Yet Another Entry for DSM-V: Nomophobia?

From The Indian Journal of Community Medicine, a study by Dixit, Shukla, et. al.


Nomophobia(1) literally means no mobile phobia that is the fear of being out of mobile phone contact. If a person is in an area of no network, has run out of balance or even worse run out of battery, the persons gets anxious, which adversely affects the concentration level of the person. In recent times there seems to have been a transformation of the cell phone from a status symbol to a necessity because of the countless perks that a mobile phone provides like personal diary, email dispatcher, calculator, video game player, camera and music player.(2) Indian market has emerged as the second-largest market after China for mobile phone handsets. Our study was undertaken to find out the prevalence of nomophobia in the Indian scenario considering the tremendous increase in the number of mobile phone users in the past decade. We decided to conduct the study in our college since the younger generation is the latest consumer of the mobile phones, and the under 25 year age group in professional colleges like medical colleges use mobile phones quite frequently since most of them reside in hostels. Day scholar students too want to be in constant touch with their family members and friends since they are out of their homes for the whole day and at nights while studying in colleges and working in hospitals.

The study goes on to say:


A study from United Kingdom on 2163 people revealed that 53% of the subjects tend to be anxious when they lose their mobile phone, run out of battery or credit or have no network coverage. The study found that about 58% of men and 48% of women suffer from the phobia, and an additional 9% feel stressed when their mobile phones are off. About 55% of those surveyed cited keeping in touch with friends or family as the main reason that they got anxious when they could not use their mobile phones.(1) A study conducted by Market Analysis and Consumer Research Organization (MACRO) in Mumbai to study the various patterns and association of mobile phone usage reported that 58% of the respondents could not manage without a mobile phone even for a day.(2)

I'll Take That Call Now.

Jill of All Trades, MD is a family physician blogger who has a post on KevinMD titled Why answering a cell phone during an office visit is a problem. She writes from the perspective of a primary care doc, and talks about the awkwardness of patients talking on the phone during their office visits. She talks about it with a detective/spy metaphor:

Me: “Your recent lab test shows that your diabetes is currently not sufficiently controlled with the current regimen. Your hemoglobin A1C, which is a lab test that tells me what your sugar level has been at home for the past three months, is 8.1. We need to add a medication at this point because…”

“Riiinnnggg!!,” a quite startling sound lifts me off my seat, as if signaling a new secret-agent assignment.

Patient: “Oh, Doctor, hold on one minute please.”

Is this a conspiracy? Before I can even respond, she picks up the cell phone and starts talking to this rather shady intruder.

Patient: “Hi, honey. I’m at the doctor’s office. What do you need? …”

I wait about thirty seconds, with what seems like an eternity in the secret agent world, and she is still on the phone with this suspicious invader. At this point, I decide to exit the premises.
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For some people, answering the phone immediately seems to be a bit of a compulsion. And for someone who's waited a long time to see an over-booked doctor, I can see why they might want to take a call. Maybe it's a call that was prearranged for a time long after the patient thought they'd be free...but the patient was surprised to find the doctor was running late, and so why should they put someone on hold for a doctor who's kept them waiting? Why is it a one-way street? Oh, because it is.

In psychotherapy it's a different story: people pay for time by the chunk and there aren't patients backed up waiting to fit into the same time slot. I feel like it's the patient's time, and I don't feel like I should say to an anxious mother, "Don't take that call." Still, I'm always a bit surprised when people feel the need to take non-urgent calls during an appointment, and to talk for a bit. I feel a little uncomfortable listening. And even for those who quickly say, "I'm with the doctor, I'll call you back," I'm not sure what that gains over having the phone off.

Does my phone ring during sessions? Yes, because sometimes I forget to turn it off--and if it rings, I reach over and silence it . Do I answer it during a session? Never. Whatever it is waits until the session is over. The only exception I make is if I'm trying to get in touch with another physician regarding the care of the patient I'm seeing during that block of time.

I let people talk on the phone or text or deal with their families or clients. No one has done it repeatedly or in a way that notably distracts from therapy. I'm a bit surprised when anyone wants to pay my fee to talk on the phone, or even when anyone runs late, but hey. If I weren't "rented out" in blocks of time, so to speak, I'd be exiting with Dr. Jill-of-all-trades whenever the phone rang.
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And on a completely different note, I noticed that Jill of All Trades has a link on her sidebar to "Shrink Rapping"....I clicked on it thinking it would be us. But, no....There's another Shrink Rapping doc out there-- Dr. Gregory Smith from Georgia and he's been at it a while. How'd we miss that?

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.

The Stressed Out Shrink Rapper

http://psychiatrist-blog.blogspot.com/2010/05/stressed-out-shrink-rapper.html

Yes, shrinks get stressed out, too. Can I tell you about it?

