Tuesday, August 31, 2010

The Texting Shrink

I like texting. It's a fast and efficient way to exchange information, and I'm a bit prone to yakking, so this allows for a no-nonsense exchange without all the gabbing about how the kids are doing or the latest on someone's ingrown toenails, or the usual assortment of small talk items. Running late, order my salad. Yes, Bobby can get a ride home with us. Or, if you're Roy: "do you have triple sec for the mango margaritas?" Roy makes surprisingly good mango margaritas without using any triple sec. Just so you know-- and I don't mean to brag-- I'm fast with the thumbs.

I text with patients as well. Do other psychiatrists do this? It works well for "Need to cancel my session this week, see you next week." Or "Running 10 minutes late, traffic." Once in a while I'll even text a reminder to someone who misses appointments frequently. I was happy to hear that there is a dentist in town who also sends text message reminders.

Here's the problem with texting patients:
People have taken to texting me with problems. "I feel horrible and like I might want to end it all right now." (This did not really happen). I've done a few back and forths and realized that I'm not good at psychotherapy via text. Usually problem texts get met with "Come in at....." and if .... is not Very Soon, or if the patient says that's not good, I call, or text "call me." I've been texted insurance information, drug reactions, appointment changes, negative biopsy results, "will you call refills in to my pharmacy?" and most notably, "Your office door is locked" after I haven't responded to the knocking, only to find my patient sitting on the hallway floor.

What's good about it? Somehow it feels less intrusive than a phone call, and the time taken up is more predictable. I'm prone to ramble and so are many of my patients-- texts messages take seconds and phone calls can take minutes and involve many phone-tag back-and-forth exchanges. When someone texts their pharmacy number, I can click on it and get through--if it's on voicemail, I often have to re-listen when I have a pen available, and often the number is at the end of a long message. It seems to me that texting is no less documentable than a phone conversation, so I can't come up with any legal reasons it's not kosher.

What's bad? I have taken to telling patients that while I'm happy to try to negotiate appointment times via text, or "running late" messages, that it's not a good way to negotiate problems-- for drug reactions and symptom changes, we should start with the phone. My biggest concern is that if I'm on vacation, there's no way to set a coverage text message, and my voicemail has the names and numbers of covering doctors. I've been pretty clear with people that I'm not blowing them off, and that if they don't get quick reply to a text message, they need to CALL the office.

What do you think? It's a different take on the shrink when there's nearly instant access a good deal of the time.


Rach said...

Dinah, you're a good, kind hearted soul. My shrink would never in a million years do text-messaging. Hell, he won't answer an email without charging for it!

Anonymous said...

My shrink had to sign an agreement with his insurance company promising no emails or texts with patients. If he didn't sign, his premiums would go up tremendously.

I wonder if the insurance company fears some sort of "paper trail," if something goes wrong.
- Em

Retriever said...

We've communicated in a variety of ways with family members' shrinks over the years. Worst was the phone. In kiddie emergency we would leave detailed message on shrink's private line. Not to hear back for hours and then from a secretary, by which time, we would have taken things into our own hands, called police, whatever. Turns out, secretary would have transcribed and decided what was important in the message (and got it wrong). Next shrink kid had (bless him) was willing to give us his personal cell to avoid going thru the awful messaging system. Mercifully no crisis to test it, and I was careful not to abuse it. I called once and left a verbal message describing a response of kid to new meds. Other family member, email is preferred method of communication. Shrink is old enough not to know how to text (also works from home, so only uses cell as a phone and rarely, like to get on call messages).

I agree with Rach, you are a very kind hearted person. Short, prompt responses must greatly reassure anxious patients.

I mostly text in personal life, as my college aged kids prefer it, and it is the only way to limit endless conversations. I work full time, and have kids with issues, run a blog, and have many writing projects, so have little time for long conversations (sssh: writers aren't always that sociable anyway, sometimes the phone rings when I am just drafting out an essay and I am frantic to outline it before I forget something)

When I was in parish ministry, it might have been a good tool as a youth minister, but it wouldn't have been much use in my work with the adults or the pastoral care. As my family used to grouse, a large part of my work was hours in th evenings on the phone with parishioners with problems who would call. You can't really text in response to a prayer request...

Sunny CA said...

My impression is that you are potentially leaving yourself open to 24-hour a day patient contact. I enjoy turning my cell phone OFF and ignoring it if I feel like I want a break from it. With patients texting you may feel you are never off. Perhaps by specifying you will ONLY take "running late", "making or breaking appointments" and "med refills" you will feel OK over the long run, but gosh, what a burden.

Anonymous said...

YES, I text my therapist and 99% of the time it's re: re-scheduling of appointments and she texts me with the same sort of concerns ... never with a problem. I would say we send a text no more than once a month ... more like 7 times a year. I feel it's less intrusive in her day, she says she likes it for the same reason. It's easier for her than replaying voice messages and she can reply she with all the needed info in less than 10 seconds "7:30 on Monday will work."

Since I don't text re: problems or just to "text" it has worked for us. By the way, I'm not the sort of client who likes to call either. I hate my voice on voicemail so I love that it's okay for texts.

Anonymous said...

Ah, Rachel, none of it's about a kind heart---I never once thought how nice it would be if my patients could text me immediately, it's about how much easier it is for me in terms of communicating--nice side effect if patients like it. (they seem to)

Anon: your shrink has different insurance than I do

Sunny CA: I turn the phone off during sessions, when I'm not somewhere I can talk privately, and when I'm asleep or when I'm on vacation. I don't think anyone assumes immediate feedback via text. I did get some non-urgent text messages from a patient on a Sunday evening, and I did not respond because I didn't think it was a reasonable expectation to encourage.

