Sunday, September 30, 2012

Please Pass the Valium

In today's New York Times, I learned that Roche, the makers of Valium, will soon be closing the doors of their New Jersey plant.  In Valium's Contribution to our New Normal, Robin Marantz Henig writes:

Taking a pill to feel normal, even a pill sanctioned by the medical profession, led to a strange situation: it made people wonder what “normal” really was. What does it mean when people feel more like themselves with the drug than without it? Does the notion of “feeling like themselves” lose its meaning if they need a drug to get them there? 

Ah, we like to question What is Normal here at Shrink Rap.  Okay, time to pop my Xanax.

Saturday, September 29, 2012

What Rich, Beautiful, Brilliant People Talk About In Psychotherapy

On on Boy Doctor / Girl Doctor post, one reader wrote about my novel, Home Inspection:

I was kind of surprised and amused by how mundane much of what Tom and Polly talked about in therapy seemed. These characters were far more attractive, intelligent, accomplished and worldly than I am, and yet their sessions often didn't sound all that different than my own.

Ah, so I do see some amazing people for psychotherapy and this got me thinking about a few things.

First off, let me remind you that Polly and Tom aren't real, they are fictional characters and some of their dialogue is not about being a realistic therapy session, it's about progressing the plot.  Each chapter is a therapy session, and while the length varies a bit, sometimes the space just needed to be filled for the sake of the format.

Second off, let me tell you that rich, brilliant, gorgeous, accomplished people talk about the same things that dumb ugly people (oh please forgive me, I don't actually think of my patients as dumb and ugly!)  talk about in psychotherapy.  The degree of detail and the propensity to want to talk seems to be a feature of individual personality, and not a product of money, brains, luck, or good looks.  Smarter people sometimes use bigger words.

This is what everyone talks about in psychotherapy:
  • Interesting things they've done or places they've been since the last session.
  • Distressing interactions with important people in their lives, so if they feel dissed by someone, that tops the list.  Wealthy, gorgeous, smart people feel disrespected and misunderstood in the exact same ways the non-beautiful people do. 
  • Anything that's upsetting or aggravating.  If you've never been in therapy, let me assure you I hear a great deal about technology fiascos and car/home repairs.
  • Sometimes people actually talk about their psychiatric symptoms, but less often then you'd think, and sometimes only when specifically asked about them.  They do talk a fair amount about medications.
  • Their medical issues and the medical issues of their family members. Sometimes the medical issues of friends and co-workers.
I'm sure I'm missing some things, you'll fill it in.
There are no more free days to promote Home Inspection, so it's selling for 99 cents for a few days only.
Double Billing is getting hundreds of downloads and I couldn't be more pleased.
If you're interested, the books are listed  here 

Thursday, September 27, 2012

Novel Downloads at the Right Price

Dear Readers:

Over the course of the summer, three of my novels have become available on Kindle/Amazon.  Kindle allows for a few days of free promotional downloads, so I wanted to let you know that all the books are available at no cost for just a brief time.

Double Billing is the story of a woman whose life changes when she discovers she has an identical twin she never knew existed. It's a short book and is intended to be a quick read.  It will be available as a free download from Thursday 9/27 through Monday 10/1.

Mitch & Wendy : Lost in Adventure Land
is  about two siblings who are struggling with their relationships in the aftermath of their parents' divorce. The story takes place on Wendy's 10th birthday when the kids get lost in an amusement park, only to learn they are being followed by a man who knows all about them from Mitch's misguided Facebook life.  Written for 3-5th graders, or the very young at heart.  It will be available as a free download
from Thursday 9/27 through Monday 10/1.

Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment.
Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find love. It will be available as a free download on Thursday September 27th only, and for 99 cents from 9/28-10/1.

If you don't own a Kindle, you can install a free Kindle app on your computer, tablet, or cell phone by going
All three books are also available as as paperbacks from Amazon.

Rather than giving different links to all these books and formats, there is a single link to my Amazon page with all the options here.

