Guidelines for Prescribing Psychiatrists in Consultative, Collaborative, and Supervisory Relationships

As part of patient care activities, most psychiatrists enter into a variety of professional relationships with other clinicians. In particular, they are often asked to prescribe medications to the patients of other clinicians. When the division of responsibility in these relationships is ambiguous, the quality of treatment may be affected. Quality of care can be improved by delineating responsibilities and clarifying expectations between providers about communication, documentation, coverage arrangements, sharing of confidential information, and handling of emergencies.

A task force of the Harvard Risk Management Foundation in Cambridge, Massachusetts, has considered these issues and has developed guidelines for psychiatrists who work with other caregivers. By design, the task force specifically limited itself to guidelines for psychiatrists. With this clinical and risk management focus, we constituted the task force principally of psychiatrists. Therefore, we did not consider it proper to advise other mental health disciplines providing consultation, collaboration, or supervision, although we hope these guidelines will prove useful to other disciplines.

The task force also specifically confined itself to the role of psychiatrists asked to confer or treat in a manner that would likely involve the prescription of medications. Although psychiatrists clearly provide other important services to other clinicians, the problem cases that prompted the formation of the task force pertained to the prescribing role, and we thought this limited scope would help in keeping our work focused and on schedule. These guidelines offer a structure for approaching consultative, collaborative, and supervisory relationships. They will not apply in all circumstances, nor will all elements of the guidelines pertain in a given situation.

In the course of working with other caregivers, a psychiatrist may develop concerns about the quality or safety of the treatment another clinician is delivering. In our view, the patient's care and well-being are the primary obligations of every physician. When a psychiatrist believes that the appropriateness of a diagnosis or the quality of treatment is questionable, he or she should take action commensurate with the level of concern for the patient's safety. Often a forthright discussion with the other clinician will resolve the matter. For more complicated situations, the psychiatrist may wish to seek advice from an independent colleague or contact a risk management consultant.

This paper describes the guidelines developed by the task force, including definitions of key terms—consultation, collaboration, and supervision—and recommendations for working effectively with other clinicians. Examples of specific situations that might be encountered are offered to illustrate the usefulness of the guidelines.

Definitions

The task force recognized that "consultation," "collaboration," and "supervision" currently convey different and sometimes overlapping meanings to health professionals (1,2,3). Moreover, psychiatrists and psychiatric residents serving in these roles are faced with complex and ambiguous demands that can carry medical-legal risk and interfere with effective and collegial working relationships (4,5,6,7,8). We offer the following definitions toward a common understanding of the terms.

Consultation

Consultation occurs between two professionals who are licensed or credentialed to provide patient care. One—the consultee—requests an opinion from the other—the consultant. (The fee arrangements for consultative services vary, from third-party payment to direct payments from the patient, family, or consultee; however, payment is not a point of discussion in this paper.) The consultee considers the recommendations of the consultant and decides whether to follow them, based on the consultee's knowledge and understanding of the patient.

A consultation can be formal or informal. A formal consultation is usually based on a review of the patient's record or a meeting with the patient, or both. In a formal consultation, the consultee usually includes the consultant's recommendations in the patient's medical record.

By contrast, when performing an informal consultation, the consultant rarely learns the patient's identity, reviews the medical record, or engages in direct contact with the patient. Informal consultations have been called "curbside consultations" (9). A consultee should obtain permission from an informal consultant before recording his or her name in the medical record.

As an independent health care professional, in a formal consultation the consultant determines the appropriate scope of the patient's examination, which may differ from what the consultee requested. The consultant's documentation should be consistent with the consultation provided.

Because this definition of consultation assumes that the consultee has enough professional training and knowledge to evaluate and implement medical recommendations made by the consultant, the task force discourages prescribing psychiatrists from considering their interactions with unlicensed clinicians to be consultations. A psychiatrist asked by an unlicensed clinician for a pharmacotherapy consultation should recommend that the patient be referred for a full formal psychiatric evaluation.

Example of an informal consultation.

At a conference on mood-regulating agents, a psychiatrist sought out the lecturer after her presentation and asked for advice about the treatment of a patient whose renal disease made treatment with lithium salts problematic. Although the patient's identity and thorough history were not discussed, sufficient information was conveyed about the patient to establish which medication might be safer and potentially effective. The consultant's suggestions were implemented, but her name was not recorded in the patient's record.

Example of a formal consultation.

