Monday, August 15, 2011

My Next Appointment Is..

I've been at it a long time, and one thing (of many things) that I still have not gotten down is scheduling.  I seem to have a method to my own madness, but somehow I imagine it's not how other people do this.  I've heard other shrinks say, "I'm booked for the next 4 weeks" or say they aren't taking any new patients.  Some people put a "no new patients" message on their answering machine.  Wait, so no appointments for 4 weeks?  What if a patient calls and needs to be seen very soon? Like this week?  If you can't wait, go to the ER?  I thought the point of having a private doc was that you didn't have to go to the ER unless something couldn't be handled safely as an outpatient.  And if you tell the world that you don't take new patients, then don't people stop referring to you?  It seems to me that patients will come in and announce, "I'm doing better and want to come less often,"  "I'm moving,"  "I'm done," or they will cancel an appointment, not call back, and not be heard from again for weeks or months.  Sometimes it all happens on very short notice and life can be very unpredictable.

In my pre-shrink days, I thought that psychiatry worked such that patients came every week (or twice a week, or whatever) and had their own slots.  Tuesday at 1, that's me!  So a psychiatrist had every slot full with patients this way, and could be "full," until a patient finished and stopped coming, and then another soul was let in to the Tuesday at 1 slot.  Gosh that would be nice, but it doesn't seem to work that way.  Patients have job obligations or class schedules or sick relatives or childcare responsibilities or they have treatment for other medical conditions that have to be scheduled.

Prospective Patient:  "Are you taking new patients?"
Shrink:  "Yes.  I have Tuesday at 1 available."  
PP: "Every Tuesday?  I'm a college student and I have a class that meets Tuesdays at 1.  And I'm not sure I need to be seen every week, don't you need to evaluate me to know if I even need therapy?  Or, I can't afford to come every week."

So what does the shrink do?  Turn that patient away?  He has a class at the only open time.  And when the neighborhood internist asks, "Are you taking new patients?"  Does he say, only if they will come every Tuesday at 1 pm?  Funny, answering machines never seem to say, "I'm only in the Blue Heart Insurance network and I only have one opening for Tuesdays at 1."

I tend to keep things looser.  Some patients have set time blocks, but with most people, even my weekly patients, I've found it works best --for me, in my own chaos-- to set appointments as we meet.  I generally have space in my schedule so that if someone (an existing patient) calls and says "I need to come in" and they can be flexible, I can fit them in within a day or two.  And even though much of my scheduling is done at the last minute, my schedule end up mostly full.  When it gets very full, I start wishing I was a little more organized about it.  You want an appointment in two months?  Oh, call a week or two before you want to come in.

The truth is-- and it took me a while to get here-- this fits in best with my personality.  If something fun comes up, I don't have to say "sorry can't do that" because my schedule is etched in stone.  I once moved all my patients to fly to Boston and sit in Green Monster seats (Rob, that's for you).  I like being able to roll things around, and I can't ever get my act together to plan vacations far in advance.  So when a patient comes in and says "I can't keep coming Fridays at 1 because I have a new job," or someone calls with a problem and wants to come in, I like being able to accommodate them.  And am I taking new patients?  If I'm feeling rushed and over-scheduled, then I'm not. especially if I already have any new evaluations in my schedule... but next week, who knows?

You'll tell me what works for you? 


Sarebear said...

My psychiatrist, well there was 6 weeks between our last two appt's, previously it was always a month. Between the last one and my next one, there's two months.

Now, if she'd said or indicated that, "Oh, I don't need to see you as often, " whether or not she gave a reason, I'd assume there was not enough need to see her more often.

But when you're told that her schedule is pretty full, first for the next six weeks, and then for two months, that makes you wonder if she's got the time to take care of her patients well; I've thought to myself, "What if there's a patient who needs to be seen soon? Even if they can wait a week to 10 days or whatever, they are SOL with her."

And one time recently they called the week before my appointment, and then the day before, (with the usual day before reminder) and asked that if I didn't need the appointment to please call them because they needed it.

Um, I'm a patient, who has had this scheduled for a long time, thank you very much; Those messages made me feel like chopped liver! Of course, if there was someone in crisis, I felt kind of bad, but . . . if I changed my appt, her schedule was too full to get me in within any reasonable time frame.

