Phone Intakes

[randomdoc1]

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Well the thing is, how do you know if it is truly low acuity or not if all you ever had was phone encounters with a patient? By then, you may already be up to your neck in some serious mess once the realization is there, if it is ever realized. Also, the fact that a provider is paid regardless if a patient shows or not, it's not if you get paid, it's how much/little.
The brutal reality is that even on a salary model, it is a function of what is in budget. Even hospital systems do this. If they have more preponderance of non-paying claims, the pool of money is smaller to pay a provider more (whether it be less salary potential or less pay per RVU). Where else does the money come from? My office yes, does have a productivity model and we are now offering a salary model. How is it that providers here can easily get full time pay at a 0.6 FTE? We don't miss a dime.

 

[Merovinge]

Those are all great case examples of why "strictly phone intakes," as if that was planned or your exclusive option forever, isn't what we're talking about. I'm talking about whether some initial assessment by phone is preferable to no care at all when a patient has issues getting video to work. In the cases you gave, I'd gather some history (and collateral if the family was available) by phone and then slot the patient into a f/u slot within a week or two to complete the assessment (either face to face if I don't have confidence they can fix their video issues or video and emphasize that they need to get it fixed and review with our IT service that will do test runs with patients.) The alternative is making those new onset psychosis patients wait 2 months to get a full intake slot.

And in my setting, I'm paid for all of this. Well, I'm also paid if they no-show or if I use their video issues as an excuse to not have a visit. But I'd rather patients actually get timely care.

The question is what does an initial consultation/evaluation by a physician mean and is what you are doing it. You can make whatever argument you want over is this better than nothing, but that's not actually the question. You are taking this patient and establishing a doctor-patient relationship during a phone intake as a physician and the question is if your phone call meets the standard of care to do so.

I don't think the alternative wait time or what you are paid matters at all. If you got asked to testify in a case about a patient who had a phone intake with a psychiatrist and then xyz happened before their next appointment, what would you say? If you heard of a residency program that had residents doing phone intakes what would you say about that program?

I am all about pragmatics but at some point we need to have a minimum viable product for a psychiatric evaluation (I would argue this has already been eroded by lots of folks in the field) and I definitely do not think a phone call can be it. People are clearly free to disagree.

 

[FlowRate]

Well the thing is, how do you know if it is truly low acuity or not if all you ever had was phone encounters with a patient?

But you're not. You're seeing the patient by video or in person the next time.

The question is what does an initial consultation/evaluation by a physician mean and is what you are doing it. You can make whatever argument you want over is this better than nothing, but that's not actually the question. You are taking this patient and establishing a doctor-patient relationship during a phone intake as a physician and the question is if your phone call meets the standard of care to do so.

I don't think the alternative wait time or what you are paid matters at all. If you got asked to testify in a case about a patient who had a phone intake with a psychiatrist and then xyz happened before their next appointment, what would you say? If you heard of a residency program that had residents doing phone intakes what would you say about that program?

I am all about pragmatics but at some point we need to have a minimum viable product for a psychiatric evaluation (I would argue this has already been eroded by lots of folks in the field) and I definitely do not think a phone call can be it. People are clearly free to disagree.

I'm curious where you personally draw the line. Or, in other words, trying to clarify what exactly you find to be substandard. What's the difference in your opinion between phone triage and a phone intake/establishing a pt-doctor relationship? Are you against settings where you give recommendations on patients you haven't personally seen e.g. e-consults, integrated with primary care, staffing resident cases from home, etc.? Do you decline video appointments when the A/V quality is not pristine? Must an evaluation always be completed in a single session?

 

[Candidate2017]

I'm talking about whether some initial assessment by phone is preferable to no care at all when a patient has issues getting video to work.

The alternative is making those new onset psychosis patients wait 2 months to get a full intake slot.

And in my setting, I'm paid for all of this. Well, I'm also paid if they no-show or if I use their video issues as an excuse to not have a visit. But I'd rather patients actually get timely care.

For me, as a professional granted the right to practice by the state and a board of my peers by virtue of rigorous apprenticeship, continuous study, proven competency, and willingness to accept financial liability, the basic question always boils down to: Is this the standard of care?