In non-fiction news, Shrink Rap: Three Psychiatrists Explain Their Work, written with Clink and Roy, will be released as an audio-book very soon.  It remains available in hardcover/softcover/Kindle/Nook, but so far, Hopkins Press has not felt inspired to give it away for free.  The three of us are very pleased with the enthusiastic reviews it has gotten.

I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.

Finally, If you do read any of the books, please consider putting a review on Amazon.  

Thank you so much,

The Accessible Psychiatry Project

Wednesday, September 26, 2012

Boy Doctor / Girl Doctor

Jesse was reading my novel, Home Inspection, a story told through the psychotherapy of two patients.

"I was reading the chapter where Tom talks about decorating his new home, and I thought, 'No patient has ever talked to me in that kind of detail about such things.' "  

Really?  People tell me stories in a lot of detail, at least some do.  I started to think about it, do people talk to me in that detail.  Maybe not.  Then my next two patients came in. One talked about a favorite food that was on special at a grocery store and how they only stock it for certain seasons. The next talked about the seating arrangements (chair by chair) for a party she is organizing.  Yes, people talk to me in that kind of detail.

It left Jesse and I to wonder if there is some difference about our styles that people talk to us about a different degree of detail, or if people talk to female psychiatrists about different things than they talk to male psychiatrists about.  What do you think?

Tuesday, September 25, 2012

Double Agent

 Yesterday, I heard Dr. Glenn Treisman talk at the Department of Psychiatry's  Grand Rounds at Johns Hopkins on "What is a Doctor."  You'd think we'd all know what a doctor is, but Dr. Treisman always has a unique and humorous slant to those obvious slices of life.  His talk was about the forces pulling physicians to look out for the best interests of the patient, while also looking out for the best financial interests of the institution they work for as well as the best financial interests of society.  He threw in some historical references and his talks are always entertaining as well as informative.

At the beginning of any professional presentation, the doctor must "disclose" any conflicts of interest -- in other words, if he receiving any money from pharmaceutical companies.  Dr. Treisman started his talk with a series of Disclosure slides which reflected both his wit and a statement of the problem.  He let me borrow them to reprint here:
First slide:
I am engaged in Doctor-Patient relationships that I was taught ethically constrain me to work in the best interest of my patient
I work in an institution that was founded by Johns Hopkins to provide care to the poor and indigent of East Baltimore
I have been instructed to provide “Excellence” in my work
Second slide:

I am paid by Johns Hopkins which has directed me to:
Decrease the time patients are in the hospital
Maximize reimbursement for hospitalization
Maximize the revenue I generate
I am barraged by “cost-saving” efforts by insurance companies that use bullying insurance reviewers and time wasting paperwork barriers to decrease the delivery of the care I recommend for my patients.
Third slide:

I have been recently informed that I am a “steward of resources” and that I need to conserve medical resources
I have been recently informed that “Patient satisfaction is the coin of the realm”
I have been informed that my Ryan White funding is contingent on efficient care (shorter visits) and improved measurable outcome targets 
Fourth slide:
  •  I have been informed that I am to use “Evidence-based interventions” and follow guidelines and protocols that I find less than optimal for many of my patients
Some of these conflicts of interest may have affected the views and information presented in this presentation, or perhaps are the subject

Ah, Dr. Treisman has a lot of "disclosures," touched with a little sarcasm, but he does a good job of illustrating the conflicting pressures doctors are being put under to act as agents for society and institutions in ways that conflict with being the advocate for the best interest of the patientSo that you know, he works with AIDS patients in an outpatient clinic, and with inpatients on one of the country's two psychiatric inpatient pain units.  His patients travel from all over the country to be admitted to this unit, often arrive in a state of desperation, and the struggles with insurance companies to permit their care are considerable.

Just a word on the graphic: it's from a show called Get Smart (the 1970's perhaps) about a spy named Maxwell Smart who had his phone in his shoe.  It's where I learned about "double agents."  I figured I needed to explain this one.

