Texas Medical Board Fiasco

Today's medical board critique focuses on the June 14, 2013 Texas Medical Board "Agreed Order" against psychiatrist Jhansi Raj, MD linked from this page.

According to the order TMB based it's action on the following facts listed in the "Complaint" dated September 12, 2012:

"1. In September of 2006, the patient was hospitalized by Respondent for depression and suicide ideation with a plan to shoot herself. The Patient was placed on suicide watch because she had expressed an intention to kill herself. The suicide precautions were terminated the day before she was discharged.

2. The Patient was at high risk for suicide after discharge because [sic] she had a long-term history of major depression, schizophrenia, hallucinations, substance abuse and addiction, and homicidal and suicidal ideation. The Patient had 19 prior psychiatric hospital admissions.

3. Respondent discharged the Patient and within three hours the Patient retrieved a gun, [sic] she had hidden in her mattress at home, and shot and killed herself.

4. Respondents discharge of the Patient fell below the standard of care in that it came too soon after the Patients suicidal expressions [sic] and after too short a period of "stability," especially in view of the Patients emotional lability and the presence of stressors outside the hospital, including the possibility of incarceration. Furthermore, the Patient had just been put on new medication and there had not been adequate time to observe the Patient's response."

The Agreed Order lists as "mitigating factors" the fact the Dr. Raj had not "followed" the deceased as an outpatient, and even admits that "... the Patient's discharge by respondent did not cause her completion of suicide." However, it goes on to accuse Dr. Raj of failure to meet the standard of care.

TMB has failed to meet the standard of medical board actions. TMB has failed to establish how longer hospitalization could change the "high risk" it presumes to be associated with any of the facts listed in item 2, none of which can be altered. Furthermore, the board has failed to describe what would have constituted standard of care. It appears from these documents that the fact of the suicide alone, something over which Dr. Raj had no control, other than indefinite preventive detention, over what she did after discharge, determined that he did not meet standard of care.

TMB has an obligation to those it serves to delineate the standard of care as an explicit amount of time. To simply state "too soon," "too short" and "adequate time" suggests that TMB will deem any amount of time preceeding such a bad outcome to fall "below the standard of care." Furthermore TMB has failed to establish that longer stay in hospital would have lessened either any stressor "outside" the hospital or the stress associated with the "possibility of incarceration." The Board has a further obligation to state what it considers to be an "adequate" time to observe the Patient's response to new medication, which it has neglected to do. Failure to state such a standard constitutes negligence on the part of TMB and those who sit on that board.

What should other psychiatrists learn from this action? The message from TMB is clear: If your patient kills herself after discharge, you discharged her too soon to meet the standard of care, and TMB will punish you. Perhaps if the TMB believes as it implies that the "possibility of incarceration" contributed to the suicide it should hold responsible the judge who ordered the incarceration. Until TMB establishes and publishes an explicit standard of care Texas psychiatrists should refuse to discharge any patient until ordered to do so by an administrator or judge.

On the other hand perhaps TMB may have acted in this case out of motivation that had nothing to do with standard of care at all, but had everything to do with what Dr. Raj's name reveals (his race or national origin).


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