I think that if she continues to be so over-busy, that I may just give up on getting decent or adequate or minimal psychiatric care. Since sometimes she isn't decent, and it's a tossup on a few occasions between the latter two.

But then since the 150mg of Lamictal is the only thing keep some of my mania partially at bay, well, I have to suck it up and put up with sucky psychiatry.

And now, my husband just got a low-paying job that starts at the end of this month, so I need to call and change my mid-September appointment; will it be pushed to mid-October or later? Especially since I need a 4:20pm appointment or later, it may be awhile before she has that available.

Then, after his first 8 weeks of training, I may have to reschedule the next appointment when he gets his real work schedule . . . will that make it be 3 months to the next appointment, twice in a row?

I'm kind of annoyed, although if I can see her less frequently than I used to, I'm not too sad about that as I don't like to see her . . . but of course since it seems as though I'm going less frequently because she's too busy, rather than because my needs have changed, that makes me think/wonder about her caring more about her bottom line than providing adequate care. Yes, I know docs need to make money and need to be concerned abou that, but I have to think about how her practices affect me.

Sunny CA said...

My psychiatrist runs his practice like you do. He has complained about current insurance reimbursements which disallow weekly visits for many clients, so he ends up having to have more than one patient alternate in a particular time slot which he does not like. Also he feels that due to insurance companies he does not see many of his patients as often as they ought to be seen (in his view).

When I first called my psychiatrist he told me he was fully booked, but that I should call him back "some time in the future". I wondered why he did not take my name and number and call me when he had an opening. Also, I was unsure how to interpret "some time in the future", so I went to a very unsatisfactory drugs-only psychiatrist plus an unsatisfactory psychologist for 6 months before I got the courage to try calling my current psychiatrist again. He then had an opening and he's been flexible in seeing me, so I have no idea what was going on at the beginning when I first called.

Knot Telling said...

As an NP who worked primarily in a hospital-affiliated clinic, my situation was somewhat different from yours. I kept an hour free at the end or beginning of the day - if not every day, then several times a week - and that hour was for emergencies, new patients and Stuff Happening. If I wasn't seeing anyone at that time, I used it for paperwork or reading or whatever.

It worked well for me, but I think you and I are very different. If asked to describe me, none of my family or friends would come up with "spontaneous" as their first thought. I once had a supervisor who used to drive me out of my mind (as it were...) by scheduling our meetings from one time to the next. "I need consistency!" I protested. "Let's talk about that," she said.


Anonymous said...

for my colonoscopy! LOL!

Thinking of changing my chair for a photocopy machine, makes for easy work, just plant my arse down and press PRINT! LOL!

Rach said...

I agree - depends on what's going on in life. When I was working, I liked having that predictable 1:00 Tuesday spot so that I could schedule work around it. As my jobs have changed, I've been more flexible (I prefer afternoon to morning), especially when I call on a Monday morning and I want (no, need) an appointment on Monday afternoon, latest Tuesday morning.

jesse said...

Dinah, I think you have it exactly right. I don't understand that other way of running a private practice either. Three theories: either those doctors think it sounds good never to be available, they see so few patients each week that they basically never are available, or they are so hounded by nuisance calls that they put that message up as a screen.

Dinah said...

Sarebear: Ugh. Sorry to hear about your frustration.

SunnyCA: Perhaps he assumed you would find another doc. If someone calls and insists it has to be me, then I'd see them. Mostly people are looking for a-shrink-any-shrink.

Knot Tellin'-- my life is sort of like this, I schedule from the middle of the day out, with the first hour and the last hour going last (if possible)--I'm never too sad to go home early or to sleep in a little.

At some point, I realized that if I consistently filled every hour I have allotted in my head to work, and every one showed up and no one canceled, that I would soon go nuts. I do think this is the secret to my flexibility. I want to work a certain number of hours a week, but I block off about 4 or 5 more than that.

Rach: Hi! (I don't have much to add but I'm happy to hear from you).

Jesse: So don't you think that giving people a set time increases the likelihood that they will stay in treatment? Or that they will put it as a priority and not say they can't come because they have a hair appointment? Doesn't it encourage therapy as an ongoing process....I have a fair number of people who expect to get a lot out of periodic sessions or who come when the chips are down. And this is fine with me but isn't it a different kind of work? Does it seem like 'way back when' people were more willing to put up with more set schedules for the sake of the therapeutic process and now the world as a whole is less pinned to timed obligations? Or is that my imagination?

jesse said...