It matters not whether something benefits the patient, increases access, serves the greater good, relieves suffering, is reimbursed by a third party payor, is required/not required by one's employer, etc. The question is always: Is this the standard of care?

"It's better than nothing" is a road to hell paved with good intentions. Give me a dart gun loaded with Haldol and a helicopter ride over the local homeless tent city q28 days, and I can single handedly make a huge positive difference in many people's lives and the community, albeit with maybe a 1% death rate, or less. But totally indefensible as a physician despite the greater good.

 

[forchinet121]

For me, as a professional granted the right to practice by the state and a board of my peers by virtue of rigorous apprenticeship, continuous study, proven competency, and willingness to accept financial liability, the basic question always boils down to: Is this the standard of care?

It matters not whether something benefits the patient, increases access, serves the greater good, relieves suffering, is reimbursed by a third party payor, is required/not required by one's employer, etc. The question is always: Is this the standard of care?

"It's better than nothing" is a road to hell paved with good intentions. Give me a dart gun loaded with Haldol and a helicopter ride over the local homeless tent city q28 days, and I can single handedly make a huge positive difference in many people's lives and the community, albeit with maybe a 1% death rate, or less. But totally indefensible as a physician despite the greater good.

It is standard of care until established otherwise

 

[randomdoc1]

It is standard of care

but so are NP pill mills? don't mind me, I just like cracking jokes--not looking to argue!

 

[Candidate2017]

It is standard of care until established otherwise

I applaud your "eff-around-and-find-out" attitude. Someone's gotta keep pushing the envelope until an adverse outcome gets litigated and sets a clear medicolegal precedent as to whether it is standard of care.

 

[randomdoc1]

I applaud your "eff-around-and-find-out" attitude. Someone's gotta keep pushing the envelope until an adverse outcome gets litigated and sets a clear medicolegal precedent as to whether it is standard of care.

meh, that's the standard of how things get set up/law gets made xD
However many times X has to happen until something gets written into law hahahahahaha

 

[Merovinge]

But you're not. You're seeing the patient by video or in person the next time.

I'm curious where you personally draw the line. Or, in other words, trying to clarify what exactly you find to be substandard.

What's the difference in your opinion between phone triage and a phone intake/establishing a pt-doctor relationship?
One is an appointment to establish a doctor/patient relationship, the other is a short appointment to determine if it's worth pursuing a doctor/patient relationship, I think this is pretty well delineated.

Are you against settings where you give recommendations on patients you haven't personally seen e.g. e-consults, integrated with primary care, staffing resident cases from home, etc.?
Of course not for patients seen in person by a PCP or a resident physician. Those have nothing in common with what you are discussing. E-consults would be the same thing when driven through in-person doctor/patient relationships with PCPs. I would not support a text based e-consult without any doctor interactions with the patient.

Do you decline video appointments when the A/V quality is not pristine?
Only the point of not being able to have an intelligible conversation. Of course you can handle patches of lag/static or less than 4k image quality and still get a large amount of information from the video portion of the call.

Must an evaluation always be completed in a single session?
Absolutely not, we routinely schedule back to back week revals in CAP where people understand that full recs will follow the completion of the process. However, when anything acute to present at that initial session it would be managed as such.

 

[Stagg737]

There are many psychiatric conditions that suck to live with that would benefit from not having to wait two more months to start treatment, when they already waited two months for the intake appointment where their video setup didn't work. That doesn't mean they need emergency care.

And that may be true, problem is you're not going to get the same picture over the phone as you do when physically seeing the patient, so you're just not going to know what you're actually missing. Having a condition that "sucks to live with" is not the same as having a condition that is causing severe life deficits and I'd argue that most of the time patients suck at reporting important signs and symptoms that may alter treatment plan. You're just not going to know what you're missing.

So you think there aren’t patients who legitimately can’t come in? Or can’t afford to get video? I don’t know about your patient but this is not a false choice for a lot of people

I'm sure they exist, but they are far more rare than people think. Even the most poor and destitute individuals still have access to video in this age. I see rural patients who literally live over an hour away from any pharmacy in towns of less than 100 people and I am yet to encounter anyone who cannot use video or whose connection is consistently so poor that we cannot at least do 5-10 minutes of video during their appointments.

