Friday, August 18, 2006

Calling Back...



I like to think that as rapping shrinks go, I am reasonably accessible. My office line is a cell phone-- "it goes where I go"-- and just in case, I give patients my home phone number. There are times I'm completely unreachable: I turn the phone off during sessions, when I'm at the movies, on airplanes, and when I sleep at night (ah, that's why folks have my home number). If I'm somewhere I can't talk privately, I let the phone ring through to voicemail and I listen to the message soon after. Anything urgent, I return right away; I generally return all calls by the end of the day, and most of my messages have to do with scheduling or rescheduling appointments.

Anything urgent I return right away. I said that already. It leaves the question of what is urgent and how one defines this. Shiny Happy Person--my favorite shrink blogger across the pond where things seem to work a little differently and people say things like "bugger all"-- likes to run polls about the odd things nurses call to request of her. GirlMD likes to blog about the silly phone calls she gets in the pediatric ER. The tone of both bloggers is one of frustration, even annoyance, and may I borrow a little of that for this post? Please forgive me, even (or especially?) psychiatrists can have trying moments.

So confabulated patient calls last week-- her sister is in an awful bind with her boyfriend. She needs my advise on what sister should say to fix this awful affair. The message ends with "Call me ASAP."

I don't call back. But it nags at me all day. She's my patient and she wants me to call back. The request, however, seems so unreasonable, that I don't. She calls again, "Call me ASAP, my sister needs your suggestions." I can't take it. I call back, happy to get a machine, and leave a message saying something to the effect of I've never met your sister, I've never met her boyfriend, and I have no idea what she should say to fix the problem.

I will add that I'd gotten a similar call from another patient the week before with a similar request to help a friend who was being actively threatened by a untreated mentally ill spouse: in this case I did call back and tell her what agencies could offer help. I refused to speak with the friend, however, but I told my patient what avenues the friend could take.

It's Friday night. The phone rings, I let it go to voicemail and check it. I've run some labs on a patient, I've told him I'll call if there are any problems, otherwise he should assume they are normal (there's no reason they wouldn't be, and hey, this is a confabulated story) and I'll discuss them with him next session. His message says he wants to know what his blood sugar was. It was normal, I don't remember the exact value; I remember it was normal. He wants me to call him back (he doesn't say urgently, but my understanding is he feels this can't wait until Tuesday's session). He's not diabetic, he's never been diabetic, he's never worried about being diabetic or hypoglycemic, and I don't feel like being obligated on a weekend. It is more, I know, with this particular patient, about the connection than it is about the lab value.

I didn't call him back. While mostly I like that patients sometimes get comfort from our interactions, sometimes feeling so needed is a bit overwhelming. Sometimes I'd like to be just a little less connected, especially on a Friday night.

18 comments:

Sarebear said...

I am all conflicted about calling or not calling my mental health professionals, generally my ologist.

I really don't want to bother them.

Then again, a year ago, when I had my worst Bad Mommy of the Year day (my daughter's first day of first grade, and she was not old enough, in my opinion, to walk home yet, so she didn't know how to, and we'd walk over there to pick her up, plus she's high-functioning autistic, well, I forgot that the first week was early out, and she was there at the corner of the school grounds just WAITING for us, two hours later the school calls us . . .), anyway, after she was home, I was SO HORRIFIED AND FREAKED OUT AND JUST HATING MYSELF, and I couldn't sort out everything I was going through. So I called him, and he helped me sort out and figure out that when I was lost in Opryland when I was 11, that alot of those feelings were mixed up in this, and he helped me talk through it, and then separate these from the forgetting her at school event. That was one of the most horrible days of my life, and a 13 minute phone call (I felt bad at his time I took, though) helped me IMMENSELY.

It's no wonder, though, that I'm feeling a building anxiety about her first day of school next week . . . I bet I'm more scared about it than she is, lol!

Anyway! Back to the subject of phone calls . . .

Then there was the time, an hour or two after getting home from an appt., when something he said just hit me really hard and HURT, because it apparently hit a deep issue that he didn't know about, and I hadn't been consciously aware of for awhile . . . anyway, given this deep issue, what he said (if he had known about the issue) would have been a horridly cruel thing to say and expect and stuff. So I called him and was sobbing and told him I hated him . . .

Lol! Don't know if YOU ever get calls like that . . .