I think things are less pinned down but yes, absolutely, it is better when patients have a set time and both they, and I understand and work with that. I try to stay with that if at all possible.

Dinah said...

Jesse: my guess is that your better at this than I am. I think the point of my post was that I've pretty much given up even trying to get people settled into their own set time, at least in part because I like the flexibility of having things loose.

Sunny CA said...

My psychiatrist does try to schedule "set" times for patients, particularly weekly and twice weekly patients. As a patient, towards the beginning of seeing my pdoc, at times I would be hanging on by my fingertips from session to session and really needed that time slot when it came. Hence, there's a certain aspect to scheduling that affects patients state of mind, as well. Now he could call and cancel an appointment and I would be fine, though he has never done that (though twice he accidentally scheduled another person at the same time as my session).

Anonymous said...

My psychiatrist is more like you. I have a set time slot but not infrequently she needs to change it. One of the things I like about that is that it also makes it not a big deal if something comes up for me and I need to change the appointment. She respects my commitment to working with her and I definitely respect her. I feel like I am a priority (as I assume her other patients feel as well) and making the time to see her weekly is a priority for me, but the flexibility to change if needed is invaluable. In some respects, it keeps the people (her, me) as the important parts of the equation, rather then the exact minute.

She also always manages to find extra time if I need an urgent appointment (or if she thinks I need an urgent appointment) which I appreciate as well. Psychiatrists who are less flexible may have infinitely tighter frames....but are their patients really any healthier?!

PDF doc said...

My own clinics are booked front to back - start at 8, finish at 3, no lunch or breaks. If there are emergencies, I see them at 7. I prefer to leave earlier rather than start late, so if I am not fully booked I leave early.

My psychiatrist's "well" appointments are once a month or thereabouts. Not always the same time or day. Even my first appointment was about a month. When not well, these go to weekly or less as needed. He just tells me when my next appointment is. Even when suicidal, it was weekly (with hefty meds), a gamble but I appreciate his recognition that in my post divorce life, no income is no house...and that would probably tip me over anyway.

summitdoc said...

I think this must vary considerably by practice location. I am in private practice in a small college town in the Midwest, and there is such a shortage of mental health providers that no one- the 5 of us in solo/joint private practice, the resident/attending clinic from the local University, and the 'not-for-profit' administrative agent for the five area counties- can get a new patient in for a month or more.

I have had to start a 'wait list' for new patients. I then schedule one slot/day for new patients and the rest of the day is for established returns. Returns may be as often as two weeks or as rare as 3-6 months, but the most common return is monthly.

Usually my office manager works down the wait list to fill the 'new' slot, and often a new may decide to cancel an upcoming appointment because the crisis is over or they get in with someone else. My office manager then fills that slot with another new off the wait list or plugs in established returns that may call to be seen more urgently.

Regardless, there is a true shortage of providers here and each and every slot gets filled, and if someone has to call to cancel that slot will get filled within minutes by someone, new or established, on a 'wait list'. I hate having a 'wait' for new patients, but it is the only way I can make sure I provide my established patients the care they deserve- As well as trying to keep my hours under control so I don't burn out in a year or two!

tracy said...

What if the Psychiatrist you truly, deperately want to see has no openings and is very busy, (Clinic, Faculty), but won't even put you on a wait list or anything?

Anyone who reads here regularly knows it is the 4th year Resident i am still "pining" for...i am begining to think he just doesn't want to see m e , although the first time i called him, about 2 years ago, he seemed genuinely pleased to hear from me...

i know, i know, just "get over it"....but it is sooooo hard.


Svetlana said...

I work as a psychiatry resident, although not in the US but in Europe. I loved this post because it expresses pretty much the way I feel. I also never understood how some one can be "full". I usually schedule the next appointment for each patient a week ahead - for some patients, there is a certain routine to it, I have one patient, for example, you usually comes on Monday 9am, and that´s fine, but every week, we agree whether he would come next Monday at 9am or not. Other patients, just like you said, have children or flexible office times or whatever, and sometimes they come at 8am, other times at 6pm. I feel like it works well both for me and for them.