Thursday, February 04, 2010


I often get calls from patients who want to come in "as soon as possible." Especially new patients, but sometimes established patients. I try to be as flexible and accommodating as possible, but sometimes it gets a bit inconvenient. Now I'm in confabulation mode, but I'm curious about readers' opinions of how one should respond to emergencies. Often, I offer an appointment asap and the person requesting it can't make it and asks for another time. So it becomes a bit of juggling of priorities. And I'm left wondering how much the doc should be thinking about juggling (if at all). So let me fly some scenarios by you, and I'm curious as to what you think. The details are all confabulated, but the essence of the stories have gone down in some form over the past few years.

For both the doc and the patient, I'm going to use the example of a hair appointment as a non-urgent but meaningful conflicting issue. It can be hard to schedule hair appointments, they take a while so they aren't that easy to reschedule, and someone else is inconvenienced (the stylist) by a change, and the consequence of delaying the appointment is meaningful (ya gotta live with ugly locks until you can get rescheduled). For the sake of my confabulation, you don't have to pay for a missed appointment, and it's hair, life goes on even with a bit of frizz (tell me about it).

For the sake of the uncontrollable, I'm going to use the car breaking down-- no one asks for this, it throws a miserable wrench in life, it's unanticipated, and if you can't get there, you can't get there. It could be "I was in the ER with chest pain," or "my husband locked the deadbolt and took the keys to work (and oh, we live on the 10th floor so I couldn't crawl out a window") but the broken car is the example of beyond someone's control to a reasonable degree.

Story #1) So patient calls and wants to come in emergently (asap). I look at my schedule and I have lunch time free, I finish at 3, and I have a hair appointment at 4. I offer 12 noon. Not good, patient has a hair appointment at 11:30, can I see her at 4? I can't (though I don't say that it's because I have a hair appointment). What's a shrink to do?

Story #2) Patient is having an emergency. Ah, a few days ago I came to see pt outside of regular office hours because pt was so clear it was an emergency and it couldn't wait until next available appointment. It was an emergency and I remained worried about pt. Pt canceled follow up appointment because his car broke down, but it was still an emergency, so could I meet him later in the day when relative would be home from her hair appointment and could bring patient? I quietly think: it's an emergency, relative knows it's an emergency. Can't relative cancel hair appointment? But it's been presented as this is something that would either be unacceptable to relative, or pt would be uncomfortable asking this of relative (and this I understand). Patient asks if I can move appointment to later in the day, a time I'm usually in the office. Oh, but I didn't have any appointments scheduled that particular day that late in the day, and I guessed it...a hair appointment! We looked at our schedules and couldn't come up with another time for many days and this is what we scheduled for.
Do you want to know what I did? In the first scenario, I offered the patient a half appointment at the end of the day, and I was a late to my own "hair appointment," but every thing got done. I felt a little uneasy about it because-- The patient's other obligation actually felt a bit less conflicting then an actual hair appointment, and let's just say my own obligation got short-changed, and the issue at hand wasn't a psychiatric emergency.
In the second scenario, I felt more conflicted. I know the patient wanted to come and he was out of control of the some of the scenario (? did he ask relative to skip hair appointment? Did he offer to drive another family member to work and borrow their car?). If this same patient had called and did not already have an appointment for that same day, and if my schedule was completely booked, I would have come back in the evening after my new doo to see him.

So what do you think?


Marie said...

As a client who has been on the other end of that phone call, I can say I'm very grateful when my shrink sees me ASAP. (I've only had two real emergencies in two years, by the way.)

And I've always taken the very first appt. offered. In a true emergency, everything else is less important and can be rearranged. Even hair appointments.

HappyOrganist said...

