June 02, 2000

from the president of Psychiatric News Magazine

Prescribing Practices

BY DANIEL B. BORENSTEIN, M.D.

Kaiser Permanente is the oldest and most successful HMO in the country. Some would say it is the cream of the crop when it
comes to HMOs. Recently, a lawsuit brought to light that its San Diego branch had a policy in which its psychiatrists prescribed
medications to psychiatric patients without having examined the patient. The patients were evaluated by other mental health professionals
or trainees, following which the Kaiser psychiatrists were asked to prescribe psychotropic medications without a comprehensive
or any other face-to-face evaluation. Apparently, this practice had been going on for more than 10 years and had never caught the
attention of either the licensing authorities or the psychiatric society.

It is dangerous to prescribe medications without personally evaluating patients. The patient may have other medical problems,
be taking another medication, or have a diagnosis that is different from that suggested by a nonpsychiatrist. Some medications
may be contraindicated, and others may have unacceptable side effects for particular patients.

Prescribing any medication without a face-to-face evaluation is a violation of California’s Business and Professions Code.
Physicians who violate this code are subject to sanctions by the Medical Board of California. Sanctions can range from
probation to suspension or even revocation of the physician’s license, depending upon the seriousness of the violation.
Most states have similar laws.

In addition to the legal ramifications, this practice by a psychiatrist is a violation of APA’s Principles of Medical Ethics
With Annotations Especially Applicable to Psychiatry. The following sections and annotations of the principles would apply in this case:
 

•  Section 1: "A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity."
 

• Section 3: "A physician shall respect the law. . . ."
 

• Section 5, Annotations 3: "When the psychiatrist assumes a collaborative or supervisory role with another mental health worker,
he/she must expend sufficient time to assure that proper care is given. It is contrary to the interests of the patient and to patient care
if he/she allows himself/herself to be used as a figurehead."
 

• Section 5, Annotation 4: "In relationships between psychiatrists and practicing licensed psychologists, the physician should not
delegate to the psychologist or, in fact, to any nonmedical person any matter requiring the exercise of professional medical judgment."
 

When the Kaiser policy became public knowledge, APA issued a press release decrying this practice. The Medical Board of
California and the local APA district branch began investigating the alleged violation. Shortly thereafter, Kaiser issued a statement
that this was the only California facility in which psychiatrists were prescribing without examining the patients and that the policy was
changed. The extent of this change and whether it applies to all the patients or just new patients is unknown at this time. Investigations
are continuing, as is the original lawsuit by a former Kaiser psychiatrist. If the changes were comprehensive, Kaiser is to be commended
for its quick, corrective action.

Many behavioral managed care organizations make it difficult or impossible for psychiatrists to provide psychotherapy to patients.
Psychopharmacology is encouraged, often for large numbers of patients. It is likely that similar prescribing practices occur in some
of the for-profit organized systems of care.

This is not to say that all managed care arrangements are unethical or illegal by any means. In fact, it is my impression that some
physician-owned and -run organizations provide high-quality care. Moreover, managed care organizations must not be singled
out as the only culprits. Similar practices have occurred in community mental health organizations and in private practice. It is
fairly common for nonphysician mental health workers to ask a psychiatrist or another physician to prescribe medications for
their clients. It is far from clear that the prescribing physician evaluates all of those patients personally.

I hope that this article will serve as a consciousness-raising and information source to help maintain high-quality patient care
in all settings. Members must resist pressures or temptations to practice in an illegal or unethical manner.