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?  

Therapick: Match.com for Finding Psychotherapists

I read today in BusinessWeek about an L.A. startup called Therapick.com, that makes short videos of therapists being interviewed about their practice and style, and allows people to search for therapists based not only on the usual location, insurance, and gender, but also on those intangible qualities best gleaned from a video.

Here's their pitch:

Finding a therapist is a personal experience. On Therapick, you can search videos, read profiles, and email therapists you might want to work with. If you don't like the vibe of a psychologist, counselor, or psychiatrist, move on to the next one. It's that simple. Our videos let you choose.

We've interviewed hundreds of licensed psychotherapists in Los Angeles, Chicago, New York, the Bay Area, and many other popular cities to give you the best selection for individual, couples, and family counseling in the United States. Whether you're looking for psychotherapy, marriage counseling, or even hypnosis, Therapick's videos give you a better sense of who a therapist is before going in for your first visit.

Sounds like an interesting idea. What do you all think?

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? 

Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

Surprise! I'm A Shrink and I'm Here to See ME!

The title of this post is a take off on the title of my last post, Suprise! I'm a Shrink and I'm Here to See You!

Today, I went to work at my office, and mostly, I saw me. All of my patients either didn't show up or canceled their appointments, except, of course, for my last patient. It was a really weird day.

I don't have an internet connection in the office and I don't have a TV. I don't even have a desk. My office mates weren't there. It was me. I made phone calls. I texted my friends. I vacuumed the carpet. I made hot tea. I talked to Clink. I thought about Roy. I listened to NPR on the radio in the waiting room. I went to lunch at a cafe in the neighborhood, chatted with the owners and checked my email on the free WiFi. I rested on the couch. It was all kind of serene. In my younger days, I would have been upset, and if I had my car, I probably would have gone home and fiddled on the Internet and done housework. I saw my last patient who said, "You should go home now, it's Friday." I did. As I locked up the office, I thought, well I didn't have to cook and I didn't have to do laundry and with limited on-line access, it was sort of like being on vacation.

Drug Reps in the Waiting Room.

Sarebear has been commenting on our posts for years now, since the very beginning of Shrink Rap. She sent us a link to one of her blog posts on Pie-Bolar Served w/ 3 Flavors of Anksia Tea and the post was a detailed discussion about her session that day with her psychiatrist. Lots of details and lots of sadness and angst, but a wonderful glimpse in to what happens in a session with a psychiatrist. I especially loved that Sarebear started her account in the waiting room where she sat with her family...the psychiatrist was running late and two drug reps were sitting there talking! What does a patient think about when such things intrude on their care? With permission, here's Sarebear's thoughts on Drug Reps in the Waiting Room:

