Thursday, January 04, 2007

Coverage & Standards of Care: by Guest Blogger CoveringDoc

First you need to read my post from yesterday: Covering Your...
So, CoveringDoc sent me his comments by way of the back door. They felt important enough to be a stand alone post, and so, with permission:

I guess that you succumbed to the temptation to tell the psychiatrist who insisted on seeing your patient that he could read about it on the blog.
It only applies for controlled substances. I think that it would be a res ipsa loquitor--"the facts speak for themselves"-- case of negligence if something went wrong and a controlled substance was involved and the prescribing physician hadn't ever set eyes on the patient. I'd rather be obsessive than negligent, if I have to choose.
The code of ethics for the AMA, with special annotations for psychiatrists, says that psychiatrists should be available to their patients for emergencies. This has been interpreted to mean WITHIN 30 MINUTES. So, I'd either make myself available in the middle of the night or not mention that I didn't have such an arrangement. (You can guess which one I decided to do.) It was when I read of that decision that I started carrying a beeper around.
I have never understood why the APA doesn't make that booklet available to all of its members, on a regular basis, or at least have frequent articles about it in the Psychiatric News.

The 30 minute interpretation was made by the Ethics Committee of the APA; it's listed in a compendium of its decisions.
I knew a psychiatrist who had his license suspended because he prescribed an analgesic for a patent.(He did it more than once, even after someone warned him.) He was a good psychiatrist , in my opinion. As a result of losing his license, he also lost his administrative job.

I've had 20 more years than you have had to hear these stories and to worry. I'm getting better(at worrying) than I used to be.
I still think that the APA and/or the MPS should tell its members more frequently what the standard of care is, particularly if it changes. The only time I''ve studied this subject since I left my training in 1974 was when I was preparing to take the Administrative Psychiatry Boards in 1986.

So thanks, CoveringDoc . Just to be clear on my last post: Every patient I see is given a written statement of how to contact me, it includes my cell phone number and my home number with instructions to call my home number if an emergency occurs during the night. I check my messages between sessions, and while I don't generally answer the phone if I'm not somewhere I can talk privately, I generally do listen to every voicemail message to be sure it's not an emergency, but I may not return non-emergent phone calls for a few hours. I generally return all my calls the same day and no one has ever complained about my lack of responsiveness or unavailability. Still not a beeper or a cell phone that rings during sessions, so I am not instantly available always.

The 30 minute standard is one I've never heard before, and one I think few physicians could uphold on an absolute basis. What if the psychiatrist has thick hair (with lots of chemicals) that takes a long time to blow dry and a cell phone or beeper can't be heard over the sound of the dryer? What if the psychiatrist gets constipated? Likes long showers? Is somewhere cellular coverage can't reach?

I'm also left, still, with the question of What's An Emergency? While we'd all agree that the guy about to jump from the bridge is an emergency, what about the distressed patient in the midst of a panic attack? My personal favorite: repeated emergency calls from a patient the Sunday I was returning from vacation-- yes, I had coverage, but she wanted me--- she realized her insurance was going to expire in a few weeks and she'd have to pay for her own benzodiazepines.

Finally, I'm left with the thought that many psychiatrists I know do cover for themselves by checking their messages-- if I go on vacation, am I responsible to insist that the covering doc promise me he'll be available around the clock and within 30 minutes to any patient of mine having an emergency?

To the patients out there reading this blog, can I ask a favor? If you have an emergency, if your shrink is away and you need to talk to the covering psychiatrist, please, please, and I can't say this loudly enough: Leave a Phone Number where you can be reached!


Midwife with a Knife said...

I know that obstetricians generally have to be able to be at the hospital within 30 minutes of a call. Actually, the standard of care (courtesy ACOG) is to be able to start an emergency c-section within 30 minutes of the emergency arising. This is probably the reason that solo practitioner obstetricians are becomming less and less prevalent.

Dinah said...

How does that work? Does it obligate an OB to live within a few minutes of the hospital, given that they might need to get dressed, get stuck in traffic? My sense is that OBs do more cross-coverage with the Expectation of being called in the middle of the night when they are on-call, whereas solo psychiatrists often cover themselves by phone, day after day. What happens if two women have simultaneous emergencies? From my good old medical school days, it seems to me that housestaff slept in the hospital and took care of the emergencies until the attendings arrived, but then again, that was at a teaching institution. Teaching hospitals also have psychiatric housestaff stay inhouse for the emergency room, inpatient coverage, and emergency consults.

