Thursday, January 04, 2007

Covering Your

Ha! How did you think I was going to finish that question?

First, let me say that it's heartening to know there are folks out there googling ways to manipulate their psychiatrists, this warms my shrinky little heart.

This post, however, is on practice coverage, meaning how do we tell patients to reach us in an emergency, what happens when we're away. Mostly, I'm talking about private practice, because clinics usually have after-hours coverage through an agency (--in Baltimore, there's a group called the Baltimore Crisis Response Hotline), an emergency room, or an elaborate coverage arrangement with docs/social workers in an on-call deal. ClinkShrink seems to be on constant call for her places of employment and has gone years at a time without a vacation (--this, I believe, is its own mental health issue, but she doesn't pay me, so I will stay silent). Roy just works all the time, but he does go on vacation. Neither of them have private practices, at least not now, so my frame of reference is non-systematic, non-scientific, non-evidence based. You don't have to read this and please don't talk about it to the FDA.

So this is the range I've noticed. Most private practice psychiatrists have machines that answer after hours, not answering services. They range in their instructions: some say if this is an emergency, call 911 or go to the ER. This is coverage?? At the other extreme, there are those docs who have a designated cell phone that they keep on all the time and their messages instruct you to call that, or a home phone number for after-hours emergencies. My good friend Camel has such a line and her machine says, "If this is a life or death emergency, call....." The good thing about having this kind of messages is that it's a lot of fun to have your friends tease you about the "life and death" line. I, of course, would never do this. No one ever tells you what a psychiatric emergency actually is, and after years of practice, I'm still not sure I know.

So what do I do? My office number is my cell phone, much easier than leaving a list of where you can reach me when. On the first visit, I tell patients, "It goes where I go." I turn it off during sessions, and I am essentially unreachable. Essentially, because the babysitter once knocked on my door, my kid in hand, to say I'd locked her out of the house. Oops. But generally, I'm not accessible, and I check my messages between sessions. I turn the phone off when I'm anywhere I can't talk privately, so you won't hear me yelling "Take more Xanax!" over the bing-bing of the cashier at the grocery store, or the yelps of those happy Ravens fans. Oh, I don't prescribe Xanax, but that's another post, perhaps one for
The Last Psychiatrist who is fond of that topic today. I turn the phone off while I sleep, so it's fine to leave a message at any hour of the day or night. If you need me in the middle of the night (and really, I do mean NEED), I give out my home phone number as part of a written sheet of office policies and contact information. This is all, I believe, a few steps beyond Go To The ER, but it's not as available as a willingness to take an emergency call anywhere, anytime with the promise that I will answer all calls on the spot. One could imagine all sorts of interest places to rest that life or death line, careful where you roll, honey. For me, it's a blend of what I can comfortably live with and still feel like I make myself available. I once consultant's on a patient who was appalled that his psychiatrist had taken three hours to return his call when he was having a panic attack. I felt for both the patient and his doctor, but I couldn't reassure him that I would be instantly available either.

What about vacation coverage? I just came back from one of those, I highly recommend them. I asked two other psychiatrists to cover my practice. My patients rarely want much while I'm gone-- refills sometimes, otherwise they leave messages for me and don't seem to want to talk to a stranger. I post the other docs numbers on my machine, turn off my cell phone, and trust that my practice is in good hands. I don't leave charts, I don't leave instructions unless there is someone specific I'm very worried about (and that person simply never calls), I often do leave a contact number or email address where I can be reached, but I'd prefer not to know. There've been no fiascos, though one doc did insist on meeting with one of my patients before he'd refill a medicine she'd been on for years. Logistically, it was inconvenient for her, but she seemed to enjoy meeting him. From my end, I was perplexed as to why they met: I generally refill existing medications over the phone once I've verified with the pharmacy that Dr. X really has been prescribing this for the patient in an ongoing manner. Patient wasn't sure if Dr. X would have filled the script without meeting first, and Dr. X wanted a signed/faxed release to discuss this with me. Life felt complicated, I just let it go, and I will mention that Dr. X continues to be my respected friend. The bets are out as to whether I'll steer him towards this post.
Most of the time, things just go smoothly.

Sometimes patients tell me their doc is away and there is no coverage. Can that be? Seems sort odd. There is probably somewhere a "standard of care" document that dictates these things. I'm hedging my bets that ignorance may be more peaceful.

By all means, chime in with your thoughts!