My psychiatrist was twenty minutes late today, which means that she got in to the office at 9:20, which was when she was supposed to see ME, but her FIRST appointment, her 9:00, was still waiting to be seen, so I had to wait longer. UGH!! She said, "I'm sorry I'm so late!!", and the other patient said, "Don't worry about it", but I said absolutely nothing . . . . . lol. Can you tell I was a little peeved? In early morning traffic, it takes about 35 minutes to get there, so we had gotten up early, and had gotten there 10 minutes early, even, not wanting to shave it right to the minute. I suppose everyone has an off day, though. It's still annoying for me, as the patient! Guess I wasn't very "patient", heh. While I waited, just after the first patient went in, a pair of drug reps, one in training, came in, and dropped off some samples in her back room, then sat down to wait. I vowed that I'd get seen before them, because patients are more important. They talked alot of business, and about where each of them had worked, and some of the details of the software they were using on the laptop, that they wish they'd had at the previous place, and stuff. It was interesting to listen to them talk. Drug reps are a sadly necessary "evil" of the medical practice, because they provide drug samples for the doctors, without which you wouldn't be able to start some of the initial doses of certain medications, and sometimes the samples are used to help some patients afford the medications, although they do NOT replace the pharmacy, not at ALL. The drug reps also provide coupons and promotions for the patients to redeem for free two week or one month supplies of the medication, with prescription, at the pharmacy, whenever their companies are offering such coupons and promotions, so again, these things are good for the patient's pocketbook, their bottom line, for being able to afford the medications, when the insurance situation isn't ideal. Obviously some of these don't last very long, while other programs will, say, take half off the cost of the medication for a year, but whatever can help the patient, is a GOOD thing. It's just, the whole salesman aspect of the thing, seems a little . . . smarmy. It also feels a bit intrusive, to have salesmen in the medical setting like that, but as I say, it is a necessary "evil", even if one wonders about the influence that they may have over a doctor's prescribing practices. The most ethical doctors will not be influenced, but no one is perfect. Anyway, sitting there for awhile, listening to them, I didn't think they worked for Pfizer, the makers of Geodon, the medication I had been reduced in dose after my recent bad experience on, and was here today to be likely removed off of and put on possibly something else, but if they did, I wanted to tell them I thought it sucked. So, I asked them eventually, "Do you work for Pfizer?" They said, "No", so I continued anyway, since they'd still have an interest, and they did, and I said, "Well, Geodon sucks". They said, "We think so too, we sell a competing product." I said "Oh, okay. I hate it, because I had unexpected side effects." They then expressed their regrets to me that I'd had a hard time, and again said that they didn't like the med. I thought the whole interaction was a little bit funny, hee. Normally I wouldn't, as a patient, have any kind of interaction with drug reps at all, but since my psychiatrist was late, and since they'd been chatting for awhile so freely in front of my husband, daughter and I in the waiting room (after all, this is the type of location that is basically their workspace for the whole day; that, and their car, so one can't expect them to just sit there silently), so their chatting had encouraged me to eventually strike up a conversation, since there was nothing else to do while I waited for the doctor. When she eventually came out, as she walked past them to the front desk, she asked them if she needed to sign something, (I assume as in, to sign for the samples they'd dropped off in her back room) and they stood up and handed her a clipboard and started talking with her, the one in training did. I wondered if he'd bring up with her anything about the competing product for Geodon, since he knew she'd be bringing me off of that one, and potentially on something else, but it seems they had enough discretion NOT to go there, which amazed me slightly, for salesmen. They just brought up the coupons and promotions that are so helpful for patients, and got the signed clipboard back, and in the middle of signing it, she called me in to the office, which helped let the drug reps know that she'd not be spending a lot of time with them, and made me feel like I was her priority. I didn't feel badly that she'd signed for the samples, because otherwise these men would just be sitting around for another 25 minutes doing nothing, when just 2 minutes of her time took care of the whole matter.

Why Am I Asking All These Questions?

I'm reading a book where the shrinky author starts off with a revelation: it's not the best care to see patients for a 50 minute evaluation, start a medication, have them come back in a month for a 15 minute med check, and refer them to a social worker for psychotherapy. It does sound like a good way to make a lot of money. If you aren't totally exhausted, overwhelmed with the phone calls and paperwork you must have seeing that huge a case load, and are someone who is gratified from this type of work, then it's cool by me. It's not what I want to do.

The author trained at about the same time as I did, and trained at an institution with a biological orientation, like the one I trained out. He talks about this kind of care as though it's standard and the usual and expected. I've never heard this as standard, and in my private practice, I see new patients for 2 hours, and want people to come back weekly for 50 minute sessions until -- they are no longer symptomatic, or they've gotten what they want out of the treatment. Some people come into treatment without symptom---their old shrink moved or died, and they just want a script and someone to rely on if they get sick. I don't insist they come every week, but I'll ask them to come more frequently than they are used to coming for a little while until I feel like I know them. Some people can't afford weekly psychotherapy or find it to be a burden, and I often respect their wishes to come less frequently, unless their illness is destroying their ability to function, in which case I think they need to come weekly. I don't see anyone more than once a week (unless there is an emergency) routinely, and I never seem to have patients who come requesting twice weekly therapy sessions. Almost everyone comes for the full 50 minute session. A few people who just aren't talkers come for half hour sessions.