So if that patient couldn’t come in you believe better care would be for him to stop getting any meds and seeing you at all?

Let's consider that specific patient. Patient continues to report symptoms aren't improving. Since it's OCD, serotonergic meds keep getting pushed higher. Patient develops serotonin syndrome leading to ICU admission. Doc never knew because patient didn't recognize it and doc never saw the patient to see physical signs. I'd argue not getting meds would have been far less harmful than an ICU admission. I've seen this exact situation within the last month or two in the ER. Not necessarily OCD diagnosis, but doc kept pushing meds higher because they were "helpful, but not helpful enough" and patient thought they were tolerating them.

 

[Stagg737]

Those are all great case examples of why "strictly phone intakes," as if that was planned or your exclusive option forever, isn't what we're talking about. I'm talking about whether some initial assessment by phone is preferable to no care at all when a patient has issues getting video to work. In the cases you gave, I'd gather some history (and collateral if the family was available) by phone and then slot the patient into a f/u slot within a week or two to complete the assessment (either face to face if I don't have confidence they can fix their video issues or video and emphasize that they need to get it fixed and review with our IT service that will do test runs with patients.) The alternative is making those new onset psychosis patients wait 2 months to get a full intake slot.

And in my setting, I'm paid for all of this. Well, I'm also paid if they no-show or if I use their video issues as an excuse to not have a visit. But I'd rather patients actually get timely care.

If it's new onset psychosis, they're likely going to end up requiring inpatient care anyway, so I'd tell the to go to the ER. For other situations it would depend. Were you able to see the patient at all? If not, I'd make them reschedule. Were you able to see there for 5-10 minutes with periods of fairly clear video and the rest was choppy/repeatedly dropped calls? If that's the case, I think it would be reasonable to continue the intake and schedule immediate f/up. Imo the bottom line for me is that if I cannot see the patient, I'm not going to do a full eval. Way too many things that I could be missing to feel comfortable diagnosing them and starting treatment. I see docs start treatment which leads to patients getting worse all the time, so maybe I'm just more cautious because of this.

 

[allantois]

I do not think getting subpar care via a phone is better than no care at all (I was actually stuck seeing a homeless patient for a while who had a smart phone..). If they can't get to an appointment and can't do video, then someone needs to come out to them and well, if there are no resources, then that is a problem for someone above my pay grade. Patients who can't go to appointments are going to be a disaster when they start asking you to also manage their physical issues since they can't get in to their PCP either

 

[forchinet121]

i dont think anyone is going to change any opinions here, fortunately phone only has not been established as below the standard of care so we can still use it for now.

 

[forchinet121]

And that may be true, problem is you're not going to get the same picture over the phone as you do when physically seeing the patient, so you're just not going to know what you're actually missing. Having a condition that "sucks to live with" is not the same as having a condition that is causing severe life deficits and I'd argue that most of the time patients suck at reporting important signs and symptoms that may alter treatment plan. You're just not going to know what you're missing.


I'm sure they exist, but they are far more rare than people think. Even the most poor and destitute individuals still have access to video in this age. I see rural patients who literally live over an hour away from any pharmacy in towns of less than 100 people and I am yet to encounter anyone who cannot use video or whose connection is consistently so poor that we cannot at least do 5-10 minutes of video during their appointments.


Let's consider that specific patient. Patient continues to report symptoms aren't improving. Since it's OCD, serotonergic meds keep getting pushed higher. Patient develops serotonin syndrome leading to ICU admission. Doc never knew because patient didn't recognize it and doc never saw the patient to see physical signs. I'd argue not getting meds would have been far less harmful than an ICU admission. I've seen this exact situation within the last month or two in the ER. Not necessarily OCD diagnosis, but doc kept pushing meds higher because they were "helpful, but not helpful enough" and patient thought they were tolerating them.