Monday, September 24, 2012

I Do Solemnly Swear

In Maryland, there is a tiered formulary for Medicaid patients.  What this means is that the physician must try a first tier medication before a second tier medication.  What makes a medication a tier one medicine? The cost.  Some medicines are more expensive than others, and beside that, the state contracts with pharmaceutical companies for special rates.  So in Maryland, if you want to prescribe risperdone, it's not a problem.  If you want to prescribe some of the other atypical antipsychotic medications, you need to fill out a prior authorization form giving the diagnosis, the target symptoms, the name of the medicine, the dose, strength, frequency, and quantity.  The doc needs to check off whether it's being continued from an inpatient setting, if there is a condition or drug interaction which prevents use of a preferred (i.e., cheaper) medication, s/he must list other medications that have been tried with their strength, frequency, dates of use, "compliance (at least 6 days/wk)" and reason for discontinuation.  Oh and the demographics of all involved including the doc's NPI number, specialty, address, fax, email, phone, and the patient's name, DOB, address, Medicaid number and height and weight and gender.  Just a simple little form.

Finally, at the bottom of the form, the prescriber must sign off on the following statement, "I certify that the benefits of antipsychotic treatment for this patient outweigh the risks."  So like how does anyone know that before the patient even takes the pill?  Risk benefit is an individual issue and depends on  a balance of side effects and response to a medication.  Until the pill is swallowed (and perhaps until quite a few pills are swallowed), we don't know if the patient will have side effects, or if the patient's symptoms will even respond.  Mind you, if the patient doesn't respond to the initial dose and we to raise it, the doctor needs to fill the form out all over.  I think the state needs fortune tellers, not doctors. 

Sunday, September 23, 2012

HealthCamp-Kansas City

Awesome "unconference" here today in Kansas City. Read all the tweets here.

Topics include:

  • empowering the next step
  • breaking boundaries
  • empowering 100M people who live with chronic pain
  • psychiatric survivors
  • finding price transparency
  • ideas for Partnership For/With Patients
  • patient voice to make clinical trials better
  • dying At and In peace
  • standards of care open to patients empower
  • patient advocacy, training, & certification
  • respect for patients at the table
At the beginning of the meeting, @ekivemark asked us to use three words to describe our passion. Here is the Wordle of the responses below.

Great people. Great discussions and brainstorming. 

One example: Check out Pat Mastors' site about the Patient Pod, which is in inexpensive tool for patients to attach to their hospital bed that serves as a message board, hand sanitizer, and place to keep your phone, glasses, etc, so they don't get dirty or lost. She has a Medstartr project (it's like Kickstarter) that will allow her to get these made and used. After losing her father to a hospital-acquired infection, she became an amazing evangelist fighting to stamp out hospital-acquired infections... thus the Patient Pod. Please consider going to Medstartr to invest in her.

Another is Erin Gilmer, an incredibly smart attorney specializing in HIPAA audits and HITECH consulting. She led an honest discussion about the barriers we place on ourselves, challenging us (and herself!) to break those artificial barriers. If you have questions about this area, her email is erinATgilmerhealthlawDOTcom.

Thanks, Mark & Maumi!

Friday, September 21, 2012

Suicide and You

Clink and I are talking at at Maryland's 24th Annual Suicide Prevention Conference next week.  When we were asked, we told them that suicide was not an area of specialty for either of us, and that we usually speak about the Public Face of Psychiatry and ways that blogs, podcasts, twitter, Facebook, and good old fashion books like Shrink Rap can help people understand what it is that psychiatry is all about.  They told us that was fine.  Still, we'd like our workshop to be relevant to the overall topic at hand, so I thought I would ask you to share your experiences with us.  

If you've been suicidal, what helped get you through? 
Did a mental health care professional say or do anything that was helpful?
Did hospitalization help?  Did medicine help?
If you had a serious attempt, do you think there was anything someone could have said or done to have prevented your attempt?  
What keeps you from acting on suicidal impulses?  What has pushed you towards acting on them?