I've worked in a number of community mental health centers. I know some clinics have huge caseloads and a full-time doc may have 500-1000 patients. I've never worked anywhere like this. Most of the clinics I've worked in have left the frequency of visits up to the doc, though certainly there is a clinic tone. In one clinic I worked in, most patients saw the doc once a month, where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk, and the paperwork burden imposed by the regulatory agencies are very heavy. Still, the standard at all the clinics I've worked in is 2 patients an hour. The no show rate is high, and sometimes a 3rd patient may be squeezed into the schedule if there is a scheduling problem.
My record is 15 patients in one day, and this was while I was volunteering at a clinic in Louisiana after Katrina, and the clinic had no full time doctors and a huge demand. It was 15 patients I'd never seen before, some were quite troubled, and it was a tiring day for me. So my hat goes off to those docs who see 4-6 patients an hour. I couldn't do it.

So what is the standard? I thought I'd ask. Of our readers, it looks like many see their psychiatrists weekly and many see them for 50 minute sessions. Just thought I'd ask. Thank you for taking my surveys and please do add your comments.

Let Me Tell You About My Friend

Hypothetical situation (with a little ring of possibility)....

So a new patient shows up at my door, referred by a friend. The patient used to be in treatment with my friend, but the friend is moving to another state. The patient is sad, she will miss her old doctor who helped her so much, and while we hit it off just fine, it's clear that I can't fill my friend's shoes.

Now here is the thing I'm wondering about: the friend who used to treat the patient is my good friend, someone I talk to all the time --Are we thinking along the lines of a Camel? Perhaps, but I'll never tell. After the move, I'll still talk to her all the time, and I'll still see her socially, even if it means a bit of planning or trekking. Should I tell the patient? My initial thought is "yes" that this will be a connection, that I can relay regards and that the patient (and the doc) won't feel so cut off. But then I wonder if maybe it will be hard to know that I am seeing the old shrink when she can't, if somehow this might be frustrating?

I'd ask here, but clearly this is one where the answers may be very individual,--oh, but why not? Go for it!

Are In-Network Shrinks Better Shrinks?

Clink and I have been having a discussion about insurance participation. It's for the book. We think.

So I've made the statement that given that insurance companies reimburse according to their somewhat random (and generally reduced) rate of Usual & Customary Fees, that they require paperwork and hoops to jump through, and that there is financial incentive for seeing a lot of patients in less time, more so then in giving slow and thoughtful care, that in some communities there is a force of natural selection and that the Best docs may be the ones who won't participate in insurance networks. Is this completely true: of course not. Some really good docs (especially inpatient and consult-liason, where there is very little option) participate with insurance companies. Maybe they live in communities where it's the only feasible way, maybe they like having high-volume practices, maybe they just participate with one or two selected insurance companies to accommodate select patients (or because they've heard the company is easy to work with, or reimburses well), or maybe they feel it's the socially responsible thing to do. Oh, or maybe they worry that if they Don't, they won't get enough referrals and make it in private practice.

So, in thinking about this, I realized I know very little about docs who participate with insurance networks. None of my friends do. I participated in Blue Cross for 7 years---they never sent me referrals and they'd send me random checks for $12.44 (like what was that a portion of?) or $44 something. The UCR was different for each patient, and they were all much much less than going fees back then.

I've been assuming that to make a living accepting insurance, that the doc needs to see a high volume of patients. That's not to say that a psychiatrist might not be willing to see a portion of their practice as psychotherapy patients and take a lower hourly fee for that, and compensate by doing high volume work the rest of the day, or by offering different levels of care based on insurance. That's not to say that there aren't psychiatrists who don't participate with insurance but still have very high volume practices, but they make a lot more money then I do (or so I believe).