I don’t know any doctor that just keeps pushing meds to infinity without checking for side effects, pushing the dose of an SSRI such that the patient is admitted to the ICU is being blamed on a phone intake? Again I just don’t buy it..you can easily screen for side effects without seeing the person, people don’t just suddenly develop the need for an ICU admission overnight, this was an issue for days or weeks and I don’t prescribe medications without checking for side effects especially if the risk for SS or something similar is present

 

[ObsequiousAplomb]

I don’t know any doctor that just keeps pushing meds to infinity without checking for side effects, pushing the dose of an SSRI such that the patient is admitted to the ICU is being blamed on a phone intake? Again I just don’t buy it..you can easily screen for side effects without seeing the person, people don’t just suddenly develop the need for an ICU admission overnight, this was an issue for days or weeks and I don’t prescribe medications without checking for side effects especially if the risk for SS or something similar is present

I agree with a small part of what you said. The doctors that push doses higher and higher every visit until adverse effects like SS occur would do it in person, with audio and visual, or on the phone. I think it's possible that maybe that type of doctor is more likely to continue audio only past when others stop doing it. But realistically I think the phone is just being blamed for a doctor's typical actions.

Clearly one should use the appropriate level of care for patients. Audio only is a lower level of OP care than audio and visual. Asynchronous probably ranks below audio only.

 

[Merovinge]

i dont think anyone is going to change any opinions here, fortunately phone only has not been established as below the standard of care so we can still use it for now.

That's a good strategy as a doctor. Form an opinion and never change it in the face of new information or consensus from your peers. Also, shoot for care that is generally considered below standard of care but has not been definitively ruled as such yet in the courts. I'm not sure what is "fortunate" about the situation unless you are working for a VC/PE firm.

 

[Stagg737]

I don’t know any doctor that just keeps pushing meds to infinity without checking for side effects, pushing the dose of an SSRI such that the patient is admitted to the ICU is being blamed on a phone intake? Again I just don’t buy it..you can easily screen for side effects without seeing the person, people don’t just suddenly develop the need for an ICU admission overnight, this was an issue for days or weeks and I don’t prescribe medications without checking for side effects especially if the risk for SS or something similar is present

I spoke with that particular patients outpt doc directly as it's someone I've previously worked/trained with and I think they are a solid psychiatrist. I've referred patients to him and still would. They did ask about SS related symptoms (twitching fever, confusion/cognitive issues, etc) and patient denied. This could have been averted with an in-person appointment as their presentation in the ER showed obvious distress beyond just anxiety exacerbation but the patient didn't know any better. Idk if that doc is changing their policy on telephone f/ups, but they said they would be requiring that patient to do in-person appointments going forward after I told him the symptoms the patient confirmed they'd been having for weeks but didn't report because they didn't know to.

I actually don't think phone f/ups are unreasonable for many patients, and I'm not really arguing against that. My example is just to show that with phone appointments we're placing a level of trust in our patients' understanding of their medical or mental situation that we oftentimes should not and that doing so during an intake when we know almost nothing about the patient seems like a terrible idea. Yes, I do blame that situation on the fact that the patient hadn't been seen in person, believe what you want but it was completely avoidable if they'd had a real appointment.

I don't care what the legal standard of care is when patients are directly harmed because the care wasn't good enough.

 

[erg923]

i dont think anyone is going to change any opinions here, fortunately phone only has not been established as below the standard of care so we can still use it for now.

Why? That kind of conclusion is a huge, huge leap and defeats the purpose of discussion of the issue on this board, no? Your attitude appears as one of stubbornness in the face of evidence and (albeit) limited peer review.

Such inflexibility is not a "good look" for a practicing physician, who's mind should ABSOLUTELY be able to be changed by evidence and peer/colleague review and feedback.

Your stated rationale is also sorely lacking in critical thought.

 

[mistafab]

I specifically come here to change my opinion when others have found good logic or usefulness in different views.

A race towards pragmatism for me.

 

[Celexa]

I spoke with that particular patients outpt doc directly as it's someone I've previously worked/trained with and I think they are a solid psychiatrist. I've referred patients to him and still would. They did ask about SS related symptoms (twitching fever, confusion/cognitive issues, etc) and patient denied. This could have been averted with an in-person appointment as their presentation in the ER showed obvious distress beyond just anxiety exacerbation but the patient didn't know any better. Idk if that doc is changing their policy on telephone f/ups, but they said they would be requiring that patient to do in-person appointments going forward after I told him the symptoms the patient confirmed they'd been having for weeks but didn't report because they didn't know to.

