Thursday, January 04, 2007

Covering Your

Ha! How did you think I was going to finish that question?

First, let me say that it's heartening to know there are folks out there googling ways to manipulate their psychiatrists, this warms my shrinky little heart.

This post, however, is on practice coverage, meaning how do we tell patients to reach us in an emergency, what happens when we're away. Mostly, I'm talking about private practice, because clinics usually have after-hours coverage through an agency (--in Baltimore, there's a group called the Baltimore Crisis Response Hotline), an emergency room, or an elaborate coverage arrangement with docs/social workers in an on-call deal. ClinkShrink seems to be on constant call for her places of employment and has gone years at a time without a vacation (--this, I believe, is its own mental health issue, but she doesn't pay me, so I will stay silent). Roy just works all the time, but he does go on vacation. Neither of them have private practices, at least not now, so my frame of reference is non-systematic, non-scientific, non-evidence based. You don't have to read this and please don't talk about it to the FDA.

So this is the range I've noticed. Most private practice psychiatrists have machines that answer after hours, not answering services. They range in their instructions: some say if this is an emergency, call 911 or go to the ER. This is coverage?? At the other extreme, there are those docs who have a designated cell phone that they keep on all the time and their messages instruct you to call that, or a home phone number for after-hours emergencies. My good friend Camel has such a line and her machine says, "If this is a life or death emergency, call....." The good thing about having this kind of messages is that it's a lot of fun to have your friends tease you about the "life and death" line. I, of course, would never do this. No one ever tells you what a psychiatric emergency actually is, and after years of practice, I'm still not sure I know.

So what do I do? My office number is my cell phone, much easier than leaving a list of where you can reach me when. On the first visit, I tell patients, "It goes where I go." I turn it off during sessions, and I am essentially unreachable. Essentially, because the babysitter once knocked on my door, my kid in hand, to say I'd locked her out of the house. Oops. But generally, I'm not accessible, and I check my messages between sessions. I turn the phone off when I'm anywhere I can't talk privately, so you won't hear me yelling "Take more Xanax!" over the bing-bing of the cashier at the grocery store, or the yelps of those happy Ravens fans. Oh, I don't prescribe Xanax, but that's another post, perhaps one for
The Last Psychiatrist who is fond of that topic today. I turn the phone off while I sleep, so it's fine to leave a message at any hour of the day or night. If you need me in the middle of the night (and really, I do mean NEED), I give out my home phone number as part of a written sheet of office policies and contact information. This is all, I believe, a few steps beyond Go To The ER, but it's not as available as a willingness to take an emergency call anywhere, anytime with the promise that I will answer all calls on the spot. One could imagine all sorts of interest places to rest that life or death line, careful where you roll, honey. For me, it's a blend of what I can comfortably live with and still feel like I make myself available. I once consultant's on a patient who was appalled that his psychiatrist had taken three hours to return his call when he was having a panic attack. I felt for both the patient and his doctor, but I couldn't reassure him that I would be instantly available either.

What about vacation coverage? I just came back from one of those, I highly recommend them. I asked two other psychiatrists to cover my practice. My patients rarely want much while I'm gone-- refills sometimes, otherwise they leave messages for me and don't seem to want to talk to a stranger. I post the other docs numbers on my machine, turn off my cell phone, and trust that my practice is in good hands. I don't leave charts, I don't leave instructions unless there is someone specific I'm very worried about (and that person simply never calls), I often do leave a contact number or email address where I can be reached, but I'd prefer not to know. There've been no fiascos, though one doc did insist on meeting with one of my patients before he'd refill a medicine she'd been on for years. Logistically, it was inconvenient for her, but she seemed to enjoy meeting him. From my end, I was perplexed as to why they met: I generally refill existing medications over the phone once I've verified with the pharmacy that Dr. X really has been prescribing this for the patient in an ongoing manner. Patient wasn't sure if Dr. X would have filled the script without meeting first, and Dr. X wanted a signed/faxed release to discuss this with me. Life felt complicated, I just let it go, and I will mention that Dr. X continues to be my respected friend. The bets are out as to whether I'll steer him towards this post.
Most of the time, things just go smoothly.