But it's occurred to me that I really don't know much beyond what I learned when I was in a group practice way back when. If you take health insurance, tell me how your practice works-- how many patients do you see in an hour, do you get paid from the insurance companies, do you like your work, do you feel the care you give is as good? And if you see a psychiatrist in your insurance network, please tell us how that goes....how long are the appointments, how often do you go in, how does the billing and co-pay work? And if you've seen both in- and out- of network shrinks, how were they different and what worked better for you?

Emergency!

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 scheduled....you 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.
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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.
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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?

Can Medicare Make ME Crazy?

I've moved. You know that. The new office is terrific, shabby chic walls and all.
So I'm working on the whole change-of-address thing. I've notified the post office, the bank, sent a zillion notices out. I've notified my malpractice insurance agent so many times that he called to tell me he changed my address weeks ago and I keep notifying him. I called the Controlled Dangerous Substance folks in my state. It costs $50 to notify them of a change of address. What gives with that. And the DEA...no forms, I tried emailing, I guess I'll send a real letter. The hospital gave me a local number, but it's out of service.
And Medicare: have I mentioned the 221 downloadable forms and how to change your address you have to fill out the 27 page enrollment form? I did? I guess I did.
Did I mention that I'm a non-participating Medicare provider? I don't want to 'enroll.' I finally tackled the form, figuring it would have a box at the end where I could check off that I'm not a participating provider....since I have not 'opted out' ...I'm actually participating by not participating. Try explaining this all to a distressed patient.

I surrender. Tomorrow, I'll try calling. I will no longer be blogging. I anticipate the next year of my life will be on hold.

If you have any answers, by all means....

Shabby Chic is Perfect!

I moved today! My new office is wonderful. Roy made fun of me because I went to 4 paint stores and 'test drove' 8 different shades of tan, finally settling on Shabby Chic (tan). It's perfect and it goes nicely with the "mushroom" colored carpeting that was being installed at 4 pm yesterday.

So I'm excited. Same furniture. Same Dinah. Mostly the same pics on the wall. Somehow, though, I feel like I got something big out of the way.

Please Print Legibly

I'm not much for paperwork. In fact, I hate it.

In my private practice, I give people directions on the phone: how to get to my office, where to park, what to bring, what to do about their health insurance, yadayadayada.... It's a lot of information. I don't have forms, except for an Authorization to Obtain/Release Psychiatric Information, and I give people a single sheet of Office Policies with my cancellation policy and how to reach me: cell phone, home phone.

No other forms, and a few times I've wished I had an emergency contact or some piece of information I didn't have at my fingertips. So I'm moving this month and I'm re-thinking my professional life. Mostly, I've funneled my anxiety into the decor--I'm now on my 5th and 6th quarts of sample paint. Why does taupe look purple when you put it on the wall?

Oh yeah, I was talking about forms. So I'm going to try sending out a few sheets of information before the first appointment: directions, where to park, what to expect, what to bring, and a form requesting some basic contact info. I've been wondering what other people do, and so I've been surfing other shrinks' websites to see what they do: a lot of them have their forms up, some even have their fees listed. This is interesting.

So the forms thing also gets interesting. Some people have really extensive, all-inclusive, no-issue-left-unaddressed forms. One doc asks people to circle the name of any psychotropic they've ever been on, and he lists the name of every psychiatric medication. Here's the list:

Abilify diazepam metamphetamine Rozeram Adderall divalproex sodium Methylin Serax alprazolam doxepin methylphenidate Serentil Ambien Effexor mirtazapine Seroquel amitriptyline Elavil Moban sertraline amoxapine escitralopram Modafanil Serzone amphetamine Eskalith molindone Sinequan Anafranil fluoxetine Nardil Stelazine Antabuse fluphenazine Navane Strattera Asendin flurazepam nefazodone Surmontil atenolol fluvoxamine Neurontin Tegretol Ativan Focalin Norpramin temazepam atomoxetine gabapentin nortriptyline Tenormin Aventyl Geodon olanzapine thioridazine bupropion Halcion Orap thiothixene Buspar Haldol oxazepam Thorazine buspirone haloperidol Pamelor Tofranil carbamazepine imipramine Parnate Topamax Carbatrol Inderal paroxetine topiramate Celexa Klonopin Paxil Tranxene Centrax Lamictal pemoline tranylcypromine chlordiazepoxide lamotrigine perphenazine trazodone chlorpromazine Lexapro phenelzine triazolam citalopram Librium Pimozide trifluoperazine clomipramine lithium prazepam Trilafon clonazepam Lithobid Prolixin trimipramine clorazepate Lithonate Primidone Valium clozapine Lithotabs propranolol valproic acid Clozaril lorazepam protriptyline venlafaxine Concerta loxapine Provigil Vivactil Cylert Loxitane Prozac Wellbutrin Dalmane ludiomil quetiapine Xanax Depakene Lunesta Remeron ziprasidone Depakote Luvox Restoril Zoloft desipramine maprotiline Risperdal zopiclone Desyrel Mellaril risperidone Zydis Dexedrine mesoridazine Ritalin Zyprexa dextroamphetamine Metadate

Just in case you were interested.

Other shrinks have fewer forms, but still post some very interesting stuff. One has photos of herself in a red leather skirt on an analyst's couch (I thought it was an ad for a TV show about a psychiatrist!), another includes his resume and mentions he was an Eagle Scout.

Okay, so tell me if you have a shrinky website, I'd love to look at it. And since I've always just asked people questions and never asked them to fill out forms, tell me how you feel about forms, both from the doc's point of view, and also from the patient's perspective. Thank you!

Oy, the Ravens, they aren't doing so well. I think they got the wrong forms.

What's In That Chart?

In Maryland, the issue of patient charts and confidentiality is a heated topic...it's even made it to the state legislature.

I don't write the most exciting of notes. The first time I meet with a patient, I take a full and detailed history and I write the whole time, so my notes essentially say what patient says, ending with a mental status examine, then my impression, diagnosis, and a brief treatment plan. After that, I don't take notes during the session. And I don't generally write about the detailed content of therapy sessions. I may leave it as "Patient talked about activities and family matters." If I change a medication, I say why, especially if it wouldn't be obvious. If I do anything risky or unconventional, I write about why I'm choosing to do this, why other options aren't sufficient, and that I've discussed it with the patient. If I'm worried about someone, I may discuss what measures I've taken to insure their safety. I don't write process notes about the psychotherapy, I don't put in very personal information that isn't directly related to treatment decisions. I view the chart as a legal document and as a clinical reference-- if the patient tells me 3 years later that some medication worked great, I can look up why we stopped a medication that worked great.

Okay, so confidentiality. No one asks for my notes. Rare requests for information from physicians, but a treatment summary does a much better job. No patient has ever asked to see my chart. And if they did, I don't imagine it would be a problem (or a very interesting read).

What do other shrinks write about?

Rethinking My Professional Life

It's time for me to sign a new lease for my office, and I'm not happy with the terms the landlord wants. Add to that how poorly the building is maintained and that the first floor retail space is probably one-third empty, and I'm thinking of relocating.

I've found a found place to go, but it's way too big....I'll need to find some other folks to share with me. And this has me thinking: do I simply want to relocate my practice as is, or do I want to form some type of cohesive group with a shared mission.

So as I think about the office layout with the freedom to create what I want, let me ask for your help. What's important in a psychiatrist's office? What colors do you like? What makes you love a physical space and what makes you hate it?

And if you're in a group or see someone in a group: what makes it works and what really doesn't work.