Marie sounds like a decent client ;)

I took my son in for an emergency appointment with our dear, departed former practitioner (i.e. the one I'm still in love with).. She was very kind to see us on short notice and after hours. And it was an emergency (he went to the hospital the very next day and stayed there for 5 days). But I digress..

oh - You really gotta be careful with those after-hours or short-notice appointments. Of course you already know that. But I'm just talking about how it can begin to confuse the relationship (and boundaries) for the client and practitioner.

Anyway - I think it's fine to say no when you can't juggle things to work an 'emergency' visit in. There ARE other resources available for people to use (I'm callous, I know).
But it's also fine to be nice, I guess... just be wary of screwing up the patient/pract. relationship by juggling your own schedule for them when you shouldn't ....

Makes me glad I'm not a practitioner of any kind! Although I do teach piano lessons now - and that's *almost" the same thing (being in charge of scheduling, etc..) It's a strange position to be in (a new one for me) =)

Dinah said...

Hmm, no boundary issue here that I'm aware of-- I don't make a point of advertising my hours to patients, I do work late one night a week, but all these appointments transpired in my office during normal business hours and a fee was charged.
In psychiatry the issue of "emergency" can be vague, and fortunately these calls are fairly rare. With a new patient, I simply offer the first available appointment.
I hold a fairly loose schedule, because that's what I'm comfortable with. It gives me a bit of flexibility which swings both ways. I suppose if I consistantly said "my next available appt is in 6 weeks, if you have an emergency, go to an ER" ...but a life with that kind of rigidity would drive me nuts.

HappyOrganist said...

Well it's good to be flexible, then ;)

All the books I read on 'boundaries' said "don't schedule lots of extra-hours, etc" for 'special' clients.. well they said to be careful anyway, as it can create problems (or can be an indication of problems).

Anyway, who cares. I'd sure love to know if our former practitioner was bending over backwards for us at times. It was hard to tell if she was working hard to work us into her schedule (we saw her frequently the first little while) or maybe her schedule was just that open. I don't know. But as a client, it seemed like she was making room for us and our situation. Which I guess is ok - but it's hard to tell if we were really a case that merited that kind of treatment or not.

Rach said...

I totally agree with Marie.
There have been times where I've needed to see my shrink and he's fit me in the same day (once within 2 hours), or sees me on a weekend for an additional session.

Over the summer, I often had to change my schedule to try and fit my schedule's to the shrink's. That being said, I try to leave my schedule open enough so I can get extra time on the couch when the need arises.

As a patient, I try and explain what the "emergency" is - sometimes what i think is super urgent is something that he thinks can wait 2 days or so.

What do you consider to be an emergency, Dinah? Maybe that's the better question.

Sunny CA said...

I feel the same way Marie does, that when I have a psychiatric emergency, nothing at all is important enough to keep me from my psychiatrist's first available appointment. My psychiatrist uses an alternative method to handle emergencies, though. The phone. His schedule is tight and he may be booked solid the day of a client emergency. In the 10 minutes between clients he returns client calls. He is very to the point and it's amazing what he can accomplish in a 5 minute phone call. He then schedules a follow-up phone call (if necessary)that he takes at home that evening. The 5 minute call between clients is free. The phone call from home is billed at the same rate as an office call, by the minute/hour. Once a relationship is established a phone call works as an occasional alternate to meeting in person and it is a whole lot easier to fit in, and can be cut to the barest minimum of time. I have been grateful that my psychiatrist will take calls at home in the evening and on weekends.

Anonymous said...

ha ha, it's not just psychiatry in which what constitutes an "emergency" is vague. You wouldn't believe the things many people call 911 for. Uncomplicated barfing, simple sprains, the common flu ... But you probably had a rotation in an emergency department, so that's probably a distant memory somewhere. But anyway, I'm glad to hear that you / other mental health professionals are taking your clients/patients on an emergent basis, even if it's only briefly. I'm sure it often helps patients a lot to be able to touch base with a provider they already have a working relationship with, possibly resolve something before it gets worse or reaches crisis level, and probably means that the patient/client gets more helpful, faster, and more compassionate care than they might in some anonymous emergency room where they have to wait around for hours and then be disrespected by emergency staff who don't understand or dislike mental health patients.