A psychiatrist sought consultation from a colleague with expertise in the treatment of refractory psychotic disorders. The consultant obtained sufficient information from the consultee to focus the consultation request, then interviewed the patient and offered suggestions for further treatment. The consultant's recommendations were documented in a letter sent to the consultee and incorporated into the consultee's medical record for that patient. The consultee implemented the suggestions he felt to be most relevant to the patient's care.

Collaboration

Collaboration, sometimes referred to as cotreatment, dual treatment, or split treatment, occurs when two licensed or credentialed professionals share ongoing responsibility for complementary aspects of a patient's treatment. This relationship differs from consultation in that each clinician is independently responsible for the application of particular skills in the direct care of the patient (10,11).

The delineation of responsibilities should be determined by the collaborators and then discussed with the patient to clarify roles and to obtain the patient's consent to the arrangement. We urge that the psychiatrist's medical record reflect these discussions, including dates, and document the arrangements that have been established.

Collaboration is often initiated by a request for an evaluation or consultation. For example, a licensed psychologist providing psychotherapy may ask a psychiatrist to determine whether pharmacotherapy might help a particular patient. If the psychiatrist's evaluation suggests pharmacotherapy is appropriate and acceptable, the psychiatrist might begin a collaborative relationship with the psychotherapist in the care of that patient or offer referral to another clinician who could provide pharmacotherapy collaboratively.

The task force cautions psychiatrists about prescribing medications at the request of clinicians who are unlicensed or uncredentialed; this type of interaction is not a collaboration according to the definition proposed. (In some milieu programs or staff-model health maintenance organizations, collaborative relationships exist between psychiatrists and credentialed but unlicensed clinicians.) Psychiatrists prescribing medications at the request of an unlicensed or uncredentialed clinician may expose themselves to bearing most of the clinical and ethical liability. Unlicensed or uncredentialed clinicians may not have met professional or regulatory standards and may not carry malpractice insurance (see the example below).

We recognize that unlicensed or uncredentialed therapists may play an important role in the patient's life, and that in some instances this attachment may be fundamental to the patient's psychic equilibrium. We also appreciate that "alternative" therapists are increasingly recognized for their value but may not yet have achieved approval from licensing authorities. Nevertheless, it is our view that psychiatrists should recognize that clinicians without a license and conventional credentials are not held to the same medical-legal standards as physicians. In agreeing to a collaborative relationship, the physician may be held responsible for the care rendered by the unlicensed clinician.

Example of a collaboration with a licensed clinician.

A licensed psychologist sought consultation from a psychiatrist about the advisability of prescribing medication for a patient's anxiety. The psychiatrist discussed the patient with the psychologist, met with the patient, reviewed relevant medical records, and diagnosed panic disorder. The psychiatrist then offered to prescribe antipanic medication to the patient in collaboration with the psychologist. The patient agreed to add pharmacotherapy to the ongoing psychotherapy, and the clinicians delineated responsibilities for the patient's care.

Example of responding to a request from an unlicensed clinician.

An unlicensed therapist referred a patient to a private-practice psychiatrist for evaluation and treatment. The psychiatrist requested some preliminary information about the patient and also asked about the therapist's background and credentials. The psychiatrist indicated to the therapist that she would accept this transaction as a referral for evaluation and treatment but could not enter into a collaborative relationship with the therapist. The psychiatrist asked the therapist to have the patient call to set up the appointment.

As a result of the evaluation, the psychiatrist diagnosed major depression and started the patient on antidepressant medication. The patient chose to discuss his diagnosis and treatment with the therapist. A report of the patient's evaluation and treatment was not sent to the therapist; however, at the patient's request, the psychiatrist discussed the patient's condition and treatment plan with the therapist.

Supervision

Supervision, for the purpose of these guidelines, is a mandated relationship between two professionals in which one—the supervisee—is generally obliged to follow the recommendations of the other—the supervisor—over a period of time. The supervisor is expected to evaluate the competence of the supervisee, taking into consideration his or her background, training, and experience, and to confer responsibility on the supervisee accordingly (12). However, the responsibility of supervisors for quality of care, and the malpractice risk attendant on that responsibility, is fairly well established (13,14).

A national standard of care, rather than a community standard, now characterizes the malpractice judgments of the majority of courts. Supervisors have a duty to ensure that patients under their supervisees' care obtain the national standard of care and that supervision is adequate to ensure that the standard is met. Since the 1970s, malpractice cases involving residents in all specialties have principally concerned whether a standard of care was met, the adequacy of supervision, and vicarious liability for supervisors and service chiefs.

