treatment means a sharing of authority and control over patient care, meaning a
loss of autonomy for each clinician. There is a widespread perception therefore
that split treatment is associated with significantly greater risks (Macbeth,
the sources of legal exposure? There is potential liability for all
psychiatrists who prescribe psychotropic medica-tions, see patients with
depression and anxiety, especially those patients with severe disorders, and
treat patients with significant suicide potential. Further, informed consent is
an important area of concern.
patients are shared in split treatment and it is dif-ficult for clinicians to
communicate with one another, there is ample opportunity for there to be a rise
in missing information, miscommunication and a decrease in quality of the
doctor– patient relationship. Patients are usually seen less frequently by the
physician in a split-treatment relationship and the patient is of-ten not clear
whom to call in certain emergency situations. Fami-lies are usually seen by one
of the clinicians, not both. Sometimes there is a supposition that the therapist
is being supervised by the physician when the physician believes the
relationship to be col-laborative rather than supervisory. Macbeth offers the
following risk-management strategies:
Psychiatrists should familiarize themselves with
the opera-tions and routines of all practice settings. The psychiatrist must be
knowledgeable about the expertise and authority of those involved in care
The most problematic practice sites should be
weeded out. Issues include looking at staff turnover, peer review proce-dures
and credentials of key staff members. The psychiatrist should find out about
opportunities for consultation and staff interaction, system immunities and
insurance of nonphysician clinicians.
There must be careful coordination with therapists
who have greater access to patients. The psychiatrist must inform the
therapists what information the psychiatrist needs; when she/ he needs to be
told about changes in the patient’s symptoms and condition, and the strengths
and weaknesses of the ther-apists. The psychiatrist must inform the therapist
about the medication regimens (potential side effects). This information must
be updated regularly.
Psychiatrists must understand the system review and
ap-peals procedures to be able to act quickly when there are problems.
Either consultation or supervision schedules should
be set up and documented regularly to review specific patients.
Personal assessment of individual patients must be
set up with reference to her/his condition, status and treatment.
Psychiatrists should be extremely careful not to
issue an insur-ance policy to a managed care organization or other system. All
proposed contracts must be carefully reviewed and not used to indemnify by