As always, thank you for your help.  We continue to learn a lot from our readers!

Wednesday, September 19, 2012


My novels are finished!  All three of them are available in both Kindle and paperback formats.  

Next week, I will launch a free Kindle promotion from September 27th through October 1st for the two new ones: Double Billing and Mitch & Wendy: Lost in Adventure LandHome Inspection will be available as a free download on September 27th only.

More information is coming soon, and if you'd like to check out my Amazon page, you can go Here.

Tuesday, September 18, 2012

Why Psychiatric Patients Die Younger

If you're reading this for the answer, you can stop now.  I don't know why psychiatric patients die younger than people who do not have psychiatric disorders.  I think that fact only applies to those with chronic psychiatric illnesses, not to someone who has had a single episode of depression or anxiety.  What qualifies as a chronic mental illness?  I'm not sure -- but certainly if you get on-going disability (SSDI) benefits because of your psychiatric disorder, or if you live with a careprovider and attend a long-term psychosocial rehabilitation program for years, or have resided in a state hospital for years.  

How much less time do psychiatric patients live?  The numbers vary from 8 years to 25 years, though I have hard time believing that the average lifespan of a psychiatric patient is only a little over 50.  I have had a few psychiatric patients who have died young, but none under age 50.

So, if we start from the premise that psychiatric patients die younger than people without chronic and persistent mental illnesses, then why?  I'll throw out some ideas.  None of them are the right answer because there is no right answer, just my thoughts on some possible contributing factors.

  • Poor coordination of care: psychiatric patients may be less likely to make appointments, coordinate their care, and may receive medical treatment of their conditions at a substandard rate. (Roy likes this one, I bet)
  • Psychiatric patients smoke cigarettes at rates that are higher than the general public.   
  • Psychiatric medications predispose people to weight gain and metabolic syndromes that may precipitate diabetes and heart disease.
  • Psychiatric patients have high co-morbidity with substance abuse disorders and substance abusers die young for many reasons.
  • Psychiatric patients have higher rates of suicide and suicide is common cause of death among young people.
  • People with psychiatric disorders may not be evaluated as carefully as people without such disorders when they present to a medical professional with problems.  The medical professionals may be too quick to attribute problems to anxiety or depression or psychiatric concerns.
  • Certain psychiatric conditions may predispose people to  behaviors that are not good for them.
  • Certain psychiatric conditions may predispose people to have less interest in investing energy in the caring for themselves or making lifestyle decisions that favor good health.
  • Chronic mental illness is associated with poverty and this is associated with obesity, and as well as a lower likelihood of investing in more expensive and healthier food choices, gym memberships, and a full range of medical care.
  • Patients with psychiatric disorders may have fewer close relationships and family members often cajole their relatives to take care of themselves, pursue medical care, and provide a reason to live.
Just my thoughts.  Tell me what I missed.

Monday, September 17, 2012


Modern medicine has given us many beliefs that we all take for granted.  In fact, I believe that we do such a good job of taking them for granted that we come to absorb them as unquestionable facts, when we should be requesting facts to make sure they are true.  Not only does medicine help us incorporate many assumptions as facts, but it shoves them at us.  What kind of assumptions?  Well, it's unhealthy to be fat.  It's good to exercise.  It's bad to smoke (this one they may have done a good job of proving).  It's unhealthy to overweight.  Salt is bad for you.  Dietary fat is bad for you.  Trans-fats are bad for you. Dietary calcium is important to prevent bone fractures.  Vitamin D levels need to be above a certain level or you should supplement your diet with exogenous/dietary Vitamin D.  It's good to take a multivitamin.  Organic food is healthier.  Pasta is fattening (from my childhood).  Pasta is part of a low-fat, healthy diet (from my teenage years).  Pasta is fattening because it's high in carbohydrates and has little nutritional value (from my carbs-are-bad adulthood). 