But. We sorted it out and talked through stuff, although I feel really bad about calling him, but he was actually glad to be notified that something he said had brought something intense and immediate up, and was glad that I didn't let it wait a week for the next appt, cause bad behaviors would have set in. He was chagrined that something he said was a trigger for such distress for me, too.

Anyway, probably TMI. And then there's the phone call shortly after therapy, where I realize that I "accidentally" lied about something, and I have to tell him because my intention is to be completely clear, honest, and up front. I have this fear/pressure inside that leads to little lies about all sorts of things, often about what I've bought recently, or other things that my fears lead to lying because the prospect of all the judgement is just so horrible to contemplate. Anyway, I just leave him the msg, and can then go about my week knowing I'm doing my best to be honest and up front, and report any anomalies like that as soon as I realize them. (This white lying has become so automatic for me, in little things, that I often don't realize it right off).

I'm afraid you all will think the less of me because of the lying thing, but I'm really trying, on that issue. Plus, given my environment growing up, I s'pose it's understandable I would have developed that defense to prevent some of the verbal and social cruelty, in the family setting.

Sorry! TMI again, I bet. But three diff. types of calls, that I s'pose were all justifiable types . . . and yet, I am really trying not to call him for any reason, which has actually made things worse in one case. So I'm all confused about it.

All or nothing thinking again, it's either call him, or never call him . . .

Bye, sorry to go on so long.

Sarah said...

De-lurking here.

I've had a therapist who was too available for it to be healthy, in my opinion. She answered every 'emergency call', whether it was a true emergency, or just the client needing to feel a connection. She left her phone on during sessions, so if the phone rang for a good 10 minutes straight, that meant it was an emergency call, and our therapy time was interrupted. (This happened frequently). The different therapists I've had since have asserted more definite boundaries, and I really appreciate that. I see it as a model for a healthy relationship. I think your confabulated patients might appreciate your assertion of boundaries, as well. In the long run, at least.

DrivingMissMolly said...

Wow! You sound like an angel. You have also made me feel better about my "neediness" as of late. I usually call after I have cut myself, have a loaded gun in the car, etc. I feel like if I can pick up the phone I can drop the knife.

Last week I freaked and broke every dish in my cupboard. I've never done that before. I felt very out of control. I tried to calm myself and had an alprazolam, but was still raging. I called my Doc. He was nice, but he said; "I don't have any ideas of what to do." Granted, he is a 3 year resident, but those were not the words I wanted/needed to hear from him. He did try, bless his heart, and he at least was there for me. He has been on quite a wild ride with me for over a month now.

I see him Wednesday and I'll thank him.

Sarah: Very wise words.

NeoNurseChic said...
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jw said...

The only time I've called a psychiatrist was a bit of an unusual & amusing case.

My cockatiel "Mik" was having breathing problems and I suspected psiticosis, (fatal in a few hours once the breathing symptoms show). I couldn't get the vet. The psych I knew was an avid parrot man with two African Greys. So I called him for medical advice.

He called back immediately, thought my diagnoses to be correct and came over with the correct medicine. Mik lived, to annoy the cat, for another 4 years.

ClinkShrink said...

African Greys are wonderful birds.

Dinah, lovely pic. I always return your calls.

The Hair Scale is done and will be going up tomorrow.

drytears said...

I had one reg. doc who would never answer he phone or call you back... if for some reason you reached her and had a quick question such as if you had to take your med at night or in the morning she would reply by saying she doesn't do stuff over the phone and that I would have to make an appt.

I have never called my psychologist or psychiatrist... I always feel bad about calling.

I have called my NP in neurology numerous times though... always at the office though, except for one time when I was very suicidal and wanted to go back to Marshfield, but my parents didn't think I needed to go. So I called her at home (she had told me before I could call her anytime, at home even if it was late on sat. night)She talked to me and then convinced my parents to take me back. Then she even called my mom the next day to find out if everything went ok and how I was doing. She is awesome!! She's even call somethimes to ask how I'm doing. She was out of office all this last week and she's like "I may be out of office but I'm not unavaible to you, I will be home the whole time except for one day when I'm at a conference... but even then call my nurse, Ann, she will know how to get ahold of me." I could have called her this last week... but I didn't cause I didn't want to bother her. I'm sure she won't be too happy to hear that though at my next appt. :S

It's nice that you respond to youe calls like that.

Roy said...