Notfluffy said...

A agree with Marie. If you have a true emergency, you will cancel whatever else you have going on. If someone doesn't feel like it's important enough to change their hair appointment, then they should be willing to take whatever appointment you have available that suits their schedule.

While it is wonderful that you are so flexible and can meet your client's needs, some people will take advantage of that far too easily.

I feel Happy Organist's pain, since I'm a music teacher as well, and have had people rearrange my entire schedule because they wanted to make plans with friends...

Keep up the good work, Dinah, and don't let people's hair appointments get you down! :-D

Paperdoll said...

I have only ever called my psychiatrist when I am in a real jam. The day I was in A&E (Emergency room to our US friends) and was feeling like a total loser, I left a message on his machine. He called between patients and said to the A&E pysch reg "send her on over". I didn't care what my hair looked like, it was clean and brushed, so the roots may not have stood up to close inspection, so what's important here. I saw him daily for a week till we got things back under some control. Hair done .. a week later than it needed.

I was in London on business when things next went bad. He scheduled a phone appt for me. I think he offered a pre-first appt time or a post-last appt time. I chose one and stuck to it. I set the alarm for 5 am London time and called.

I wouldn't call unless I needed help between appts. If it is offered, I am most grateful (personal trainer, french tutor, cooking masterclass, nail bar booking and hair appointment aside) and will fit in.

I think the pdocs have training in this. Psych 101 : If your patients appointment with the ghd and some bleach takes precedence over your appointment, you are correct to to question their definition of emergency.

Trichotillomania, however may be a line-ball call.

moviedoc said...

Real medical (that includes psychiatric) emergencies dictate immediate response and resources not available in an office. Wayne Fenton met with a patient on a weekend. He's dead, and his patient is a murderer. (I'm not sure which is worse, for them or their families.) Dial 911 or go to the emergency room. But phone, and now Skype, often suffice when talking to someone who knows the patient can save a trip to the ER.

Anonymous said...

I've rarely contacted my psyc outside of an already scheduled appt because I simply feel too guilty for bothering him..even if he's instructed me to do so. His schedule is always so booked that getting a same day appt is impossible, but he'll always return a call the same day, even if it's at night from home.(which makes me feel even more guilty) If I'm truly having an emergency though I appreciate ANY method of contact. I would never expect a therapist to rearrange their prior appts (hair or otherwise) in order to see me..and just assume my options would be the ER, or to figure something else out on my own.

I do wonder, from a therapist point of view, what you constitute an emergency "worthy" of an additional session/call? Maybe you just know, by knowing your patients, which emergencies are, for lack of a better description more "emergent" than others?

For me the biggest downside of the phone call return as opposed to an office visit is the privacy factor. If hubby, kids are around when my psyc calls back, and my "emergency" is not something I want to share with them, it can get a little tricky.

Anonymous said...


I have had a lot of "emergencies" in the last few years. Most of them were because I was suicidal or wanted to hurt myself very badly. I only expected a 5 minute call back. Questioning whether I should go to the ER or use another crisis plan. I think that is an emergency?

Rach said...
This comment has been removed by the author.
Meg said...

@ anon, you consider barfing and sprains to be silly 911 calls? Never gotten one for a UTI? Or a stubbed toe?

moviedoc said...

This discussion raises the issue of the ubiquitous voice mail OGM: "If this is a (medical) emergency, hang up and dial 911." (I chuckle when I hear "medical." Does that mean if it's a non-medical emergency, you're supposed to wait for a call back from the doc?!)

My OGM does include those words (sans medical), because my official position to my patients is that I do NOT provide emergency services, and anyone who call needs to know that.

I don't do psychotherapy any more, but when I did it seemed that phone calls often turned into unscheduled psychotherapy via phone (and for free) which I did not want to be doing.

tracy said...