I hate paperwork, in case I never mentioned it. And I hate dumb things that are mandated by institutions and don't make sense. So I'm getting ready to go to APA this weekend ( see you there?) and I'm trying to tie things up. It's not going so well. Here's my list:

MEDICARE.
Remember I told you that I moved and tried to change my address with Medicare? Ah, 221 downloadable forms on the Medicare website, and not one of them is a change of address form. To change my address, I had to re-enroll. 27 pages. Then they wanted my office utility bills. But I don't have utility bills, they are included in my rent. I faxed my rent invoice--it has my address, and it says "office rent" on it. It's a very nice office. I figured I was done.
Two days ago, I got a letter from Medicare. I've been denied my application as a Doctor of Medicine. I can appeal. Why? I didn't send in three things: 1) Downloadable form 558 giving access to my bank account so they could pay me. Only I'm not an in-network doc. They don't pay me. Ever. 2) my participating agreement. I'm non par and wish to stay that way. 3) my utility bills as proof of address. Am I the only doctor who rents space with utilities included?
I called. Twice. If I won't give them my bank account numbers and routing information, I'm out. Which means I have to leave my clinic job where I've been for 12 years. I don't have to fill out a participating agreement. And they'll take another copy of my rent invoice. I have 30 days to appeal. From the date on the letter which came 2 days ago. The letter is dated in April (it's now May 20th). And I'm really not happy about giving them my bank account information---what happens when they pay me for patients I see at the clinic? I'm salaried there, I don't get paid by the patient, the clinic does. If I do nothing, I'm quickly opted out, and that's a good thing...unless you're my Medicare patient and you no longer can get reimbursement or you're the clinic that wants me there. Have other people had to give their bank account info to change their address? Never done this before. Time expended: who knows. Hours. If you're a non-par provider could you offer some words of wisdom here/?

Next problem:
Clinic says I need to be tested for TB along with all the other employees. So I get a ppd placed, no big deal. Only I work there one morning a week, and in the past, I've read it myself or had a dr. friend sign off on it, because it's a hassle to get to the hospital, park, and take off work for this. Now I'm told I can't read it myself or have another doctor read it, unless it's an internist, pediatrician, or pulmonologist. Okay, found a friend, still have to get the form faxed in. Time expended: 2 hours.

Next problem:
My cell phone blitzed last night. I called. They said I needed updates and they'd push them through. Whatever. The phone worked, I thanked them, and half an hour later, I was on my merry way. Only then the phone didn't work. And my kid's phone didn't work. I called back I held. I powered off, I powered on, I removed the sim cards, I read the numbers, I switched the sim cards, I powered on and off and ate the batteries and prayed for ducks to come. The phones aren't reading the sim cards. I need to get new ones. Okay. Hours. I got to work today. The phone works fine. I called AT&T. Can't be the sim card. Husband's phone works fine. Must be the degrading tower. What's a degrading tower? Does it crumble? Why does husband's phone work? Very strange, no explanation, but tonight, all the phones work. Time expended: 2.5 hours.

I suppose the last thing is the book. Time expended 4,237 hours. Our editor wants it in Mid May. I think that happened. It's almost there. We still need a little polish on the last few chapters and a table of contents and Suggested Reading . If you know a shrink book that's been helpful to you, please let us know in the comments===we'll try to stick it in.

Hanging on for: http://www.patobriens.com/patobriens/havefun/hrricane.asp

Thank you for humoring me tonight, please send a bill

Just As I Was Thinking About You

I think I have ESP. Last week, I was thinking about a patient I hadn't seen in a couple of months, and he called, just as I was thinking about him. It's happened before with this patient. Today, I was walking to my car (where I'd left my cell phone, unsubmergered), and I started to think about a patient I haven't seen or thought about in some time. I've been treating her for over ten years, and issues of age and health have made it hard for her to get in to see me. It's been a year, maybe more, but every once in a while, she surfaces. So I'm thinking about her, wondering how she is, and I get to my car and there's a voicemail from her. Sort of eerie. I have ESP.

What I don't understand is the whole ShrinkRap with Bacon thing on our sidebar. I guess Roy did this. Why does anyone want bacon with our blog? It's just sort of weird. He couldn't have put ducks up?

And for a final thought: my husband is leaving on a jet plane. He texted to say there is a comfort dog in the next row. I can't wait to hear how the flight goes.

Thanks to everyone who's commented on our pre-draft of a chapter. I like the diversity of opinions. And to anyone who thinks their middle schooler might get something out of it, that would be wonderful!

I'll get a photo in later: let me know if you have any special requests....

My Creepy Shrink Is On the Wall Street Journal Blog

Check out the Wall Street Journal Health Blog-- Thanks to Scott Hensley for writing about those mean psychiatrists. Most aren't, just so you know. But Cruella.....

My 15 minutes of Blog Fame, though I am quite glad that Cruella is well-disguised.