I've heard of some docs setting up some kind of pay-per-minute phone, so that pts would self-regulate their use of after-session phone calls; it also reduces the feeling of being "owned" by one's patients. I think the first minute or two is free, so that there is no disincentive to call fro true emergencies. I have mixed feelings about this notion, but I understand how one can get to this point.

Of course, there are many other options now for communication; so, email and text messaging are other valid options for inter-session communications, and these can be returned whenever there is a free moment. There are services which enable docs to get paid per email, also... some insurance companies are even reimbursing docs for email, thinking that it may prevent a more expensive office visit.

drytears said...

oh... and I think you handled to people wanting info for a friend/relative very well.

What they were asking you to do is the same as me or anyone on the internet asking you for advice, you wouldn't give them advice, would you?

girl MD said...

it sounds as if you have made yourself too available and subsequently feel guilty for not wanting to be so available.
perhaps you should think about being available with some ground rules?
when i have the parent pager, the operator takes all the calls and tells them that i will get back to them within an hour. if their problem is more urgent than that, they need to call 911 or come to the emergency room.
in your case, it might be prudent to do something similar.
we need professional boundaries to preserve our own sanity. plain and simple. the work we do is hard and emotionally draining. we need to save a little compassion and empathy for ourselves.
good luck.

NeoNurseChic said...
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NeoNurseChic said...
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On the Same Page said...

When I worked in a clinic, my voicemail message said, "...If you are calling after business hours or on the weekend, and this is an emergency, IMMEDIATELY hang up and call the San Diego Mental Health Crisis Line at (800)xxx-xxxx (repeat, repeat), or 911." Likewise, this was an item of the "contracting for therapy" discussion in the first session. Now, I clarify that my patients were predominantly the persistently mentally ill, low-income and/or homeless, but I don't believe it would make a difference.

I learned my lesson about phonecall accessibility, generally, from Borderline Personality Disorder patients - the hard way. But I found the solution in Marsha Linnehan.

Roy, do you think an insurer would reimburse not returning a phone call as a "therapeutic intervention"?

DrivingMissMolly said...

In my search for a new doc, I called an office and the message on the voicemail stated that phone consultations were $75.

I am pretty sure that the doc had that in place to prevent excessive and/or inappropriate calling, but it put me off.

Perhaps those things are better discussed at the first visit because on the voicemail it sounds kind of cold to a prospective new PT.

Oh, and Foofoo, I guess that now that I have it on paper I am a "Borderline Personality Disorder" PT, but I don't excessively call I suppose because my strict Catholic upbringing causes me to tend to not want to "bother" authority figures.

(except on their blogs?? just thought of that one ; )

L

Dinah said...

Thanks for all the comments. To GirlMD and Foo: I am a solo practioner in a private office, this is not work for an agency. As such, I need to be available, and 'call 911' is not a reasonable coverage plan. People are paying for their care (I don't take insurance) and for the most part, people understand the boundaries. I think I've been called at home during the night twice in many years.

My frustration in the post is more the demands for a call back for a nonurgent issue on a friday evening (hmm..you didn't want to know your blood sugar at 10 am) or repeated 'call me back when you get this' for an inappropriate question (eg what should my sister who is not your patient do?).
Patients do call with emergencies, and I will remain available. This does not eat up or inconvenience my life, it's work I signed on to do and love.

Really, a post to vent and invite discussion.

Dinah said...

Oh, and to Roy,
Email-- still a way to get too much of a good thing. I'm not comfortable returning them, I'm not even so comfortable talking much on the phone, usually other than say a quick medication problem, I end up saying "Why don't you come in."

My malpractice renewal sits on my desk, it specifically asks if I communicate with my patients by email. I'm wondering why.

Wrkinprogress said...

Mental health patients frequently do not have good boundaries, as I'm sure those of you in the field know already. Both my psychiatrist and psychologist have messages that start out "If this is an emergency, hang up and dial 911 or go to the nearest emergency room." Both have given me their pager and home phone numbers, encouraged me to call whenever necessary, and assured me it wouldn't be a problem. However, I've never availed myself of those options, as I've never had the need (thankfully)

Bottom line, you deserve boundaries, period. You should also only be asked to treat patients that you actually know. Asking for advice regarding someone who is not your patient is just plain wrong.

Murky Thoughts said...

Where's Miss Manners when you need her?