NeoNurseChic said...

We always have to have an RN in every room on our unit and we have to have respiratory and a doc on the unit at all times. However, if the docs and respiratory have to go to the DR and then something bad happens on the unit - well......I've only had that happen to me once in the entire time I've worked there - and it was only like 2 months after coming off orientation. I had a baby have a pulmonary hemorrhage and I had suctioned frank blood out of the ETT. I was stuck far back in an isolation room, and I had called for respiratory several times over the intercom. Finally the charge nurse came in as I'm standing there bagging the baby and asked what I needed - I told her I got blood out of the ETT, and she said everybody was down in the DR and asked if I could manage it until they got back. I could - because it wasn't a bad pulmonary hemorrhage by any means. Other nurses has guided me to get iced saline and I asked a senior nurse to come to the room with me to help until more help could arrive. The baby was fine - but we're so used to having the docs and respiratory at our fingertips on our unit that it gets scary (well, only sometimes...and really more for us newbies) when we're all on our own.

I wrote my real thoughts on this contact business in the 1st post, but as a follow up to this one - even when I call my psychiatrist I make sure I leave the numbers again. On New Year's day, I had first given the number for my parents' house and also my cell because I'd be leaving at some point. Then that night, I called back and said I had left my parents' and then re-gave my cell. I always give my phone numbers when leaving messages, even to people who I know have my number. I don't like to leave stones unturned! ;)

Very interesting post - I like reading the different perspectives.

Take care!
Carrie :)

Anonymous said...

It takes a lot for me to pick up the phone and call my psychiatrist about anything at any time; I usually just tough it out until my next appointment. I did call my first psychiatrist once on a weekend, because I was having a bad reaction to a new drug (spent six hours throwing up.) I left a message with her answering service, and she called me back within an hour.

My current psychiatrist changed practices about six months ago, and right about the time of the switch, I was trying to change from one drug to another, and it didn't go well. I tried calling and leaving a message, sending him email, and paging him over a two day period (a Thursday and a Friday) but it was Monday before I heard back from him. When I hadn't heard from him by Friday evening, I decided to undo the switch myself, and by the time I talked to him on Monday, I was starting to stabilize. But I was not very happy that I hadn't been able to talk to him when I was crashing hard into depression with the med change.

Anonymous said...

Well, where I was a resident there was always a "24 hour" doc (we actually called the attending the 24 hour doc) who was in the hospital at all times and covered the staff patients. In an emergency, that attending is available to supervise directly (i.e. in the room) or indirectly (like from another c-section) if a c-section needs to be started on an emergent basis.

As a resident, I have started c-sections without an attending present (once for a cord prolapse, once for a fetal bradycardia), figuring I'd rather deal with the consequences of that than with having a dead baby (and by the time I was that brave, I'd already done 150+ c-sections).

Now, that "attending", or pretending as I prefer to call myself (after all I'm only a fellow, I'm not really "the man" yet), is myself and my colleagues. And we cover for attendings who can't get to the hospital in time for emergencies.

In a smaller town, in a smaller hospital, in a small group, I guess you would have to live pretty close to the hospital, or just always take call in-house, which could be bad for your standard of living.

-- MWWAK (can't seem to sign in to comment from work...but maybe that's a sign that I should be working)

jcat said...

My p-doc (yay...came back from annual leave on weds, so I got to see him yesterday after eternity-long Dec) arranges for coverage if he is away. But unless it was a drug crisis I wouldn't call, can't talk to someone i don't know. And if it was a drug crisis, it would be pointless calling. Cos when they ask what you're taking, and it's 180 mg Parnate as well as a bit of Trepeline and a sedative - and you're having a kind of suicidal day. Well there ain't anyone else in town who'd touch my meds, cos they are all way over limits according to PI.
When he is in town, his rooms answer calls from 08h00 to 17h0, and after that he carries a pager. Never tried calling him any later than 21h00, but he's always called back within 20 mins.
If blog-transference means checking your blog (and Fat Doctors) immediately after I get home and check email.... consider me transferred! Hope you don't mind, I've put your link up as one of my two favourites on my recently created blog.

Gerbil said...