The Shrink Rappers are off to APA. The blog may be quiet for a few days.

Note to my co-bloggers: Clink, all my emails to you bounce back. And I dropped my phone into the toilet tonight...the SIM card is saved and I could transfer it, so you can call me, but most of my numbers haven't transferred, and I haven't figured out how to text on the temp phone. Call if you need me.

Turn That Damn Thing Off!

Good morning. It's Sunday. Have you set your clocks back? I'm on my second cup of coffee with The New York Times, Max is up and barking at the neighbors, Clink has already emailed me about her chocolate consumption, Roy is working diligently on the podcast.

So on today's front page there is an article about the popularity of illegal cell phone jammers. Press a button and everyone in certain radius loses their calls

Gary, a therapist in Ohio who also declined to give his last name, citing the illegality of the devices, says jamming is necessary to do his job effectively. He runs group therapy sessions for sufferers of eating disorders. In one session, a woman’s confession was rudely interrupted.

“She was talking about sexual abuse,” Gary said. “Someone’s cellphone went off and they carried on a conversation.”

“There’s no etiquette,” he said. “It’s a pandemic.”

Gary said phone calls interrupted therapy all the time, despite a no-phones policy. Four months ago, he paid $200 for a jammer, which he placed surreptitiously on one side of the room. He tells patients that if they are expecting an emergency call, they should give out the front desk’s number. He has not told them about the jammer.

I'll be thankful I haven't had to resort to this. I don't run groups, and most people seem to get that they're paying for my time. People-- mostly parents-- do take calls during session, but they tend to keep them very brief. "I can't talk right now, I'll call you back in a few minutes." And I have to admit that sometimes I forget to turn my own phone off-- it rings and I silence it immediately-- I've never actually answered a call during someone's session. Once in a great while, someone has an extended cell phone conversation during their psychotherapy session....always a little weird for me to be trapped listening to the one-sided nature of a private communication, but hey. I'll be glad it's a rare event and extend my sympathy to Gary and his eating disorder group. Perhaps they should just do a group turnoff at the beginning of the sessions?

And How Was Your Day?

[posted by dinah]

Before I start:

ClinkShrink, please forgive me for posting over you. I need to vent, badly. I'll never do it again, really.
World: Please scroll down to Clink's wonderful post on Keeping The Faith, it's really great.

We've been talking about coverage, returning calls, standards of care: see the posts below (below Clink's wonderful Keeping the Faith post).

So, this stuff has been on my mind, and I've been thinking about Older & Wiser CoveringDoc's Guest Blogger comments about the expectation that emergency calls should be returned within 30 minutes.

So, this morning, I'm steaming my wrinkled clothes and I hear my cell/office phone. Normally, I'd let it roll to voicemail, but I've got this blog stuff on my mind, so I go glance at the number. It's a familiar number and I think it's a patient who recently had a suicidal crisis over a holiday (and yes, I called back on the weekend, several times). I answer the call, only it's not that patient, it's someone new, looking for an appointment, she tells me her name (which never registers) and who referred her. The steamer is on in the next room, my schedule is downstairs, I ask if I can call back in ten minutes. I don't have a pen/paper, but that's okay, the number is on my cell phone, I'll call right back. Ten minutes. I finish steaming, get dressed, grab my cell phone, coffee cup, and a basket of laundry and head downstairs. I throw the laundry in the wash, find my schedule, and go to return the call. Where's my cell phone? And, I think, as I call it from the house phone and don't hear it ring anywhere, what was that funny clunk I heard when I started the laundry? Well, I find my cell phone, very clean and very dead, in the bottom of the washing machine. It's now 9:30 and I have my first patient at 10, I need to get going, but my office line is my cell phone, so I'll have no phone for the day. Sort of panicked, I change my voicemail message, noting that my phone has been submerged and that I may have trouble both retrieving and returning calls for the day (please don't report me to the shrink police, CoveringDoc). I leave a message for the psychiatrist across the hall letting him know I will be showing up in his office to borrow his phone and check my messages. And then I remember the new patient who wanted the appointment. I don't know her name, I don't have her number, I feel awful as I'll just be totally blowing her off, and my final call before I dash out the door to my phone-free day is to the referring psychiatrist. I leave a message on his machine (but I don't dial his emergency number) asking if he could leave me a message if he knows who he referred to me and has a phone number.

It should have been a quiet day, but I was a little anxious without my phone (think Linus and that blanket). My husband called, heard the message and suggested I get something waterproof-- this is my second drowned phone.

So, I'm spending friday night learning to work my new phone. Referring doc actually had phone numbers, and 9 hours after my promise of "I'll call you back in ten minutes," I reached the prospective patient, apologized profusely and explained the drowned phone in the laundry story, and somehow she still wanted an appointment with Ditzy Doc (that would be me).

And what did you do today?