A supervisor may exercise guidance or control of the supervisee's clinical work, as well as of the process of supervision, directly or through a designee. The designee is a colleague with acknowledged expertise in the relevant practice area who has explicitly agreed to accept supervisory responsibility. For example, a director of a psychiatric outpatient service might ask an expert on mood disorders to supervise residents who have patients with these disorders. Not all educational and didactic activities constitute supervision; however, the task force suggests that this supervision guideline may be useful in some didactic relationships.

Supervision may be intensive—occurring at frequent intervals and with close attention to the patient and treatment—or infrequent. It may be focused or general. The parameters will depend on the supervisor's assessment of and degree of confidence in the supervisee's ability to practice independently. The supervision may change over time as the supervisee becomes more experienced and competent.

Supervision may be part of formal professional training, as in a psychiatric residency program, or it may be imposed through other mechanisms. For example, chapters 94C and 112 of Massachusetts General Laws require that the prescribing practices of a registered nurse psychiatric clinician be supervised by a psychiatrist (15). The Massachusetts Board of Registration in Medicine may condition the licensing of an impaired physician on supervision by another physician. In addition, a health care entity may impose supervision on a clinician as a remedial action to improve the quality of care being delivered to its patients.

When supervision is voluntarily sought out, the parameters of the relationship are less stringent. For example, the supervisee is not required to follow the supervisor's suggestions or to undergo assessment of competence by the supervisor. A psychiatrist who infrequently prescribes medication, for example, might ask another psychiatrist to "supervise" the treatment of a patient with a complicated medication regimen.

The treating physician who receives voluntary supervision writes all medication orders or prescriptions and has full responsibility for the care of the patient, although he or she may benefit substantially from the advice provided. This common interaction may best be considered an educational activity. If the supervisor—the person providing the ongoing education—comes to believe that the educational service is becoming a consultative arrangement, he or she should follow the consultation guidelines described above.

Example of resident supervision.

The director of an outpatient department was expected to supervise the psychiatric residents' clinical work on that service. The residents were expected to inform all their patients of the supervisory relationship and to review the management of each case with their supervisor. The supervisor's approach emphasized the development of the residents' skills, allowing them considerable freedom in their treatment choices. However, if the supervisor questioned the appropriateness of a treatment decision, she would review the decision with the resident and consider whether it was appropriate for her to insist on a different approach or to meet with the patient to ensure proper patient care.

Example of supervision of a registered nurse psychiatric clinician.

A registered nurse credentialed as a psychiatric clinician arranged for a qualified psychiatrist to take on the role of supervising physician. Together they wrote a supervisory plan in accordance with Massachusetts law and the regulations of the Massachusetts Board of Registration in Medicine, the Board of Registration in Nursing, and the Department of Public Health. Two to four times a month, the nurse met with and paid the psychiatrist for professional time to review a minimum of 20 percent of her prescriptions. The nurse documented the supervisory input in a log and, when appropriate, in her patients' medical records.

At least every three months, the psychiatrist summarized the supervision in a written record and discussed this review with the registered nurse psychiatric clinician. All patients receiving prescribed medications from the nurse were informed of the presence and role of the supervisor. The psychiatrist assumed responsibility for providing ongoing supervision to ensure that the nurse had appropriate guidance. Patients whose needs exceeded the defined scope of the nurse's practice were referred to the supervising physician or elsewhere as appropriate.

Example of imposed supervision.

The Massachusetts Board of Registration in Medicine, acting on a complaint from a patient who claimed that an addictive substance was improperly prescribed to him, determined that the prescribing psychiatrist suffered from depression and a narcotic use disorder that interfered with the quality of his psychiatric practice. After the psychiatrist underwent intensive treatment, one condition for his return to work was that he receive clinical supervision for his treatment of all substance-abusing or substance-dependent patients. He met with a supervising psychiatrist weekly and documented the supervisor's advice in his patients' records. The supervisor, experienced in work with impaired physicians and with addiction treatment, recognized a responsibility both to oversee the appropriateness of treatment and to offer guidance as needed. The supervisor also had the responsibility of informing a monitoring agency of the supervisee's continued attendance at supervision sessions.

Guidelines for consultation, collaboration, and supervision

With these definitions and examples in mind, the task force developed guidelines for psychiatrists providing consultation, collaboration, and supervision for prescribing psychiatrists. Discussions, evaluations, and recommendations relevant to patients' care should be documented in their medical records.