@Meg....That wasn't very understanding and borders on cruel what you said to Anon. And yes, i too would like one of the Psychiatrists to define what exactly they would consider an "Emergency". Or does it vary from patient to patient, as i imagine it would?

@ Moviedoc i see why what you do now is movie reviews...

tracy said...

Meg If you weren't talking about the Anon right above you, i apologize, sincerely.

moviedoc said...

Emergency is defined somewhere in fed. statutes, probably EMTALA. The essential elements are that if intervention does not take place within minutes (a) then there will be some serious (b) possibly irreversible damage.

It should not vary from pt to pt.

I write opinions as well as movie posts:

Marie said...

I guess the whole "emergency" would depend on what kind of service one gives.

In an ongoing, therapy relationship, it was an *emergency* when my mom was hospitalized for attempting suicide across the country.

Was I in danger? No. Was I suicidal myself? No.

Did I need my therapist to help me sort through this? Yes. And I'm grateful he did.

Sarebear said...

It's a good thing I see my psychologist for therapy, and not the psychiatrist I fired last fall, because he'd NEVER return phone calls. Like 90% chance never, really.

One of the main reasons I got frustrated with him, but not the only one. He even admitted to me that he's not a very good businessman.

He likes working with people, it's the business end he can't handle well.

But OH the whole PHONE thing made me want to SCREAM. I can't believe I lasted with him for a couple years, but He, at least, LISTENED to me, as opposed to the previous psychiatrist, who didn't 2/3 of the time. Which . . . is a bad thing when you are prescribing medications.

AND, when I titrated myself down off the Cymbablta, and eventually got low enough/ off of it and could see what it had done to me, ie, 7 months of being almost a zombie every day, in bed 85% of the time or more, almost constantly, and suicidal, granted the 5 week period about 6 weeks in to it where I felt HIGHLY suicidal went away, and he was like, GOOD, and he had sort of given me the impression that if I hunkered down and got through that it'd go away, well, really it just went down to simmer from pressure-cooker levels . . . .
he never asked about it again . . . I mean, I did report some suicidal ideation, but he assumed it was my "usual" stuff . . . . and who was I, to assume any different, I thought the same. At the time, until I came off the stuff myself. I mean, isn't the doctor supposed to be suspicious of stuff like this, especially considering my sort of black-box warning-type reaction to that med?

I'm ANGRY that he just left it at that and was LAZY and just . . .

Well, it confirmed I was right to fire the guy.

Hell, he never even returned my phone call initally REPORTING that I thought I was having this high suicidal ideation reaction thingie imposed on me by the medication, last spring 2009 . . . . what kind of psychiatrist doesn't even return that kind of phone call?


I saw him within two weeks of the call but still.


I gotta get going on finding a new one. 7 weeks out from surgery now, in more pain than I thought I'd be but oh well, it's time to get on with life.

Here's hoping Psychiatrist #3 will suck less than the first two.

Anonymous said...


No, I haven't personally seen a stubbed toe, but I hear about stuff like that happening. The point is that some people's compensation abilities get overextended far more readily than others', and those people are more likely to panic and call 911 for something others of us would think is easily managed with a cold pack. But it's still an emergency to them, and I don't expect the average citizen to be able to sort out what constitutes a life threat or other emergency. Even if it's just the flu, there's still value in being able to reassure and support (and possibly educate) someone who's panicking. That sort of anxiety is, in some ways, an emergency in itself, albeit not life-threatening. But yes, it's amusing in other respects.

I disagree with moviedoc -- emergencies *do* vary from patient to patient, regardless of the text of statutory law. Psychiatrists (and other health care providers) don't exist to serve laws (though they end up doing that, as well); they assist and treat patients. Also, the patient may be more aware of what will cause irreversible damage than the health care provider at first glance. Anyway, this is getting off topic.