CPT Billing Codes for Psychiatrists and Psychotherapy

Joseph j7uy5 over at Corpus Callosum posted a review of some articles in the recent issue of Archives of General Psychiatry.  One of the articles was "National Trends in Psychotherapy by Office-Based Psychiatrists" by Ramin Mojtabai & Mark Olfson (Arch Gen Psychiatry. 2008;65(8):962-970).

He linked to an LA Times summary of the article, which suggested that medications were increasingly "replacing" psychotherapy.  Joseph's take on the newspaper article was right on the money... that the article did not address whether medications were "replacing" psychotherapy, but "Instead, what the study says, is that psychiatrists are, on average, spending a smaller proportion of their time doing psychotherapy. It is possible (indeed, likely) that other practitioners are doing the psychotherapy, while the psychiatrists are devoting more of their time to medication management."

I'm going to go one step further and say that it doesn't even say that (though it still is probably true).  What the study says is that psychiatrists are billing for fewer and fewer psychotherapy visits.  Click on the image above and it takes you to a .pdf of the form that survey participants used as part of the National Ambulatory Medical Care Survey, which is what this study is based on.  It's a lot to complete, and I'm guessing that participating psychiatrists had an office staffer complete these forms.  And the office staff probably decided whether to darken the psychotherapy square only for patients scheduled for 45 minutes or an hour.  Or, maybe based on the billing code used.  I doubt that they asked the doc after each visit if she "used psychotherapy" with the patient.

Anyway, here is what the study "found":

Results:  Psychotherapy was provided in 5597 of 14 108 visits (34.0% [weighted]) sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often. 

Conclusions:  There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.

I wasn't able to find my issue of AGP around the house, but I'm sure that these limitations of the study were discussed.  Nonetheless, I'm not here so much to critique an article I didn't read as I am to explain about how psychiatrists bill for their services.

So, anyway, I submitted a comment to Joseph's post, which wound up being so long I thought I'd post it here, regarding how psychiatrist office visits usually get coded, or billed. 

When psychiatrists submit a bill to an insurance company, there are generally 3 types of codes one can use, which are called CPT codes (for Current Procedural Terminology). One is called an E&M code (Evaluation & Management). This would mostly be one of these: 99211, 99212, 99213, 99214, 99215 (each one is more complex or time-consuming than the next, with escalating payments). Use of this code requires a specific type of documentation. A number of insurance companies may either not pay for this code for psychiatrists, or require a preauthorization.

The next are psychotherapy codes, which are based on time and the main ones are 90805 (20-30 min), 90807 (45-50 min), and 90809 (75-80 min). These also require some specific documentation and payments escalate.  (There are other codes which are used when there is no E&M component, such as 90804, 90806, 90808, but most psychiatrists actually do evaluate and manage treatment with each visit, though they may use these even codes if they don't want to bother with the documentation, which can be quite onerous.)

Finally, there is the medication management code, or 90862. There is no time attached to this one, so whether you spend one minute or one hour with a patient, you can use this one. It is paid about the same as a 99213 and a bit less than a 90805. There are very little documentation requirements and rarely requires a preauthorization, so it is the easiest one to use. Many psychiatrists will use this code, yet still provide psychotherapy to a patient during the session, commonly 15 to 30 minutes long (a few docs may only see pts for 5 or 10 minutes, if the pt is well-known to them, or in a busy clinic, but this is probably not the standard).

So, since the abstract was unclear on this matter, I thought I'd do some teaching about how it works. Given how the study was done, I think that it only truly speaks to the success of managed care policies in paying less and less for psychiatric treatment. Of course, you get what you pay for.