An effective consultation, collaboration, or supervision begins with a thorough assessment of the context and circumstances of the clinical situation. Our view is that a narrow request—for example, for an assessment for antidepressant medication—while reasonable, need not limit the psychiatrist's evaluation. Psychiatrists evaluating or treating patients should exercise their judgment and extend inquiry into all relevant diagnostic and therapeutic aspects of a patient's care.

In assessing a patient, in a consultation or a collaborative or supervisory relationship, the psychiatrist should ask whether others are clinically involved in the patient's care. It can be a mistake to assume that the other clinician is the only other professional involved. A recently closed case at the Harvard Risk Management Foundation involved multiple therapists and multiple physicians providing medication, but individual group members had only limited knowledge about who was involved and who was doing what.

We also urge psychiatrists to determine, to the extent possible, why they have been asked to assist through a consultative, collaborative, or supervisory relationship. Requests may be clear and reasonable; however, on inspection, they may derive from unexpected and at times unrecognized wishes to avoid important aspects of a difficult therapy, to inappropriately delegate responsibility, or to terminate with a patient.

In communicating with other clinicians, we urge psychiatrists to be open about, and prepared to discuss, their treatment approach, experience, and goals. If another clinician's treatment of a patient appears to be problematic, the psychiatrist should discuss his or her concerns with that clinician, particularly addressing any issues involving the safety of the patient or others.

For psychiatrists providing supervision, communication may be assigned to the supervisee, as appropriate. For example, a psychiatric resident supervisee may be asked to communicate with a patient's primary care physician or outpatient therapist. When providing consultation to a primary care physician, the psychiatrist may find it useful to determine the physician's experience and comfort with psychiatric illness and prescription of psychiatric medications.

The task force recommends that, to the extent possible, all involved clinicians define their respective roles. In a consultation, a psychiatrist is generally asked to give an opinion, which the consultee is free to follow or not, based on the consultee's knowledge of the patient. In a collaboration, the psychiatrist delivers direct care to the patient concurrent with other licensed or credentialed mental health or health care professionals.

A supervision is a formal arrangement in which the psychiatrist trains and evaluates another mental health professional. Some types of voluntary educational arrangements are referred to as supervision; however, if this type of arrangement begins to become more consultative, the psychiatrist should consider following the consultation guidelines. When working as a consultant, collaborator, or supervisor for a resident, the psychiatrist should consider inviting the resident to attend or participate in the evaluation of the patient if it would be an appropriate teaching exercise, and if the patient consents.

In all professional arrangements among multiple caregivers, the caregivers should be sure to clarify expectations about communication among themselves. Specifically, they should try to establish the content of future communications, their frequency, and the preferred methods, such as phone, e-mail, or letters. If a psychiatrist is asked to consult or collaborate with a clinician who is being supervised, the psychiatrist should ask that clinician to inform the supervisor about the psychiatrist's participation in the assessment or care of the patient. The psychiatrist should decide whether to communicate with the clinician, the supervisor, or both.

Finally, a communication plan should be established among clinicians for emergencies. Although emergencies are infrequent, they represent critical times for patients' safety and the treatment alliance, and they always challenge working relations between patients and physicians and among responsible clinicians. Clinicians should clarify who will be responsible for various aspects of the patient's care, and what the coverage arrangements for each clinician will be.

Communication includes not only the clinicians but the patient. Some of the responsibilities for communicating with the patient may be assigned to a supervisee, as appropriate. The clinician should ask the patient about his or her understanding of each of the clinicians' roles. Questions in this area not only are important in establishing roles and responsibilities but can be quite revealing of the patient's understanding and expectations of the various caregivers and treatments.

The patient's preferences, and consent, about disclosure of information must also be addressed. The clinician should convey to the patient the limits of confidentiality, including required disclosures for insurance and reimbursement purposes as well as disclosure in situations involving risk of harm to the patient or others. The clinicians' plan for sharing relevant information among themselves and with the patient should be explained to the patient. Any conflicts between the patient's and clinicians' preferences for sharing information should be addressed. If the patient does not permit clinicians to discuss relevant material with other treating clinicians, the others should be informed that information exists that the patient does not allow to be shared. Sensitive material should not be divulged without the patient's consent. Continuing treatment with a patient who does not permit open communication of medically necessary information among treating clinicians may not be clinically responsible or feasible.

The task force recommends disclosing most supervisory relationships to patients (16). For example, residents and registered nurse psychiatric clinicians should inform patients about the involvement of program supervisors and supervising physicians.

