Setting Up a Forensic Psychiatry Practice

Forensic psychiatry has increasingly become an acknowledged and respectedpsychiatric subspecialty. In recent decades, greater numbers of generalpsychiatrists have added the practice of forensic psychiatry to their clinicalpractice. More than 2,200 psychiatrists are members of the American Academyof Psychiatry and the Law, and at the present time, approximately 45 forensicfellowship programs offer specialized training in forensic psychiatry in the United States and Canada (Gold, 2004). Since fellowships in forensic psychiatry are new, and since the current number offellowships cannot produce all the psychiatrists needed for forensicexaminations, most psychiatrists add forensic psychiatry to an establishedpractice rather than completing a fellowship and practicing this subspecialtyon a full-time basis.

However, significant clinical and business distinctions exist between thepractice of clinical and forensic psychiatry that should be recognized whensetting up a forensic psychiatry practice. Unlike in a clinical context, adoctor-patient relationship is not established in the practice of forensicpsychiatry. In addition, a forensic psychiatrist is employed as an agent of alawyer, court or other entity requesting forensic services. Therefore, ratherthan producing a treatment examination, an expert examination or consultationservice is rendered, and a fee is generated for that service.

Developing a Business Plan

All new businesses should begin with a business plan. Most psychiatristslack skill in developing such plans. A written plan is not required, and manypsychiatrists may choose not to complete such a plan at all. However, abusiness plan can be an important tool in assisting forensic psychiatrists todevelop the methodology and metrics necessary to properly construct a business.This is particularly important for the solo practitioner, who may not have thebenefit of the checks and balances present in group practices. The developmentof a business plan requires a business model, even if that model is cognitiverather than written. The psychiatrist is advised touse an acceptable reference or professional advisors for developing a businessplan (Abrams and Kleiner, 2003).

Table 1

describes the four majorcomponents involved in planning any business, including a forensic psychiatrypractice. All businesses should begin with a

mission statement

, consisting of a few sentences that conciselydescribe the forensic psychiatrist's purpose. For instance, this might include:"The mission of the XYZ Forensic Psychiatry Practice is to provide state-of-the-artforensic psychiatric analysis of worker's compensation cases claimingpsychological harm." A well-articulated mission statement provides guidance toall individuals working within the practice.

The vision statement of a forensicpsychiatry practice is also described in a short sentence, if possible-or a fewsentences at most-to describe where the practice is headed, as guided by themission statement. In our current model, it might state, "The XYZ ForensicPsychiatry Practice will be recognized as this state's leading provider ofworker's compensation injury forensic psychiatric assessments."

Core values describe the ethicsand values of the practice (the business culture) that will be used by thepsychiatrist to guide the mission and vision of the forensic psychiatrypractice. Again, this should be a succinct statement, such as: "The XYZForensic Psychiatry Practice will at all times embody the core values ofhonesty and objectivity when providing forensic psychiatric examinations.Examinations will be completed with integrity, compassion and excellence."

The strategic portion of planning the forensic psychiatric practicedescribes the strategies for how the practice's mission and vision will be completed. Strategy is the what of the process, while tactics are the how of the process.

Practice Tactics

Since most psychiatrists will add a forensic psychiatric practice to atreatment practice, they should analyze carefully how to balance the twoendeavors. It is critical to maintain dynamic stability in both practices asthey develop in a parallel fashion. Many well-honed clinical skills will applydirectly to the practice of forensic psychiatry. Nevertheless, certain businesstactics can enhance the incorporation of a forensic practice into a treatmentpractice.

Customer orientation.Forensic psychiatrists should maintain a customer orientation that may differfrom that of their clinical practice. In forensic psychiatric practice, one hasclients rather than patients; therefore, the complex interactions and communicationsnecessary in forensic psychiatry best lend themselves to having someoneavailable to answer calls and provide information to potential clients ratherthan using answering services or telephone voicemail systems. Loss of businessin a forensic psychiatric practice can be substantial as a result of usingvoicemail or other mechanical or electronic answering systems. The individualwho answers the phone for the forensic psychiatrist should be trained toprovide as much information as possible to the caller or prospective client.This enhancement of information transfer can be improved by the use of Websites for the benefit of the prospective client. In forensic psychiatricpractice, most juries are highly familiar with Web sites and will not find thisto be an unusual practice.