Do we believe most of these things?  I think most people do and I'm the skeptic.  I generally keep quiet about my skepticism because it's a game where you don't know the answer until you're dead, and if I die a young death, I don't want to give anyone the satisfactions of saying, but of course, she wouldn't take her Vitamin D, her calcium supplements, and she salted everything.  She got what she deserved.  

So with that thought, I figured I would steer you to an article in the New York Times, "In Obesity Paradox, Thinner May mean Sicker." The article starts by talking about how among people with diabetes, those who are overweight fare better than those who are not, and the same is true for people with some other illnesses.  This is not the fashionable thing to say, we all believe (myself included) that if you have risk factors, then losing weight helps you to be healthier. 

 Harriet Brown writes:

In 2005, an epidemiologist, Katherine Flegal, analyzed data from the National Health and Nutrition Examination Survey and found that the biggest risks of death were associated with being at either end of the spectrum — underweight or severely obese. The lowest mortality risks were among those in the overweight category (B.M.I.s of 25 to 30), while moderate obesity (30 to 35) offered no more risk than being in the normal-weight category.
Whatever the explanation for the obesity paradox turns out to be, most experts agree that the data cast an uncertain light on the role of body fat. “Maintaining fitness is good and maintaining low weight is good,” Dr. Lavie said. “But if you had to go off one, it looks like it’s more important to maintain your fitness than your leanness. Fitness looks a little bit more protective.”
That is a message that may take a long time to reach your family physician, however. “Paradigm shifts take time,” Ms. Bacon said. “They also take courage. Not many people are willing to challenge the weight conventions. They’re just too culturally embedded, and the risk of going against convention is too high.”

Now let me just point out that the fact that heavier people may fare better with diabetes does not necessarily mean that a thinner person with diabetes who gains weight will do better, or that any given overweight person with diabetes might not do better if he loses weight (we all know people who control their diabetes with lifestyle changes and no medications).   It may mean that gaining weight helps, or it may be that there is something intrinsically different about thin vs. heavy people with diabetes. 

In 2007, a study of 11,000 Canadians over more than a decade found that those who were overweight had the lowest chance of dying from any cause.  

As time goes by, we get fatter, and we also live longer.  What health assumptions do you make that might be hard to forgo? 

Sunday, September 16, 2012

Other Shrink Blogs

I've stumbled upon two Shrink Blogs I'd like to share.  While there are plenty of medical blogs, there still are not all that many are about psychiatry.  A handful, but they come and go, and given the number of psychiatrists, it still seems small to me.

Dr. Greg Smith blogs here:
He also has a twitter feed.
I'll let you check it out.

Dr. Jordan Smoller has a blog over on Psychology Today .  I stumbled across his blog today and thought, wait, I know him.  Dr. Smoller's blog is called "The Other Side of Normal" which is the same name as a book he wrote.  Funny how that works.  In one of his posts, he starts by talking about his first real job as a research assistant in 1983.  That lab had another research assistant: me.  So Jordan is stuck in my mind as we were as back then.  He introduced me to rap, a form of music I had never heard of.  Jordan would walk around our shared office mumbling something about a blind dog and a seeing eyed man.   Anyway, I suppose we all grow up, and in some strange bid for universal balance, I eventually had a child who spent years walking around my house rapping, and I became the Shrink Rapper while he became the "normal" guy.  Go figure. 

Check out their blogs and tell me what you think.

Thursday, September 13, 2012

Saying the Right Thing

I just read a very touching article on the New York Times Well blog by an oncologist who talks about a visit with a deceased patient's wife and children.  I finished the article, The Widow's Doctor Visit  and thought, if I ever have that illness, I want this man to be my doctor.  I never think that, but this oncologist's insight into what a grieving family is going through is remarkable, as is his willingness to openly discuss it.  He tells the widow that the patient was lucky to have such a supportive wife.  He tells the son his father wore the same shoes, so he too must be a spiffy dresser, like his dad (oh, actually the writer said 'fancy' but I like spiffy better).  He tells the children that it's okay if they are a little glad that they don't have to watch their father suffer and to have their worlds revolve his medical condition.  He has some sense of what it is that families are looking for,  and that's nice.