Poll Results: It's Hard to Talk About ......... in Psychotherapy

From our sidebar poll: Sex	72 (31%)
Professional Fees/Payment	59 (25%)
The therapeutic relationship	90 (39%)
Medications	8 (3%)

Votes : 229


My vote went towards Professional Fees, in case you wanted to know. When people don't pay, it's still stressful, and I still feel awkward about asking to be paid. For a lot of people there's a discomfort about psychotherapy of "I have to pay someone to listen to me." If I have to ask to be paid....well.... it's a reminder that I'm here for reasons besides my total devotion to patient care (--I got bills, too)...and if I have to ask to be paid repeatedly, well, it can make everything feel pretty uncomfortable.

Okay, sometimes it's hard to talk about the therapeutic relationship. But as the shrink, it's never hard to talk about sex or meds.

Feel free to chime in....

Everybody Doesn't Need Psychotherapy

There, I said it. And primary care docs do just fine at treating many cases of depression. Everybody doesn't need a psychiatrist. There, I said that, too.

So, with my years of experience with my psychotherapy practice, here is my bullet-point formula for who needs psychotherapy:

• Oops, I don't have one.

I have no idea. Some people find that psychotherapy is essential to dealing with mental illness. Some people find it helps them sort out their maladaptive behavioral patterns and enables them to stop doing the same things over and over. Some people...oh I could go on and on. I touched on this in my post You're Supposed To Get Better, back in July, when I did go on and on (so what else is new?). The bottom line: there are people who come willing and readily to therapy, they talk openly about their problems, they do the work of therapy, and they don't get better, they don't change, but if they get comfort from it and it helps sustain them through their suffering, that's good. Only some people don't even find therapy comforting. Other people resist coming, "My primary care doc's been telling me to call you for two years now." They come in begrudgingly and filled with skepticism, talk about their problems, often for not all that long (a few weeks, a few months, maybe less) and they get a lot out of it. "I wish I'd come sooner."
Some people come, don't say much of anything, but still get better, feel comforted, or find that it's helped them to change.

My next post will be When To Refer. Maybe later? It's a holiday, so we'll see.

And finally, the Shrink Rappers met yesterday to do a couple of podcasts. They were both themed, though apparently Roy plans to post the second one first, so we had the pleasure of talking about the "last podcast" before it was done. So, if I have this right, Dr. Chris Kraft joined us for the "first" show and we talked about the Sexual Re-Orientation treatments. If ClinkShrink is our walking encyclopedia of Prison History, well Chris knows an awful lot about the history of Sex! The 'second' podcast is a discussion about the appropriate and inappropriate uses of Benzodiazepines. Essentially, the show consists of the three of us Screaming at each other. So I promised a series of posts on benzos, perhaps I do short ones as a prelude to the My Three Shrinks bloodiest podcast ever.

The best part was going out for Indian food after. I am the type of person who always enjoys eating a good meal with friends.

The Patient Who Wouldn't Pay

I posted the latest poll on the sidebar and I thought there would be hands-down winner, that everyone would agree, the hardest thing to talk about in therapy is MONEY. Payment. Fees.

Maybe it's just from the therapist's side, but I HATE TALKING ABOUT MONEY. I really hate it. How much do I hate it? A lot.

On the phone before I meet someone, I'm very clear about a bunch of money things-- I hate this, it turns me off, but people have the right to know what they're getting into and if it isn't clear there are a lot of misunderstandings. So I don't participate with insurance companies, the patient needs to pay up front and then submit the bill so the insurance company will reimburse him directly. He needs to call the insurance company before he even comes in-- it's called "preauthorization" and if you don't jump through this hoop, some companies will refuse to reimburse at all. Many companies have a separate managed care component for mental health and ask for a treatment plan. The patient needs to find out how many visits he has before a treatment plan needs to be submitted (it may be 1, it may be 8, it may be 11, it may be never) and he has to to tell me Where to send the treatment plan to. Then he has to count the appointments so I know when the next treatment plan is due (--oh, actually I have a system for doing this, but it doesn't hurt to have a back up reminder). I tell the patient the cost of the evaluation and the cost of a regular 50 minute session. I tell them to expect to pay at the time of the visit-- that's the most comfortable way I've found to say it. A lot of people say "no thanks, I'll find someone in my network," and that's fine. I say a few other things too, like how to find my office and what to expect, and that it's fine to bring someone if that will be helpful, and definitely bring your medications.