Evidence-based models. Evidence-based medical models are becoming increasinglyutilized in the practice of psychiatry. Forensic psychiatrists should adhere toDSM diagnostic categories and evidence-based medical models. Use of idiosyncratic diagnoses or failure to provide scientific evidence to support conclusions may render testimonyinadmissible under the legal criteria that govern the admissibility of expertevidence (Daubert v Merrell Dow Pharmaceuticals, Inc.,1993). In addition, mental evaluations should be standardized and based onacceptable mental measurements. While the face-to-face mental statusexamination is required within the psychiatric examination, triersof fact usually assume that a portion of certain types of forensic examinationswill be quantified. Therefore, the forensic psychiatrist should develop arelationship with a psychologist who can provide measurements of:

• Reading skill
• Intellectual capacity
• Neuropsychological assessment
• Psychopathology

Laboratory tests.The use of structural and functional brain imaging and appropriate laboratorytests should be included in the examination when appropriate. If thepsychiatrist does not perform neurological examinations when evaluating claimsof cognitive disorders or brain injury, this should be provided by otherpractitioners.

Technology.A successful forensic psychiatry practice depends upon judicious use ofefficient and productive technology. Use of word processing technology,dictation services, templates and computer scheduling can increase efficiencyand reduce time demands. Conducting weekly staff meetings, wherein cases arediscussed and examination strategies completed before the examinee arrives, canenhance productivity further.

Financial affairs.The success or failure of a forensic psychiatry practice often revolves aroundfee issues. Financial arrangements between treatment and forensic psychiatrydiffer markedly. In forensic psychiatric practice, psychiatrists should haveclear, written contracts with their clients; this prevents professional orethical lapses. Obtaining a retainer fee prior to examination is advisable,ethical and customary in forensic psychiatry. Prepayment of the fee prior tothe examination ensures that no perception of contingency fee arrangementsexists, and it facilitates honesty and objectivity in the examination process.Acceptance by the client of the retainer fee seals the contractual arrangementand thus allows the psychiatrist unlimited objective latitude within the courseof the examination. This will become particularly important when thepsychiatrist's opinion is not helpful to the client or entity who retained the psychiatrist's services.

Communication.Communication skills can make or break a developing forensic psychiatrypractice. Psychiatrists practicing in forensic arenas who cannot communicateeffectively by oral and written methods are at a distinct disadvantage.Regardless of one's academic credentials and clinical skills, an inability to communicateeffectively will reduce the likelihood of further forensic referrals. The roleof the forensic psychiatrist is to educate the trierof fact. Testimony is a method of teaching and providing information to thosewho must make decisions about the legal matters at hand. Forensic psychiatristsshould strive to teach clearly their opinions; plain language should be used atall times.

The quality of written reports is fundamental to a successful forensicpsychiatry practice. In many instances, the report may stand on its own meritsand a case may be settled without requiring the psychiatrist's oral testimony.Reports that are poorly written, digress, contain poor logic and do not answerspecifically the retaining party's questions will reduce the effectiveness andsuccess of the practice.

Clinical skills.Lastly, lack of clinical skills may severely limit practice opportunities for anovice forensic psychiatrist. The clinical practice of psychiatry on a dailybasis--while also practicing forensic psychiatry--has a twofold purpose: 1) Itmaintains the forensic psychiatrist's clinical skills at a high level andassists in the maintenance and development of current information in clinicalpsychiatry; and 2) Triers of fact are oftensuspicious of psychiatrists testifying as an expert if they do not activelytreat patients. In some jurisdictions, this can limit the type of referralspsychiatrists receive in a forensic practice, as they may require that at least50% of practice time be devoted to treatment and medical consultation beforethe psychiatrist can testify in a medical malpractice action or other types oflegal actions. The most effective forensic psychiatrists maintain psychiatricand medical skills at the highest level possible (Granacher,2004). Table 2 provides practiceguidelines that, if followed, should considerably enhance the ability of atreatment psychiatrist to establish and maintain a forensic psychiatricpractice.

• Summary

The practice of forensic psychiatry is an intellectually challenging andextremely gratifying experience for most psychiatrists. Marketing andadvertising are not needed, as every report generated by the psychiatrist,every testimony provided by the psychiatrist and every interaction withprospective clients produces an effect that markets the psychiatrist's forensicskills in an ethical and professionally acceptable manner. The most criticalfactors for success in forensic arenas are the psychiatrist's clinical skillsand integrity.

References:

• References 1. Abrams R, Kleiner E (2003), The Successful Business Plan: Secrets and Strategies, 4th ed. Palo Alto, Calif.: The Planning Shop.
  2 .Daubert v Merrell Dow Pharmaceuticals, Inc., 509 US579 (1993).
  3. Gold LH (2004), Rediscovering forensic psychiatry.In: The American Psychiatric Publishing Textbook of Forensic Psychiatry, SimonRI, Gold LH, eds. Washington, D.C.: American Psychiatric Publishing, Inc.,pp3-36.
  4. Granacher RP (2004), Starting a forensic practice.In: The American Psychiatric Publishing Textbook of Forensic Psychiatry, SimonRI, Gold LH, eds. Washington, D.C.: American Psychiatric Publishing, Inc.,pp55-89.