Psychiatry Residents Qualify as Psychiatrists under Statutory Requirement of Medical Examination in Texas for Civil Commitment Proceedings
In In re A.R.C., 685 S.W.3d 80 (Tex. 2024), the Supreme Court of Texas considered a case involving a psychiatry resident who was practicing under a physician-in-training permit and filed an application for temporary court-ordered mental health treatment for a patient, Mr. A.R.C. The county attorney filed a motion for an order of protective custody based on the psychiatry resident’s documentation. Mr. A.R.C. filed a motion to dismiss, stating that a psychiatry resident does not qualify as a “psychiatrist” under the relevant statute. The Supreme Court of Texas ruled that psychiatrist residents are qualified as psychiatrists under the statutory requirement.
Facts of the Case
The respondent, Mr. A.R.C., was a 34-year-old man who presented to the emergency room on July 24, 2022 with psychosis and delusions. His presentation led the attending physician, Dr. Morales, to file an application for emergency detention, which was authorized. This authorization required Mr. A.R.C. to be kept in a medical facility for up to 48 hours to undergo further evaluation. On July 25, 2022, Dr. Paez, who was a second-year psychiatry resident at the Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine, evaluated Mr. A.R.C. Dr. Paez was practicing under a “physician-in-training” permit at the time. Based on Mr. A.R.C.’s presentation, Dr. Paez wrote a certificate of medical examination and filed an application for temporary court-ordered mental health treatment on July 26, 2022. Dr. Paez wrote that Mr. A.R.C. “presented a substantial risk of serious harm to himself or others” (A.R.C., p 82). Based on this, the El Paso County Attorney then filed a motion for an order of protective custody, which was signed by the probate court.
A probable cause hearing was held on July 28, 2022, and a final hearing was held on August 1, 2022. During the probable cause hearing, the judge found that Mr. A.R.C. presented a substantial risk of serious harm to himself or others, and the court concluded that “there were sufficient grounds for continued detention pending the upcoming final hearing” (A.R.C., p 82). On July 29, 2022, Mr. A.R.C. was examined by Dr. Kutcher-Diaz, who was also a second-year psychiatry resident. Dr. Kutcher-Diaz wrote a second certificate of medical examination, determining that Mr. A.R.C “was mentally ill and that this mental illness made it likely that A.R.C. would cause serious harm to himself” (A.R.C., p 82). This second certificate of medical examination was required by statute: “A hearing on an application for court-ordered mental health services may not be held unless there are on file with the court at least two certificates of medical examination for mental illness completed by different physicians each of whom has examined the proposed patient during the preceding 30 days. At least one of the physicians must be a psychiatrist if a psychiatrist is available in the county” (Tex. Health & Safety Code Ann. § 574.009(a) (1993)).
On August 1, 2022, Mr. A.R.C. filed a motion to dismiss. This was based on the argument that, because they were residents practicing under physician-in-training permits, neither Dr. Paez nor Dr. Kuther-Diaz qualified as a psychiatrist, and therefore, the state was not in compliance with Tex. Health & Safety Code Ann. § 574.009(a). The court rejected this argument, and the judge ordered Mr. A.R.C. to undergo inpatient mental health treatment for 45 days and to receive forced medication. Mr. A.R.C. appealed to the Eighth Court of Appeals and again argued “that the residents did not qualify as psychiatrists and that, even if they did, the evidence was legally and factually insufficient to support the probate court’s commitment order” (A.R.C., p 83). In a divided decision, the court of appeals agreed with Mr. A.R.C.’s argument that the residents did not qualify as psychiatrists according to the statute and subsequently vacated the order and dismissed the application.
Ruling and Reasoning
The Supreme Court of Texas stated that, despite the lack of a specific definition for psychiatrist in the statute, other statutory provisions as well as the ordinary definition of psychiatrist indicate “that the certificates signed by Dr. Paez and Dr. Kutcher-Diaz complied with Tex. Health & Safety Code Ann. § 574.009(a)” (A.R.C., p 83). In reaching this decision, the court asserted that the statute references psychiatrists as “a subset of the larger class of physicians” and that “What the statute says about physicians, therefore, helps inform its understanding of psychiatrists” (A.R.C., p 83).
The court then referenced the statute’s description of a physician, which includes “a person authorized to perform medical acts under a physician-in-training permit at a Texas postgraduate training program approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board. Id. § 571.003(18)” (A.R.C., p 84). The court stated that this definition therefore qualified Dr. Paez and Dr. Kutcher-Diaz as physicians under Tex. Health & Safety Code Ann. § 571.003(18)(C), although they acknowledged that Mr. A.R.C. did not necessarily dispute this. The court asserted that the qualification of Drs. Paez and Dr. Kutcher-Diaz as psychiatrists therefore depends on whether the term psychiatrist conveys a meaning that excludes them. The court then turned to ordinary definitions of the term psychiatrist by considering definitions from standard and medical dictionaries. The court stated that, based on the definitions considered, “We have no trouble concluding that the term ‘psychiatrist’ has a plain and discernible meaning that reaches the two residents here” (A.R.C., p 84). This determination was based on the finding that the term psychiatrist refers to physicians who specialize in psychiatry and that both Dr. Kutcher-Diaz and Dr. Paez qualified given their advanced training in psychiatry.
The court clarified that determination of the “minimum statutory requirement for qualification as a ‘psychiatrist’ should not obscure that, under Chapter 574 of the Mental Health Code, it is the court—not any physician, no matter how credentialed—that determines whether involuntary commitment is necessary or lawful” (A.R.C., p 85). The court therefore held that Dr. Kutcher-Diaz and Dr. Paez qualified as psychiatrists under Tex. Health & Safety Code Ann. § 574.009(a) based on being “physicians” who specialized in psychiatry. The court of appeals’ judgment was reversed, and the case was remanded for consideration of remaining challenges.
Discussion
The Supreme Court of Texas’ holding in this case is directly relevant to physicians who specialize in psychiatry, not only to residents practicing under a training permit. As stated by the court in this case, when defining the term psychiatrist, the legislature “may strike whatever balance it determines best protects the rights of individuals and of the public” (A.R.C., p 86), if it does not transgress basic constitutional requirements of involuntary commitment (Tex. Const. art. I, § 15-a.). The court indicated that there is a range of how legislatures may define psychiatrist, depending on factors such as the needs and available resources of the public. A more stringent definition of psychiatrist, such as a requirement in statute of board certification, may emphasize expertise, whereas a more relaxed definition, such as only requiring a psychiatrist in certain contexts, may emphasize resource availability. This balance may result in differing definitions of psychiatrist in different jurisdictions or in different statutes, which may therefore have legal impact on those practicing psychiatry in those areas. The lack of a uniform statutory definition of psychiatrist necessitates that those practicing psychiatry be familiar with the definitions that are used in their location.
This holding also has implications for those involved in psychiatry training programs, including residents, attendings, and administrators involved in program development and maintenance. The court here found that a psychiatry resident’s qualification as a psychiatrist depends, at least in part, on the presence of advanced training in psychiatry. This is an important factor to consider as a resident is providing treatment, which may include involvement in certain legal applications and certifications and may inform the level of supervision and direct involvement necessary from an attending psychiatrist. Psychiatry training programs should review the legal definition of psychiatrist in their jurisdictions to clarify what responsibilities may be most appropriate for attendings to assume rather than residents.
- © American Academy of Psychiatry and the Law