Oh, and I don't encourage email because it's too time-consuming and open to use as an alternate form of therapy, a malpractice risk, and because I don't want my email to be filled with patient issues. I answer my patient emails with some polite form of "Why don't you give call me."

drkkolmes said...

From the conservative point of view, my biggest legal concerns with text messaging clients would be the potential confidentiality dangers associated with loss of phone by either my client or myself, and then having a string of text messages that can be read by anyone who picks up the phone. I also would not want to back up this phone to my home computer and have client information on my home computer.

The other issue, which it sounds like you are comfortable with, would be documenting exchanges when they become clinical: medication side-effects, urgent need to come in. These exchanges do become a part of the legal record.

I don't text message with my clients, but if I did, I would certainly add a statement about it to my forms similar to my statements about email, indicating when they could expect me to respond and what is appropriate to communicate via text message.

I can certainly appreciate the appeal of it, for convenience to both you and your clients!

Anonymous said...

I usualy E mail my T with appointment scheduling
eg I would like to make an appointment on the 13 or 15 of sept at 16:00
she would reply with a date that suitable for her.
or if I have a specific problem

But usualy the e mails are short and to the point.
I prefere it to phone

Anonymous said...

I think you need to think through what you would do if you got a text that someone was in crisis and was going to attempt suicide. There have been times when I have been in crisis and known I "should" seek help and to satisfy the "shoulds" I might seek help in the manner least likely to result in help, just so I could say I tried. I don't do it to be manipulative or to create drama even though I know those are the consequences.

Texting isn't an option for me, (and I like it that way), but I can picture myself as someone who would text my doc out of a twisted sense of loyalty/responsibility, and then go off to mess with my life. I hate that I am this way, and that is why I am glad my doc doesn't text/email etc.

Just something to think about...

Unknown said...

Interesting stuff Dinah.

I love technology, but have taken time to figure out how it fits into my practice.

So many things to check these days: voice mail for practice #1, voice mail for practice #2, email - all forwarded to one inbox, texting too?

Our group recently went with an answering service for emergencies that cannot wait for a call back, but do not require an ER visit.

The patient leaves their brief message and contact number and the service texts the appropriate doctor (we all cover our own patients). The service continues to text us until we call or text them back that we got the message.

So far I like that happy medium. And patients love it.

Dinah, does your phone ring or vibrate in session? Or do you turn it off?

Dinah said...

I turn off my phone during sessions. Sometimes I forget to turn it off and the ring/text beep intrudes, but I never answer during sessions.

At this moment in time, it works for me.

snoring solutions said...

I wonder if the insurance company fears some sort of "paper trail," if something goes wrong.I agree with Rach, you are a very kind hearted person. Short, prompt responses must greatly reassure anxious patients.I love technology, but have taken time to figure out how it fits into my practice.

Dr. Steve said...

You're an idiot. This violates doctor - patient boundaries which will inevitably get crossed, and will UNDOUBTEDLY lead to abuse by certain needy patients, no matter what you tell them. The only thing you are doing is inviting a giant headache upon yourself. The only exception would be if you are some type of boutique doc catering to a select clientele, which may very well be the case. Otherwise, texting has NO place in the practice of psychiatry.

Anonymous said...

Dr. Steve (and others)--
Most are less blunt and more roundabout about calling me an idiot!

So you are absolutely right that people can take advantage of this, and sometimes needy patients do. Not a lot, and mostly it's confined to very short communications: stuck in traffic, running late, I've been known to text appointment reminders to the chronic no-showers (with promise on my part to do so).

Here's the rub: What's the difference between being needy or intrusive or suicidal (as anon suggests) via text message rather than on my Voice Mail? I still have voicemail. People still use it. For those who call or text in distress, I call them back. My office phone is a cell phone, so I'm getting the message no matter what, and if I want to sleep, or see a patient, or watch a movie, the phone gets turned off. And I give my patients my home phone number, so like by this point, what's texting going to do? It takes a lot less time and it's so much easier to respond to then looking for a quiet place to talk. (Says she who got 2 urgent messages when the phone was off during a movie last night. It was a great movie,though.)

Word verification (I'm not kidding): curse

Dinah the Idiot?

Any way you dice it, I'm pretty available but not totally available.

snoring solutions said...

In kiddie emergency we would leave detailed message on shrink's private line. Not to hear back for hours and then from a secretary, by which time, we would have taken things into our own hands, called police, whatever.I feel it's less intrusive in her day, she says she likes it for the same reason.

Anonymous said...

I think the shrink who said you're an idiot is so outdated!! Texting is brief, more convenient and is just a great medium of communication. Yes, I'd much rather read texts than listen to voice mail. We have become such a litigious society! I'm glad there are the are shrinks out there willing to practice out of the box, if you would even consider this to be "out of the box" - Think with the next generation it will not even be an issue to blog about.

Sue said...

I live in the UK, where we can wait months for appointments. I truly appreciate texted appointment reminders from the Dr or Dentist or Vet. Its March now, and I have a dental appointment in October & I've already forgotten the details, but feel reassured as I know they will text a reminder in good time.

I have CFIDS/CFS and like many sufferers, find talking on the phone very difficult, especially when there is background noise. I rely on texts and find it the least stressful way to communicate. As it makes life so much easier, I'm glad that professional people use texts in a limited way. It helps a lot.

NormalWasNotMyGoal said...

My therapist and I have found texting to be very beneficial. It certainly has it's downfalls but the pluses win out, atleast in my situation.