Because so much of what can be accomplished in treatment will be contingent on the patient's resources, as well as the resources of the family and community, the task force recommends that the psychiatrist inquire about insurance, financial resources, and other economic considerations that could influence treatment decisions. The psychiatrist should also assess the availability and appropriateness of having family or significant others assist in treatment implementation, through such activities as supporting medication compliance, monitoring the patient's safety, and providing financial assistance. Arrangements for fees and billing should be clarified by the treating clinicians.

A consultation, collaboration, or supervision may entail addressing some of the following areas and issues. As noted earlier, a full psychiatric evaluation will typically be needed, especially if the consultation, collaboration, or supervision is complex or involves safety concerns such as suicide, homicide, or property destruction. Diagnosis is enriched by a formulation of the case (what stresses have had an impact on what vulnerability—somatic or psychological—to produce the current clinical picture?) and by identification of the clinical issues needing immediate attention (17,18). In any request for pharmacotherapy, the psychiatrist should be mindful of transference or countertransference issues that might be influencing the request.

As a consultant, as well as in any collaborative treatment, the psychiatrist should recommend further steps as appropriate, including additional diagnostic interviews or tests; pharmacotherapy, addressing relevant drug interactions; psychotherapy, such as individual, group, or family treatment; and other support, such as vocational education or training, assistance in obtaining entitlements, rehabilitation, and self-help or recovery programs. If the psychiatrist plans to provide treatment, the risks and benefits should be discussed with the patient, and the patient's informed consent obtained as appropriate.

The clinical intervention should not be considered complete until all providers clarify their responsibilities for treatment and follow-up.

When engaged in supervision, the psychiatrist should assess the supervisee's diagnostic and treatment skills, including the ability to understand diagnostic procedures and results, such as imaging, laboratory studies, and neuropsychological tests; the ability to develop a biopsychosocial formulation, including transference and countertransference issues; the ability to identify key issues requiring immediate attention; and the ability to understand the various aspects of pharmacotherapy, such as classes of drugs, indications, dosages, interactions, and side effects.

The psychiatrist should also assess the supervisee's understanding of the role of the supervising or prescribing psychiatrist and when to contact the supervising psychiatrist. Finally, a supervisory plan that articulates and addresses the learning needs of the supervisee should be developed and revised as needed.

The prescribing psychiatrist should be careful to follow through with established agreements. Particularly important is communicating results of assessments and any plans for diagnostic or therapeutic interventions that the patient and other clinicians are anticipating. The persons expecting information should be told of any delay, rather than being kept in the dark about when information will be forthcoming. When appropriate, relevant information should be communicated to authorized recipients as agreed on and with written consent—for example, from the family, payer, licensing board, or training program. In consultation, the follow-through should also include possible return appointments. Finally, the psychiatrist should consider discussing the procedure to be followed if either the patient or one of the clinicians wants to redefine or terminate the treatment relationship.

Conclusions

Psychiatrists increasingly are involved in a variety of professional relationships with other clinicians. The roles of these clinicians are often ambiguous and uncertain. Although uncertainty can be diminished, it cannot be eliminated—a fact that it is important for clinicians to acknowledge among themselves and with the patient and significant others. Effective consultation, collaboration, and supervision is always a partnership among all involved. Engaging the patient in the complex process of understanding roles and responsibilities is likely to involve the patient more actively in the process of treatment, thereby improving the alliance and the patient's experience of being treated respectfully.

In this paper, we have offered definitions for consultation, collaboration, and supervision and have provided a structure and guidelines for consultative, collaborative, and supervisory relationships. In our view, the patient's care and well-being are the primary obligations of every physician. Many of these guidelines will be useful, but like all guidelines, they will not apply in all circumstances, nor will all elements of the guidelines pertain in a given situation. Discussions, evaluations, and recommendations relevant to a patient's care should be documented in the medical record.

Acknowledgments

This article reflects the work of a task force of the Harvard Risk Management Foundation. Task force members were Lloyd Sederer, M.D. (cochair), James Ellison, M.D., M.P.H. (cochair), MaryAnne Badaracco, M.D., George Dominiak, M.D., William Falk, M.D., Gordon Harper, M.D., Burt Johnson, M.D., Catherine Keyes, J.D., Nancy Nitenson, M.D., David Osser, M.D., Randall Paulsen, M.D., Peter Reich, M.D., Andrew Stoll, M.D., and Gail Tsimprea, Ph.D.

Dr. Sederer is affiliated with McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02178 (e-mail, [email protected]). Dr. Ellison is with Boston Regional Hospital in Stoneham. Ms. Keyes is with the Harvard Risk Management Foundation in Cambridge.