I have never known any solo clinician to promise to return a call within any specific period of time, except for one who promised to return all evening calls by 10pm. I also think it's perfectly appropriate for an outgoing message to suggest 911 in case of actual emergency--even if you promise to return calls within 30 minutes, perhaps your patient is on the roof of a building and can't wait that long! In my outgoing messages, I also include the number of at least one local crisis hotline.

On the other hand, I work for an agency which has an emergency pager (which I never have to carry, thankfully!), and if patients don't receive a call back within 30 minutes, they are supposed to try again. This is a pretty good system, especially for our popuation--except that occasionally the pager goes out of service for one reason or another.

Cell phones and pagers give us the illusion that we can always reach someone when we want/need to. But interruptions of service happen--even for good, old-fashioned land lines. Until about 6 years ago, my parents' phone would go out every time it rained--and once it was out for days because a squirrel got fried on the wires.

So I think all we can do is our best to make sure our patients/clients have after-hours care. If we can't promise to interrupt a shower, a concert, or sex every time someone calls with an emergency (or an "emergency"), then perhaps we ought to suggest 911 as a backup plan.

Bardiac said...

I knew there was an advantage to my profession! Shakespeare hasn't had an emergency in almost 400 years.

NeoNurseChic said...

Gerbil - Very good comment! I like that! I was also a bit shocked to see the 30 minute return call policy...and even moreso that this could be used for grounds for a lawsuit or something along those lines. For the neurologist's office where I go, they used to have an emergency line and I think they still have the emergency after-hours answering service. However, I've called them before and they have told me that if I don't get a call back in 30 minutes to call again, and I've done that - and some nights just never gotten a return call. That's happened more times than not, so it does tend to be a bit frustrating.

And then - to follow up on the entire thread topic - I just got home about a half hour ago from my much-anticipated psychiatry appt. Posts here sometimes get me thinking about different things that I then talk about in my appts - and the comment I left on the first post was the tip of the iceberg of the strong feelings I've been having this week. In the last few minutes of my appt, we got on the subject of coverage with respect to how I was feeling this week. I think it started because I had mentioned leaving the message on New Year's Day and then calling back that night to leave updated phone numbers, and he asked how I felt when I didn't receive a return call on that day. I said that I hadn't expected one, but it would have still been nice to talk. I won't get into the whole discussion, but it was funny because I think before the discussion went that way, he was getting ready to rap up the appointment, but all the sudden sat back in his chair more and faced me fully to continue the discussion since I was discussing my feelings about him - which I never do.

I told him that I had tried to page him a few times before and had gotten a return page if it was during the day, but not at night - and I've never paged later than about 9pm. This was a first - I had never discussed this with him before, and in all honesty, I had just assumed that he had known I'd paged him and just not paged me back since it was after-hours. But he first said, "Were those pages recent?" I said no - I didn't remember exactly when, but they were awhile ago - and I didn't page the other day because I had not gotten pages back in the evening so I figured it would also be the same on New Year's Day. He said that he almost always has the pager with him, and if he saw my number on the page, he would most certainly call me back - so somehow I just happened to page him the only times he hasn't received the page. Interesting... It's still hard for me to say things about being frustrated, angry, or let down about not being able to talk to him earlier this week when I really needed to. He asked if I had questions about his coverage, and I explained how I had noticed the voice mail messages change between his old office, where he had left a lot of instructions, and his new office, where all of that was missing. (I couldn't just say the part where the emergencies are directed to go to the ER or CRC....why can I just not say some things? Dumb...) He reminded me that he is going away the week of the 15th, and said he would have somebody covering (hmmm...perfect timing...ha!) and that he would give me the name and number next week and would certainly leave it on his voice mail.

I also said that I had never paged later than around 9pm or so because I don't feel right waking people up in the middle of the night for times when I just get anxious or depressed about things. I said it would be nice to be able to talk at times outside of normal business hours on occasion, but not something I would do regularly - and I certainly wouldn't feel comfortable calling at 2am. We've had a lot of discussions about my blog, but I have never given him my blog address. In other words, I haven't given him the choice to look at it or not. I did, however, show it to my mom for the first time ever around Christmas. So today I said that not giving him the blog address is sort of akin to not wanting to call and bother him - him having the blog address would be like burdening him outside the appointment. I wouldn't want him to feel like he had to read it and I certainly wouldn't want him to read it and then have to feel concern about something I wrote when this was also something done outside of the appointment. (Now I'm curious for you 3 - would you want to know if your patient had a blog? And would you read it if they did? Maybe this is a topic for a post? I do, afterall, mention my psychiatrist on my blog - but I don't say a whole lot about him, and certainly not with the intent of him reading other words, nothing manipulative intended to be read by him.) He then said it sounds like I'm trying to be responsible for not burdening him instead of leaving that up to him. I guess that's true... I don't like to be a bother to anybody.