But it isn't actually true that I would want this guy to be my doctor.  The truth is, if I had a bad illness, I'd want the doctor with the best outcomes, not the doctor with the best beside manner.  And really, I know the I know this doctor can write a moving article (this is worth a few points in my book) but it doesn't mean that his interpersonal delivery is wonderful -- it may be and I certainly liked him from what I read. But if I had a chronic illness, or one where a bad outcome was virtually guaranteed, then I'd want the best bedside manner and the doctor who could pad the ride with some kindness and sensitivity.

They don't teach you in medical school to tell the wife who has just cared for a terribly ill husband that he was lucky to have her.  They should. 

What do you think?  Oh, and do surf over to the Well blog and read the article. 

Then, if you want, surf over to KevinMD and read this article and let me know if I was mistaken to find it offensive.  I just couldn't get a feel for the author's tone.

Sunday, September 09, 2012

I Am Not A Robot

Why does blogger ask this? 
 Do I look like a robot?
 Do I act like a robot? 
 Do I sound like a robot? 
 Why?  Because I am not a robot.

I'm sorry the "Prove You're Not a Robot" demand for blog commenters is sometimes hard to complete.  Unfortunately, this is a blogger issue, and not something we control.  It makes Shrink Rappers prove we are not robots as well, and sometimes I find the mere implication a bit annoying.
Oh, but it was fun writing this post.  

Saturday, September 08, 2012

You're Too Fat!

We hear a lot about obesity and weight control these days: eat less, exercise more.  Our first lady is very interested, and it's fashionable to believe that more vegetables and less TV will make one thinner.  I say "to believe" because we really don't understand the role that exercise has in weight loss and, at least for some people, exercise alone is not enough to drop those pounds.  

What role do, or should,  doctors have in solving this epidemic we have of overweight and obese Americans (now 2/3rds of adults)?

Over on KevinMD, Dr. Arya Sharma blogs about why weightloss advice may be unethical: he notes that patients regain weight,  that advice is unethical, and that while weightloss may alter measures of risk, we don't have hard evidence that losing weight increases longevity.  Oh, and then their is the issue of sensitivity.

Yesterday, on Talk of the Nation, Neil Conan and his physician guest, Dr. Ranit Mishori, talked about how doctors address the issue of weight problems with their patients.  I listened to 20 minutes of the 30 minute broadcast, the link will let you listen, too.  The first person to call in noted that she had uncontrolled hypertension, she's 20 pounds overweight (despite power-walking 5 miles/day), has trouble controlling her eating, and her doctor reads her the riot act about how she has to get her weight under control.  Her response, despite continued high blood pressure readings, is to avoid the doctor, cancel and delay appointments, and to feel badly about herself.  The second caller said his doctor yelled at him for a half hour to the point that he cried and his response was to lose 110 pounds, which he has kept off.

Finally, there was recently a study in the journal Obesity which shows that overweight physicians are more likely to address weight/diet issues with obese patients than are physician who are overweight themselves. What the article doesn't say is whether patients are more likely to lose weight if their doctor (slim or not so slim) discusses the issue with them and encourages lifestyle changes.

If we had effective treatments for obesity, I think I would be more enthusiastic about encouraging doctors to be more engaged in weight loss, or first ladies' to promote growing vegetables, or mayors from banning super-sized sodas.  As is, we have little to offer, psychiatrists and their medicines are certainly part of the problem for some folks, and those people who do lose weight and sustain their weight losses (a small percentage) are often self-motivated.  While I only heard the call-in patients' side of the story on the NPR piece, I was appalled that it sounded as though this patient was being told she must lose weight for adequate blood pressure control -- it seems to me that patients with illnesses that can be abated or controlled with lifestyle changes should be counseled to do so; if they don't or can't comply, then they should be offered aggressive pharmacologic treatments.  I know many thin people who require 3 anti-hypertensive medications to control their blood pressure, and many slim diabetics who require multiple medications.  And perhaps this patient's doctor is offering medications, but her presentation led the listener to believe that her physician feels her hypertension is her fault and there is little to do if she won't diet.