I actually don't think phone f/ups are unreasonable for many patients, and I'm not really arguing against that. My example is just to show that with phone appointments we're placing a level of trust in our patients' understanding of their medical or mental situation that we oftentimes should not and that doing so during an intake when we know almost nothing about the patient seems like a terrible idea. Yes, I do blame that situation on the fact that the patient hadn't been seen in person, believe what you want but it was completely avoidable if they'd had a real appointment.

I don't care what the legal standard of care is when patients are directly harmed because the care wasn't good enough.

A big chunk of this debate boils down to "are patients reliable self reporters, and do they think to report things that we as mostly rationale clinicians think they should or will?" and the answer in my experience has always been "not enough that I can take their word on for it" and that is true from the homeless schizophrenic living on the street through the big shot CEO and every demographic in between.

I am another in the column of "standard of care" when used to mean average or typical practice means NOTHING to me when it comes to my own decision making, because the average quality if mental health care in this country is abysmal.

 

[erg923]

A big chunk of this debate boils down to "are patients reliable self reporters, and do they think to report things that we as mostly rationale clinicians think they should or will?" and the answer in my experience has always been "not enough that I can take their word on for it" and that is true from the homeless schizophrenic living on the street through the big shot CEO and every demographic in between.

I am another in the column of "standard of care" when used to mean average or typical practice means NOTHING to me when it comes to my own decision making, because the average quality if mental health care in this country is abysmal.

Humans lie. All the time!

 

[Merovinge]

A big chunk of this debate boils down to "are patients reliable self reporters, and do they think to report things that we as mostly rationale clinicians think they should or will?" and the answer in my experience has always been "not enough that I can take their word on for it" and that is true from the homeless schizophrenic living on the street through the big shot CEO and every demographic in between.

I am another in the column of "standard of care" when used to mean average or typical practice means NOTHING to me when it comes to my own decision making, because the average quality if mental health care in this country is abysmal.

It appears House was right all along!

 

[forchinet121]

Why? That kind of conclusion is a huge, huge leap and defeats the purpose of discussion of the issue on this board, no? Your attitude appears as one of stubbornness in the face of evidence and (albeit) limited peer review.

Such inflexibility is not a "good look" for a practicing physician, who's mind should ABSOLUTELY be able to be changed by evidence and peer/colleague review and feedback.

Your stated rationale is also sorely lacking in critical thought.

Why? Because there was a lot of discussion, I read the arguments and don’t buy them. I presented arguments and people don’t seem to buy them either. The conclusion is no one is going to change their mind. Discussion over.

 

[randomdoc1]

Humans lie. All the time!

Way more than we originally estimate too. As someone who does billing and collections as well. It also shows a lot in substance use situations, which is rampant in our line of work.

I also find it quite interesting that everyone wants to be evaluated and treated for inattention. But no one gives a rap about their diabetes, dental cleanings, or cholesterol. Now why is that? LOL

 

[erg923]

Why? Because there was a lot of discussion, I read the arguments and don’t buy them. I presented arguments and people don’t seem to buy them either. The conclusion is no one is going to change their mind. Discussion over.

What does ''don't buy them" mean?

This seems deliberately obtuse, no? You are right and everyone else/your colleagues are totally wrong? Get real, son.

 

[forchinet121]

What does ''not buy them" mean?

This seems deliberately obtuse, no? You are right and everyone else/your colleagues are totally wrong. Get real, son.

It means I don’t agree with their arguments and I have a differing opinion. Not everyone is going to agree with you all the time.

 

[whopper]

I don’t know any doctor that just keeps pushing meds to infinity without checking for side effects

I have. I've seen in plenty of times. Not literally to infinity, but to a point where they kept pushing a dose higher and higher despite that it was obvious this was a no-no, and because the doc kept pushing it a bad outcome happened.

pushing the dose of an SSRI such that the patient is admitted to the ICU is being blamed on a phone intake?