I hate talking about money (did I mention that?). What I don't do is ask for payment during the session, it feels tacky. Most people write a check at the end---they were told this is the policy on the phone. If they don't, I send a bill at the end of the month, with all the other bills. The majority of people mail or bring a check, and it's just not a problem. Here and there, someone just doesn't pay. I hate asking. Eventually, I ask. Usually I don't, and eventually the patient pays, but I've been stiffed by a few people.

There was once a woman who'd seen me for years, payed at every session, and then had an unexpected financial crisis and now was really struggling. I didn't ask her to pay for the full session, instead, I nagged her to submit to her insurance company and at least pay the portion they would pay. Should I mention that the reason for her unexpected crisis was that she outspent her excessive standard of living? I've had this happen a few times, and I tell people to catch up at they rate that they can. In the case of people who have had true crises (lost jobs with few assets any way), I will slide their fee. But I'm not so comfortable doing that when the patient drives a late model luxury car or owns a vacation home. I'm sympathetic to their sudden financial plight, but I need to make a living, too. My hardest is the patient who struggles and struggles just to make a living, sleeps on the couches of friends, every purchase is a hardship, and I would say "forget it," I'll see you for free, but for that little drug habit--- if you can swing upwards of $50/week on your habit, another $50 for your cigarettes, a few bottles of wine, then maybe it's good to make a minimal payment on your shrink bill to that shrink who calls around to get you free samples.

Do you want to hear about the surgeon who came twice and never paid the bill? Or the patient who moans about every dime of the bill and the struggles to get reimbursed, but spends in a way most people wouldn't dream of spending on luxury trips, 5-star restaurants, homes so big the utility bills are bigger than his medical bills? Or the few patients I've seen who simply didn't pay at all--even after being asked, uncomfortably, repeatedly, just said "next time," or "I'll send a check" or "I did send a check." The odd thing is these aren't people who are talking about their financial hardships, they're people who are talking about their vacations and boats. The reality is they make a profit by not paying, because they get reimbursed by their insurance companies (often these same patients will ask to have the statements regenerated two or three times), but they never pass along the fee. This is called fraud, I believe.

Uncomfortably, I've been left to say on a few occasions, "Why don't you catch up and then call to schedule the next appointment." I hate talking about money.

I'm sorry, I sound bitter and this is an issue with so very few people. Most people, if they fall behind, they say something and I'm happy to have them catch up at their own pace, and they do. Nothing specific set me off tonight, I just was surprised that more people have trouble talking about sex than money. Maybe I'm feeling a little Grinchy. You can guess which I'd rather talk about.

Preconceived Notions

Roy referred a patient to me the other day. Thanks, Roy!

The patient made a point of telling me both on the phone and when we met that Dr. Roy had given her a list of psychiatrists, but he'd circled my name. Of the docs on the list, I was the one most highly recommended, or so the patient says.

When I was a new-be psychiatrist and someone came to me saying, "So-and-so says you're really good," I felt a bit uncomfortable, worried I'd disappoint. Sometimes patients came after 3 other shrinks didn't fix them, and I was fresh out of residency: it was a bit intimidating.

I've not done any research on this-- it's more anecdote and if I had real data, I assure you it would be useless---but now I like it when people walk in with the idea that I'm an extra-special shrink. A lot of treatment, especially the beginning of treatment, is about hope, and if people believe they're seeing someone good, someone better than the rest, they walk in hopeful and it seems to me that they're more likely to both connect with me easily and to get better.

There are lots of good psychiatrists in Baltimore, I'm nothing special. But if the patient comes expecting to be helped, chances are better that I'll succeed than disappoint.