Monday, September 03, 2012

The Doc and the Cell Phone

I debated calling this The Shrink and the Cell Phone, but I don't think the cell phone problem is unique to shrinks.  Maybe it should be called The Person and the Cell Phone.

Oh, I remember the good old days, before cell phones, before answering machines, before texting, chatting, Facebook, email, and even call waiting.  Okay, I remember black and white television with three stations and you stood up to change the channel and there were no curse words.  I remember rotary phones.  Oh my, just saying this, I feel a million years old.  

Unlike some old folk, I don't think many of these new-fangled inventions are a bad thing.  I remember waiting by the phone for calls, not wanting to leave the house if I was hoping a boy would call, missed connections where I was in one place and my friends were in another, and the general anger that one felt toward a parent or sibling who wouldn't get off the phone when there were important social engagements to be honored.

Almost everyone I know over the age of ten has a cell phone now.  They have their own numbers and you can text or call them and the expectation in our world is that one is available.  Unless of course they don't want to be.  Don't charge your phone? Perhaps you're passive aggressive.  Forgot it again, maybe you've a touch of ADD?   Harry picks up for everyone but me....could I be getting a tad paranoid?

So cell phones have replaced pagers and every doctor I know has a different relationship with theirs.  Some give their numbers out freely, others do not tell their cell numbers to patients.  So the first question is Who Gets the Number?  Is there a line of defense to screen calls and protect the doc from patients who might interrupt them with trivial concerns while they are with patients, sleeping, or simply don't want to be bothered?  Many doctors direct patients to an office number where staff decide what might warrant calling the doc's cell phone.

The second question is what to do about the calls that come?  Is the phone left on at all times, so that it interrupts patient appointments, bubble baths, dinner with the family?   This, I believe, depends on how crucial the doctor is (or perceives himself to be) and his/her individual personality.  If you're the only attending coverage for the ICU and the housestaff is to call you with emergencies, you probably are obligated to leave it on when you're on call.  I know plenty of psychiatrists who leave their cell phone on as an emergency number around the clock, take calls during sessions, and when they are busy with social obligations.   I also know plenty of doctors who don't return calls even if they are identified as being important.

I don't think there is an exact answer to this.  Individual psychiatrists are often their only coverage, besides the obvious, "If this is an emergency, call 911 or go to the nearest ER"....and while many docs feel obligated to take emergency calls, it may not be reasonable to assume a psychiatrist is never going to leave the phone in the other room, go for a swim, or turn it off in a movie theater.  

I think I have the ultimate love-hate relationship with technology.  I like all of it, but I feel compelled to check so many things, so many times.  My sanity hangs in the balance.  I give everyone my cell phone number, but if I don't recognize the number, I let it ring to voice mail -- I get lots of spam calls, I seem to be on every shrink head-hunter's list.  I also don't answer the phone during sessions, while I'm in the shower, when I'm asleep, or when I forget to turn the phone from silent to ring.  I don't answer when I'm at the movies or swimming laps, or in the grocery store, or in a restaurant or anywhere I can't have a private conversation.  I usually listen (except in the movies or if I'm submerged) to make sure it's not an emergency, in which case, I return calls sooner rather than later.  It's a mix, I hope, between being available, and having some control over my life.

I know shrinks who take all their calls immediately because they worry that a patient might be calling when they are on the verge of doing something bad -- and maybe the shrink can persuade them not to? -- or because a patient might be having a crisis or emergency.  Is any given shrink, I wonder, really able to alter an outcome, to talk a patient out of doing something horrible and irreversible, by being available immediately, 100% of the time?  Is immediate availability a standard we should set?  Does it set the stage to say that if only you'd answered the phone, then bad things wouldn't have happened?  

What do you think?