Medicolegal Issues

What are your responsibilities after a screening call?

Current Psychiatry. 2014 September;13(9):54-57

References

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Dear Dr. Mossman,

When I take a call from a treatment-seeker at our outpatient clinic, I ask brief screening questions to determine whether our services would be appropriate. Shortly after I screened one caller, Ms. C, she called back requesting a medication refill and asking about her diagnosis.

What obligation do I have to Ms. C? Is she my patient? Would I be liable if I didn’t help her out and something bad happened to her?

Submitted by “Dr. S”

Office and hospital Web sites, LinkedIn profiles, and Facebook pages are just a few of the ways that people find physicians and learn about their services. But most 21st century doctor-patient relationships still start with 19th century technology: a telephone call.

Talking with prospective patients before setting up an appointment makes sense. A short conversation can clarify whether you offer the services that a caller needs and increases the show-up rate for initial appointments.¹

But if you ask for some personal history and information about symptoms in a screening interview, does that make the caller your patient? Ms. C seemed to have thought so. To find out whether Ms. C was right and to learn how Dr. S should handle initial telephone calls, we’ll look at:
• the rationale for screening callers before initiating treatment
• features of screening that can create a doctor-patient relationship
• how to fulfill duties that result from screening.

Why screen prospective patients?
Mental health treatment has become more diversified and specialized over the past 30 years. No psychiatrist nowadays has all the therapeutic skills that all potential patients might need.

Before speaking to you, a treatment-seeker often won’t know whether your practice style will fit his (her) needs. You might prefer not to provide medication management for another clinician’s psychotherapy patient or, if you’re like most psychiatrists, you might not offer psychotherapy.

In the absence of prior obligation (eg, agreeing to provide coverage for an emergency room), physicians may structure their practices and contract for their services as they see fit²—but this leaves you with some obligation to screen potential patients for appropriate mutual fit. In years past, some psychiatrists saw potential patients for an in-office evaluation to decide whether to provide treatment—a practicethat remains acceptable if the person is told, when the appointment is made, that the first meeting is “to meet each other and see if you want to establish a treatment relationship.”³

Good treatment plans take into account patients’ temperament, emotional state, cognitive capacity, culture, family circumstances, substance use, and medical history.⁴ Common mental conditions often can be identified in a telephone call.^5,6 Although the diagnostic accuracy of such efforts is uncertain,⁷ such calls can help practitioners determine whether they offer the right services for callers. Good decisions about initiating care always take financial pressures and constraints into account,⁸ and a pre-appointment telephone call can address those issues, too.

For all these reasons, talking to a prospective patient before he comes to see you makes sense. Screening lets you decide:
• whether you’re the right clinician for his needs
• who the right clinician is if you are not
• whether he should seek emergency evaluation when the situation sounds urgent.

Do phone calls start treatment?
As Dr. S’s questions show, telephone screenings might leave some callers thinking that treatment has started, even before their first office appointment. Having a treatment relationship is a prerequisite to malpractice liability,⁹ and courts have concluded that, under the right circumstances, telephone assessments do create physician-patient relationships.

Creating a physician-patient relationship
How or when might telephone screening make someone your patient? This question doesn’t have a precise answer, but how courts decided similar questions has depended on the questions the physician asked and whether the physician offered what sounded like medical advice.^10,11 A physician-patient relationship forms when the physician takes some implied or affirmative action to treat, see, examine, care for, or offer a diagnosis to the patient,^9,12,13 such as:
• knowingly accepting someone as a patient¹⁴
• explicitly agreeing to treat a person
• “acting in some other way such that the patient might reasonably be led to assume a doctor-patient relationship has been established.”¹⁵

Also, the “fact that a physician does not deal directly with a patient does not necessarily preclude the existence of a physician-patient relationship,”¹² so a telephone conversation can create such a relationship if it contains the right elements. Table 1¹⁶ highlights actions that, during the course of screening, might constitute initiation of a physician-patient relationship. Table 2 offers suggestions for managing initial telephone contacts to reduce the chance of inadvertently creating a physician-patient relationship.

In the eyes of the law, whether a physician-patient relationship was formed depends on specific facts of the situation and may be decided by a jury.^13,14 In the case of Ms. C, Dr. S might avoid premature creation of a physician-patient relationship by refraining from offering a diagnosis at the conclusion of the screening call.¹⁷

References

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What are your responsibilities after a screening call?

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