not personally know these nonphysician clinicians, he relied on the managed care company to ensure their competency through its credentialing process. There was no direct contact with the nonphysician clinicians because the cases were "managed" by someone at the managed care company.
The psychiatrist subsequently learned from an article in the newspaper that one of the nonphysician clinicians had been charged with sexual misconduct by three patients. These three patients subsequently filed a malpractice action against the psychiatrist and an ethics complaint claiming that he knew or should have known that the nonphysician clinician was an incompetent and unethical practitioner. Although the psychiatrist settled the malpractice claims, he was reprimanded by his APA district branch, which concluded that he had not maintained adequate collaboration with the nonphysician clinician. This collaboration might have alerted him to the possibility of incompetent or unethical treatment.
Although there may be a third party in these situations, such as a case manager, the psychiatrist must personally ascertain important patient information from the nonphysician clinician and the patient and make an independent judgment about the course of treatment. When this communication occurs in a safe and accountable way, there may be less necessity for direct contact between the psychiatrist and the nonphysician dinician. If the psychiatrist has any indication that the nonphysician clinician is incompetent or that there is evidence of unethical behavior, a course to protect the patient must be pursued through the case manager and the patient.
REING USED AS A FIGUREHEAD
A psychiatrist was hired by a managed care company on a 10 hours per week basis to provide medication consultation, supervision, and consultation to a group of 30 mental health care professionals who were providing psychotherapeutic services within a clinic to a population of 130,000 individuals. While at the clinic, the psychiatrist was asked to sign insurance forms, fill out disability papers, and see 5 to 8 patients per hour for medication management. He had limited supervisory or consultative time with the other mental health care professionals, although there were team meetings weekly. The managed care company told the insured population that it had a fully trained psychiatrist on staff who provided supervision, consultation, and direct patient treatment.
One of the psychiatrist's patients had a complicated medical problem, and on one visit the psychiatrist felt too constrained by time pressures to adequately evaluate the new medications that had been added to her medical treatment. She subsequently had severe side effects from an increase in her psychotropic medications and filed an ethics complaint against the psychiatrist, daiming that his treatment was incompetent and that he was presenting himself as providing competent treatment when in reality he had inadequate time to do so.
Psychiatrists have an ethical duty to protest systems that they believe are unethical. One protesting physician may have limited impact in such a case; professional, patient advocacy, and legislative bodies may be able to address these dilemmas better. In the absence of such relief, psychiatrists should not allow themselves to be used in a figurehead role.
DELEGATION OF MEDICAL JUDGMENT
A family physician had been seeing a woman in his practice for many years for the treatment of migraine headaches. The patient had received 50 mg of amitriptyline nightly for 5 years. On a recent visit, she complained of depression and he increased her dose to 100 mg nightly. He then referred her to a psychologist who collaborated with a psychiatrist.
After evaluation, the psychologist requested medical records from the family physician and called the collaborating psychiatrist. He told the psychiatrist that the patient appeared to have a major depression and requested that the psychiatrist call in a prescription for fluoxetine. The psychiatrist did not think that there was a problem because the family physician who had been seeing the patient regularly had referred her. The psychologist received medical records from the family physician that included an electrocardiogram reporting first-degree atrioventricular block. The psychologist made a mental note to inform the psychiatrist of this.
The patient started taking fluoxetine. After 1 week, the psychologist was called by an emergency department where the patient had been taken after experiencing an arrhythmia. She was comatose. The patient was found to have a toxic level of amitriptyline (due to the addition of fluoxetine) on a laboratory workup. Her family filed an ethics complaint against the psychiatrist for incompetent treatment and complained to the local grievance committee for psychologists.
When prescribing authority is inappropriately delegated to insufficiently trained professionals, the psychiatrist (or other physician) is always over the ethical, and often the legal, edge.
The dilemmas relating to split treatment are similar in training settings. In these situations, however, there is a higher likelihood of adequate communication and collaboration among the treating professionals. If this is not the case, the same difficulties regarding ethical pitfalls can occur. The training setting is an ideal place to learn the principles of sound clinical and ethical collaborative treatment and the problems of inadequate collaboration.
A psychiatrist referred patients to a psychologist working in the same office building. The psychiatrist asked the psychologist to give him 20% of the fees collected for these patients. The psychiatrist provided no services other than acting as the referral agent.
This arrangement constitutes unethical fee splitting. Fee splitting is defined as payment by or to another physician or nonphysician clinician solely for the referral of a patient. It is imperative that when psychiatrists and nonphysician clinicians establish their financial relationships, they do so in a way that does not constitute fee splitting. Set fees based on supervision or administration should be negotiated between the professionals and should be open to renegotiation should the need arise.
Patients should be able to trust that their referral to another mental health care professional is on the basis of the expertise of that individual and not primarily because of financial incentives that the referring physician receives. In addition, patients need to be informed whether there is any financial, supervisory, or other collaborative relationship between the professionals providing treatment.
A psychiatrist employed several psychologists and paid them a salary that was adjusted relative to billed hours. The psychiatrist billed the patients for their time spent with the psychologists (indicating this on the billing) and received the income. Patients were informed that the psychiatrist employed the psychologists. The psychiatrist provided medication management for patients seen by the psychologists, overhead expenses, and supervision for the psychologists.
This arrangement is acceptable and does not constitute unethical fee sph'tting. The psychiatrist clearly has responsibility both ethically and legally for the patients treated by the psychologists.
There are many situations in current practice that differ from these vignettes. The principal ethical dilemmas are those involving conflict over what is in the best interest of the patient compared with what is in the best interest of the professionals. When there is a conflict between the two, resolution should favor the best interest of the patient.
Psychiatrists considering split treatment responsibilities can ethically undertake such relationships if:
1. They are able to keep informed in an adequate and timely fashion of the nature of treatment and the progress of patients.
2. They can assure themselves that the treatment is being provided competently.
3. They provide enough supervision, consultation, or collaboration to ensure that their ethical, medical, and legal responsibilities toward patients are met.
4. The split treatment is consistent with local or state guidelines outlining psychiatrists' responsibilities to patients and in conformity with state licensure requirements and the scope of practice of all professionals involved.
Ethical principles require physicians and other mental health care professionals to provide fair and honest care in the best interests of patients, without harming them, and with their informed consent. Following ethical guidelines can assist all professionals in their mutual goal of providing improved treatment to patients.
1. American Medical Association Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions With Annotations. Washington, DC: American Medical Association; 1997.
2. American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC: American Psychiatric Association; 1997.
3. American Psychiatric Association. Guidelines for psychiatrists in consultative, supervisory, or collaborative relationships with nonmedical therapists. Am J Psychiatry. 1980;137:1489-1491.