Sometimes patients tell me their doc is away and there is no coverage. Can that be? Seems sort odd. There is probably somewhere a "standard of care" document that dictates these things. I'm hedging my bets that ignorance may be more peaceful.

By all means, chime in with your thoughts!


ClinkShrink said...

I met a physician once (not a psychiatrist) who required all potential patients to sign a waiver in advance that they knew the doc would not be available outside of regular business hours. No emergency numbers, nada. Separate from the obvious patient care issues, that seemed a bit reckless to me but it only goes to show you can do anything until it's challenged.

And did you notice how I let you and Roy post for the past week without interrupting?

DrivingMissMolly said...
This comment has been removed by a blog administrator.
Anonymous said...

There was someone who's license was rescinded a few years ago, because they went out of town and didn't provide coverage for emergrncies.I checked my messages at 4.30 this morning.

Dinah said...

I liked your comment but then you took it off!

DrivingMissMolly said...


Thanks. I felt it was too angry and that I was possibly having "transference to the blog" that I felt was inappropriate. Glad you read and liked though.



ClinkShrink said...

Lily it didn't sound angry but you did make some good points. Consider reposting. I'm with Dinah on that.

Camel, was that doc a psychiatrist or other type? And the coverage issue was the only allegation? That seems harsh.

NeoNurseChic said...

I wanted to write my response to this last night, but the precious 2 hours of sleep I get a night lately are important to me, so I decided to sleep instead! All day today while I was at work, I considered signing onto blogger to leave my response, but again - I don't like work computers to have any connection to my internet life whatsoever, so I decided not to - but I had bits of my response formed in my mind. Last night, I only read the post because I woke up with esophageal spasm at around 2:30am - I was drenched in sweat and just shaking it hurt so badly - good thing I now sleep with a bowl next to my bed. Can't even make it to the bathroom before the spasms cause whatever small bit might be in my stomach to be expelled. heh... I've got a rattly cough today, so I think I done aspirated.... nice one. So I was up reading blogs because I needed a distraction for a bit and was afraid to fall asleep and have it happen all over again. Totally not relevent to the post at all, but I guess I'm saying that I've had the post/response on my mind because this topic is very relevant in my life right now.

First off, I don't like to talk to substitutes......I don't care how good thy are. I have a hard time talking to anybody about certain things in my life, so the fact that I have told my psychiatrist things that I've never told anybody also means its highly doubtful I'm gonna pick up the phone and talk to somebody I don't know, even in a crisis. I'd rather deal with it on my own (or not deal with it, depending) than talk to somebody I don't know. Maybe it's just fear of the unknown. I told my psychiatrist that once (because as soon as I got back from England, he left for New Zealand which meant about 3 weeks with no appointment and the last time I had gone 3 weeks with no appointment, was just I was worried) - and he said, "well what do you think I tell the person covering about you?" Hmmm...never thought about THAT before. Just figured that he wouldn't have told them anything. I dunno why. It's not like nursing sign-out - but then again, I can see why it might be important to have the bare details - especially about certain circumstances. Doesn't matter for me anyhow - because I still will never call and talk to somebody I don't know.

For my psychiatrist, I have his office number and his pager number. I have paged him a couple of times during the day way back when we were trying to set up my 1st appt when he moved hospitals. I have also tried to page him a couple of times in the evening (never later than like 9pm) and he didn't return the page or mention it the next time I saw him, so I no longer do that. His old voice mail at the university had a whole list of directions - times he would return calls between, what to do if your call was urgent, whom to call if it was after hours, the number to reach the psych resident on call, etc. Now.....he doesn't have that. He also used to give me a coverage name and number but lately he hasn't done that either. His current message does state that if it is an emergency to go to the nearest ER or crisis response center. I dunno..... I hate when offices just send you to the ER.

