Tuesday, June 17, 2014

Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 
      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient out while taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.


  1. "Good diagnostic work-up?"

    What tests are you talking about?
    Labs - blood tests, glucose levels, thyroid exams, hormone levels...?

    These things are not done routinely tested (sent out for testing) by psychiatrists, yet can be at the heart of the matter for anxiety, depression, etc.

    IMO, psychiatrists set themselves up for malpractice lawsuits by ignoring these very obvious things.


    1. True dat. I was mostly talking about taking a complete initial history, but ruling out medical causes should be a priority. Picking up on evidence for those is supposedly the advantage psychiatrists have over psychologists, and why psychologist prescribing is such a bad idea.

    2. 'Supposedly'

      Got dat right.