At any rate, it was an interesting discussion - and very relevant to the topic. Of course - it was right at the end of the appointment because I had really wanted to discuss my thoughts on what had happened in my family that week...but still a very important part of the conversation.

Take care!
Carrie :)

Anonymous said...

The problem of having my psychiatrist call me back is probably one of the most thought about questions in my mind (along with him problem with punctuality)... No matter how many numbers I leave, and how many suggestions regarding the best time/#/way to reach me, it'll sometimes take him up to 5 days to call me back... Is this a normal thing of a psych doesn't have a secretary??? It always makes me scratch my head and sigh in annoyance.

Gerbil said...

Carrie, glad you liked my comment :)

So after leaving said comment, I went off to see my own therapist (therapists in therapy are the worst, man!) and on the way back I began to wonder if she kept a blog. I have a blog, obviously--not that I write about my clients--but I draw the line at MySpace, as it seems so much less anonymous.

I wouldn't read a client's MySpace page or blog on purpose, unless I was specifically invited to check it out. Even then, I probably wouldn't look. But what if I found out that a past or present therapist of mine kept a blog? I probably wouldn't read that, either--it would just be too weird. However, I would definitely wonder if he/she wrote anything about me!

Dinah said...

JCAT: this is not transferance to the blog, it's a simple compulsion, nothing to worry about.

MWWAK: thanks. Being an OB sounds like a miserable lifestyle any way you dice it. I hope you love what you do.

Gerbil: certainly don't promise to return calls in 10 minutes, you never know what may happen (see my post today).

Carrie: I can barely keep up with reading my own blog (remember, 2 other people writing). I would read a patient's blog, or anything else, if requested. Without the request, I suppose I'd check it out once, but I wouldn't keep reading regularly unless it was very short posts with very funny jokes. Clink only reads patient blogs if they consist of bad puns, and Roy only reads patient blogs if they include recommendations on the next must-have gadget. You should see his new microphone.

NeoNurseChic said...

Haha very cute. And I'm sorry about the phone! I've known this to happen to others - as well as a number of friends who have had phone in the pool accidents... (A public service reminder: do NOT drink near pools...unless you want to risk your life! Fortunately for most that I know, only the phone went in!)

As I said, I haven't given him the blog addy. This morning, I had a reader from UPenn, but I don't think it was him. I spoke with him about a diary I used to keep today because on New Year's Day after the bad news, I brought my 3rd diary back to my apartment and read half of it while sitting on my bed that night. (Dumb move - when depressed and upset, don't do things that make yourself more depressed and upset.... I guess that is public service announcement #2!) So I mentioned something about how after I read it, I shoved it in a drawer under some clothes - and he responded that I must not want to really think about it. I said that I do - I intend to read it again, but not right now. Too much right now. We did, however, talk about a number of things I had read. So then he said something like, "Well if you don't want to read it, then you probably don't want me to read it." I was like...huh? Read my diary? Are you nuts? Instead I just said something like, "" Wasn't sure if he meant that seriously or as some sort of metaphor to my not wanting to talk about certain things.

But that made me think again - should I give him the blog address? Again...I feel like that's putting some burden on him. What if I wrote on my blog post about feeling super depressed? Then if he read it...would he worry? I dunno... I think I'm overthinking this. I overthink everything.

We do talk about the blog a lot. Mine, yours, half the other ones I read if they are relevant to whatever we are talking about at the time. But mostly mine - because I write a lot on the blog that is on my mind - but I also allude to things at times that I don't say - still it allows me to get it out there. And that's a release for me. When I was telling him about having 3 diaries and a memory of being a child, sitting curled up on the heating vent in the house (I'm weird like that...) in between a stereo speaker and the sliding glass door, writing about my latest tiff with my brother and other random 7 year old things, he said, "Sounds like you've been spending years trying to find an out for your emotions through writing." You could say that. I think music still takes the cake for me as far as emotional outlet - but both are things I've done for as long as I can remember.