This is a nonsense standard. First even if someone wanted to attempt suicide with an SSRI the amounts to where it becomes dangerous are such that even a 30 day supply of the maximum dosage of an SSRI, if taken all at once is pretty much never fatal. So if you wanted to use the standard "I've never seen anyone admitted to an ICU because an SSRI was used" is not an equivalent argument for the real question on the table. CAN A DOCTOR PERFORM AN ACCEPTABLE JOB IF ON PHONE INTERVIEW ALONE.

To which I already answered, not to the degree where it should be done as an acceptable standard. (All things being equal. COVID did make things unequal. Isolationism was heavily pushed at that time).

As we know several treatments in psychiatry aren't just based on SSRIs. There's plenty of other meds, of which several are more risky such as Lithium, antipsychotics, mood stabilizers....

The standard of is it acceptable is not simply did the bad treatment get the patient into the ICU. Having sex with a patient, openly and intentionally insulting a patient, flagrant misdiagnosis to the point where it's obvious to an overwhelming majority are all unacceptable yet that won't get a patient to an ICU.

I've tried to have patients do a COWS scale on their own (Clinical Opiate Withdrawal Scale). Educated people often times can't do it despite that for me, or a nurse it seems blatantly obvious. E.g. you ask a patient to do a pulse on their own, majority need to be explained what this is, that it's based on a minute, and then while this is simple, some patients flip out and say they can't do it. They won't be able to tell if their pupils are dilated because they're not accustomed to measuring what is and what isn't dilated.

 

[erg923]

It means I don’t agree with their arguments and I have a differing opinion. Not everyone is going to agree with you all the time.

Son, you have to present a reasoned argument that counters the previous points/arguments.

 

[forchinet121]

Son, if you have to present a reasoned argument that counters the previous points/arguments.

Are you drunk

 

[erg923]

Are you drunk

No, son

 

[forchinet121]

No, son

Based on that sentence structure it does seem like it. Either that or you haven’t taken your meds today. Don’t neglect yourself, dad.

 

[whopper]

A short story.

I had a geriatric patient with Bipolar Disorder. She kept not taking Valproic Acid as described. Due to her telling me she was taking it, because her labs were in the low therapeutic range, and because her family told me she was still manic, and I could see she was manic, I increased the dosage. Turned out she would take the meds only a few days before the labs cause she knew the labs were going to tell the truth of how much was in her blood at the moment.

So the dosage became so much that the times she did decide to take it, cause I was going to order another lab, she was so sedated she fell down a flight of stairs and broke a femur. Now while a phone or visual interview likely wouldn't have prevented this (cause she was actively lying to me), the point is..

Point is we need all methods of observation reasonably available. Making it an across the board visual inspection is not needed will lead to several avoidable bad outcomes to a degree where such an easy option-coming in person or telemedicine IMHO can't defend allowing phone alone. I'm sure anyone who's worked in this field at least a few months can think of at least one case where they were able to figure out something going on, something very important, by the physical examination.

(In the above case, I did remark I found it odd that given the current dosage, I would've expected the Valproic Acid level to be higher, but it was still in that zone where I couldn't tell she was lying to me. I even told her she needed to be straight with me cause she was on meds where there were risks. When the bad outcome happened she and her family even told me they didn't blame me for it).

 

[erg923]

Based on that sentence structure it does seem like it. Either that or you haven’t taken your meds today. Don’t neglect yourself, dad.

Not taking "my meds." Classic. Very NOT biased at all. Right, son?

 

[Celexa]

I've tried to have patients do a COWS scale on their own (Clinical Opiate Withdrawal Scale). Educated people often times can't do it despite that for me, or a nurse it seems blatantly obvious. E.g. you ask a patient to do a pulse on their own, majority need to be explained what this is, that it's based on a minute, and then while this is simple, some patients flip out and say they can't do it. They won't be able to tell if their pupils are dilated because they're not accustomed to measuring what is and what isn't dilated.

I recently spent some clinical time with some of our non-psychiatrist colleagues who actually listen to patients lungs with a stethoscope, and was reminded that there's a very sizeable fraction of the population that doesn't know how to take a deep breath .