But what I'm getting to is this week... On New Year's day, I awoke to find out that a very close family member had attempted suicide and my dad had left to go be with her in the ER. She's physically fine - don't know about mentally - but she did have to stay inpatient for a couple of days...just got out yesterday. So this is New Year's day when I find out about this and I have so many thoughts and tears and anger and every emotion and a lot of time spent curled up on my bed, staring at the tv trying to block out everything. I called him and left a message, knowing that he wouldn't call me back that day, but that he would return my call the day after. Thing is, I REALLY needed to talk about this - in the 1st message I left for him, I summarized what happened in about 2 sentences and then said I really needed to talk to him before my appointment on Friday, but the crappy thing was that I was working 7a-7p on Tuesday, Wednesday, and Thursday. So then, he did call back on Tuesday and said he was sorry to hear what happened and could certainly understand that I would want to talk about it. Then said that he knows I work the next 3 days until 7pm and we can definitely talk about this at my appointment on Friday, but if I have any questions or concerns before then, I should call back. So I called back and left a message saying that I was fine while I was at work (although wasn't sure how I was gonna feel later that day when I didn't have work to distract me) but was spending a lot of time between anger and upset and worry on. I said that I guess I didn't really need to talk until the appointment on Friday because at least with work, it gives me that out.

I said that - but part of me feels frustrated that there is no way to arrange to just speak on the phone briefly. I have even told him in the past that I always take my lunch break from 11-12. Why can we not speak about this on the phone at least to just help me through a few of the things that were really bothering me? I'm not mad at him - just a little perplexed. I was really upset new year's day about what had happened, but I knew I wouldn't get to talk about it with my psychiatrist. So instead, I did talk some with my mom....and said things on my mind to her that I never would have thought I could say to her - not gonna even get into that here. Then, I talked on IM with 2 friends who were supprtive and then tried to make me laugh and stay upbeat.

My one friend has listened to me all week. Last night, I really had a lot of thoughts and feelings about this that I just needed to unload - and I just had to say them. I didn't want to put my feelings on my friend because I hate to do that - i don't want to be a burden on my friends, but I absolutely had to talk about it. I have even done some free associating writing just to straighten out my thoughts and understand them a bit better.

It would be very helpful if he had been available to talk even for 5 minutes. Tomorrow is my appointment and now that it's been 4 days of me sort of holding it all in and all together and just not sleeping because I can't stop thinking about all this - well, I'm sure it'll be an interesting appointment. I don't know if it will be a discussion or rather me just saying everything on my mind at 100mph until I have to stop for air.

Sorry to ramble here - this may not be as direct or related to topic as you were looking for, but this is how I feel right now - and I really would have liked to have been able to reach him outside of office hours this week. I needed that. And maybe part of me feels a bit let down because I've been left to deal with this alone, or so it feels. I couldn't just not go to work. Such is life. But even when one has to work, bad things can still happen that really need urgent dealing with. They can happen on the holidays and at night and frankly I generally tend to have my emotional breakdowns at night anyway. And it's not that I want to talk to him all the time outside of office hours, but when something huge happens, it would just be very helpful...

Sorry to ramble on and on! I'm hoping nobody who knows me in person will read this comment because it's not something I felt comfortable enough to say in public on my own blog since people I do know read over there at times.

Take care,

a psychiatrist who learned from veterans said...

I leave my cell phone number on my tape. 'In am emergency call 911. Less threatening emergencies, call me at..' Of course most of the calls I get, during the noon hour, are about "Do you take Aetna?" Now that we have learned to appreciate Saddam, there should be several schools of thought about whether not getting that question answered immediately should be grounds for losing your license vs. being taken before the Revolutionary Council and shot. Anyway, I try not to take any chances; but those signs saying 'No phones in the ICU' may leave my last thoughts wishing for the mercy of a sign to tell me, 'No phones off outside the ICU.'

Steve & Barb said...

When I had a private practice, I gave out my cell # and set the expectation I'd call back by the end of the day.

We see pts in the hospital who say they couldn't get in touch with their doc, had side effects or worsening symptoms or what not. 90% of the time, when we tried to reach said unreachable, we have no trouble getting in touch.

I think some folks are reluctant to call an "emergency line", or jump through all the hoops to contact their doc or therapist. Of course, some folks put those hoops there so that there is some kinda filtering process.