So because of that, sometimes I feel like sharing the blog with him. But now that I've made such a big deal out of NOT sharing it with him, he would probably make a big deal out of it and try to analyze why I suddenly decided to share it with him...when in actuality it's probably not.

OK - bedtime...must work at 7am and I came out to the 'rents house tonight to get my one med that I had delivered here in the hopes that it would come over the holidays. I also wanted to give my mom a navy Penn State hoodie sweatshirt that I had bought for her for Christmas (not the only thing I gave her, so I didn't feel too badly about it being late) and that had come to my apartment by the time I got back on New Year's Day. But all that means that it's a loooooong drive in tomorrow in the fog!

Take care,
Carrie :)

jcat said...

Oh dear. Not sure that I need to add compulsions to my list of mentally interesting attributes..!

alwaysthegoodgirl said...

I am a 3rd year medical student that will probably go into psychiatry. I enjoy your blog a great deal.
This post contained a lot of new info for me - when I tell people my intended field, they say, "Well, at least the lifestyle is good." I had no idea that you were expected to be available by phone within 30 minutes 24 hours/day. I had always heard that psychs told their patients to go to the ER if there was an emergency. Or if they were faculty at a learning institution, to "page the on call psych resident."

Also, can you comment on psychs not having secretaries, and group v. solo practices?

Anonymous said...

Obviously, I am giving you a PT perspective so here's my opinion/2 cents worth...

This is long, but it has to be.

Currently I am in the midst of a "crisis."

I can say with certainty that although I have dealt with psychiatrists off and on for about 17 years, I am never sure when I should call.

I am certain of this; I will NEVER call 911 or go to the ER. ER folk don't take kindly to those who have attempted suicide (3xs 15 years ago). I am assuming that is considered an emergency and it is one I am familiar with.

Old shrink, a resident that I saw while a grad student, gave me his numbers. I always called and left a message on his voicemail except for once when that number wasn't working I called the other one. I was surprised that the number I called was his cell phone and he answered while driving! I told him I'd call back but he went ahead and talked to me. I felt terrible! I don't want my shrink to die in a fiery car wreck while on the phone with me!

Fast forward to new shrink who is an academic type medical school shrink and therefore has a sect'y.

I usually don't mind talking to her but the last couple of times I have e-mailed new shrink. At our last appointment he never mentioned it being a bad thing.


I don't know what to do! Also, I am reluctant to give answering service personel information about my emergency. I have become picky in my old age, I guess.

I called shrink Dec 24 as I thought I was having an emergency and was grateful he was taking his own call that evening. I felt so guilty and bad about calling him that I, gulp, cut up my fingertips as "punishment."


Tell me what you expect from me as a patient!!! I pay $190 an hour, can you please be more communicative!!!!!

I had to talk to the on call doc once and he was very kind. It was an "early" refill on Klonopin (yeah, I know), which could have been messy. I think the pharmacy screwed up because I had a change in sig, but I also took a little too many that time...never again, though. Anyway, he was accommodating but asked a lot of questions which to me meant that he *cared*. Many years ago I called the shrink on call for my shrink who was out of the country only to have him yell at me and say "I am not going to change any of your medications. You will have to wait til Dr. K gets back". I called because I was on lithium but was having terrible leg cramps and sweating. He was an asshole and I knew him from the hospital and THOUGHT he was nice...

Check out this guy's office policies

I almost went to see him because I heard his NP was the bomb, but the $75 charge for a phone call made him sound like a tool, especially since it was on the hold information for his office.


Catherine said...

I know this is rather late in the discussion, but psychiatrists actually have phone numbers that they give out? And are expected to work in someone as soon as possible? Funny, I never knew that. Where I go an emergency means you might get seen within the same week, if that.

Anonymous said...

It depends on the setting. In private practice (where the patient pays the doc), especially solo private practices, psychiatrists give out their phone numbers. Time to an appointment varies by shrink. In clinics (in other words, the doc is paid a salary by the organization) there is generally a formal coverage arrangement for the clinic (it may be "Go to the ER") and psychiatrists do not give out their phone numbers for when they are out of the clinic.
I hope that helps.