I've had patients literally vibrating with anxiety swear up and down they weren't anxious. Have had somaticizers who complain about everything ignore their very real cardiac chest pain. I've had to tell more teams than I can remember that yes that nice little old granny in bed 11 may be saying very convincingly she can go home and she buys her own groceries and pays her bills and has a working car but actually she has a moca of 11, thinks it's 1985, and her car is a rusted scrap heap in her driveway.

Intentional deception isnt something I spend too much brain power worrying about or feeling bad when it crops up--there's more frequent danger in ignorance, unintentional misrepresentation, and taking too much at face value.

 

[forchinet121]

Not taking "my meds." Classic. Very NOT biased at all. Right, son?

No shame in the meds game, dad. You’re not yourself when you’re off them. Come home, mom is getting too happy you’re missing.

 

[erg923]

No shame in the meds game, dad. You’re not yourself when you’re off them. Come home, mom is getting too happy you’re missing.

The practice of Psychiatry is not a joke to me, son.

 

[Liquid8]

Phone intakes are a solid no for me, as my preference is that I always have to view new patients in the flesh and won't even agree to video.

Followups are a different matter and allowing that additional flexibility is usually a good thing, but I think over time you end up attracting similar personalities – most prefer to be seen in person and usually make an effort to attend.

 

[clausewitz2]

Humans lie. All the time!

 

[whopper]

A mentor of mine, whose last name started with a Z came up with "ZEST THERAPY." Dr. Z's existential slap therapy.

Tantamount to ZEST therapy was if the patient had poor insight, you did the opposite of what they wanted. They wanted to come into the hospital? Discharge. They wanted to be discharged? You keep them in against their will.

 

[smalltownpsych]

A mentor of mine, whose last name started with a Z came up with "ZEST THERAPY." Dr. Z's existential slap therapy.

Tantamount to ZEST therapy was if the patient had poor insight, you did the opposite of what they wanted. They wanted to come into the hospital? Discharge. They wanted to be discharged? You keep them in against their will.

That is part of the rubric I would use for inpatient planning. Don’t think you need treatment and it’s all a mystery why everyone else thinks you do, well maybe you should stay here a while and see if you can figure that out. You really need to be in the hospital because you can’t handle life, maybe see if we can plan to handle life just today and if you can’t handle it tomorrow, come back and we’ll address that then.

 

[whopper]

A patient was in the ER and didn't want to go into the hospital. We were going to hold her against her will. Then circumstances changed very much and she now wanted to go in the hospital, so then we were going to discharge her. (Mother wanted daughter in the hospital and evaluated cause mother alleged she was dangerous. Turned out it was all young adult BS emo-drama. We did the eval and she wasn't dangerous, then mother doesn't want her in her home after we're about to say discharge, so now the patient wants a free place with free food and TV so she now wants to stay and says she wants to come in). We tell the patient she's being discharged.

So now the patient (the daughter) is furious and yelled out something to the effect of WTF is this? I don't want to go in and you won't let me leave, and now that I want to go in you're kicking me out?

I responded, "well that's pretty much spot on...." while thinking to myself this is the first patient I've seen who's figured it out so quickly.

 

[Stagg737]

A patient was in the ER and didn't want to go into the hospital. We were going to hold her against her will. Then circumstances changed very much and she now wanted to go in the hospital, so then we were going to discharge her. (Mother wanted daughter in the hospital and evaluated cause mother alleged she was dangerous. Turned out it was all young adult BS emo-drama. We did the eval and she wasn't dangerous, then mother doesn't want her in her home after we're about to say discharge, so now the patient wants a free place with free food and TV so she now wants to stay and says she wants to come in). We tell the patient she's being discharged.

So now the patient (the daughter) is furious and yelled out something to the effect of WTF is this? I don't want to go in and you won't let me leave, and now that I want to go in you're kicking me out?

I responded, "well that's pretty much spot on...." while thinking to myself this is the first patient I've seen who's figured it out so quickly.

If she figured it out that fast and hadn't been through the process 10 times before, then I'd argue that's almost pathognomonic for discharge, lol.

 

[whopper]

Per the her and her mother this was the first time she as in the ER. ZEST Therapy again holding up that it works despite years of trials.