Pros/Cons of seeing patients in a Home Office

[MissAmanda]

I was surprised to hear than in some areas, quite a few psychiatrists have their office physically attached to (or inside) their own home (or made their garage into an office), sounds interesting. Clearly there are many pros and cons - what are your thoughts as residents and practicing physicians? Do you think patients prefer or do not prefer it?

Cons
- patients know where you live (family safety/your privacy/patients may just show up whenever they need you and can't get a hold of you (?),
- zoning laws limit this (not sure?)
- less of a division between work and family life
- patients make judgements on where you live/what your house looks like (??)

Pros
- can save on rent allowing you to lower your patient fees,
- possibly closer to patients/schools,
- tax deductions for working from home (?),
- patients feel more comfortable/at home office (?), feel more privacy
- psychiatrist can have more accommodating/flexible work hours since easy to get to/from work

thoughts? insight?

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[JamesPhilly]

I can answers some of these questions from the perspective of a child living in the setup you described. My father was a psychiatrist working in our home.

First off, you missed the biggest pros. (1) The commute to work (walking upstairs to downstairs isn't so bad). (2) More time with your kids. My father didn't miss a single meal growing up, even if he worked late seeing pts. 5-6pm was always cleared on his schedule. And he would come up between pts to check on us if my mother wasn't home, so they saved on childcare as well (when we were about 8yrs old onwards).

Growing up, the ground floor was my dad's office. I don't think my father advertised that we lived above the office, so I think that could knock a few of your cons off your list. Just don't talk about where you live with pts. I'm sure they could work it out, especially if you live in a small town like we did. But it doesn't matter where you live, in small communities people talk and know where everyone lives. But we never had any problems with pts bothering us.

My father has explained to me that it started as a money saving venture. In addition to having only one car for a family of 5, for example, we'd turn off the heating upstairs and have the heat from the office keep us warm in the winter time. In this way, many of our utilities were business expenses. It wasn't lying because obviously my dad's office needed to be heated, but it saved on bills. If you sit down and think about it, I'm sure you can come up with a lot more ideas how to save money.

In summary, my dad having his office in our home was a great experience, and I hope to emulate it in years to come.

 

[PsychBA]

In addition to having only one car for a family of 5, for example, we'd turn off the heating upstairs and have the heat from the office keep us warm in the winter time. In this way, many of our utilities were business expenses.

I hope the frugality was not out of necessity; because that paints a sad picture of a psychiatrist's life. I know some people are business minded or frugal by nature, not enjoying some of life's luxuries by choice, trying to save their money or invest it. But it reminded me too much of my childhood and I had to comment on it. When I was younger, we immigrated to States. My dad became a salesman, barely able to speak the language, trying to support a family of six. We had a single car, which constantly broke down. I had constant arguments with my father about the heat.

 

[JamesPhilly]

I hope the frugality was not out of necessity; because that paints a sad picture of a psychiatrist's life. I know some people are business minded or frugal by nature, not enjoying some of life's luxuries by choice, trying to save their money or invest it. But it reminded me too much of my childhood and I had to comment on it.

That sounds awful. I am sorry you had such a rough childhood.

I apologize if I did not explain the situation well enough. I was attempting to convey that life was good for us. It was not sad at all. My father was frugal, but not to the point that it impacted our quality of life.

We did not freeze. The heat from the office kept us quite warm (the office was always set to a high temperature). We still wore sweaters, but it was not a hard life. It was a great childhood; like I said, my father was always in our lives.

We only needed 1 car because my father did not need to commute. There was simply no need for another one.

We went to an amusement park every year. If you think about the expense of another car, you can have a lot of fun with the money saved. And we did.

My father immigrated to the USA as well, so a lot of it was his mindset. He was always trying to save money. But as I said, that did not impact our quality of life. I highly recommend the aforementioned office setup, coming from a family member's perspective.

 

[nitemagi]

The home office I believe is a more common practice 1-2 generations ago for psychiatrists, particularly psychoanalysts.

 

[PsychBA]

JamesPhilly, thanks for your sympathy. Thanks for the explanation too, I misunderstood.

 

[whopper]

Having done private practice for over a year, I'd be open to having patients go to my home but only the ones that I've seen for several months in the office that have been cherry-picked to the point where I'd strongly believe they would in no way shape or form cause a problem in the home.

 

[MissAmanda]

I can answers some of these questions from the perspective of a child living in the setup you described. My father was a psychiatrist working in our home.

First off, you missed the biggest pros. (1) The commute to work (walking upstairs to downstairs isn't so bad). (2) More time with your kids. My father didn't miss a single meal growing up, even if he worked late seeing pts. 5-6pm was always cleared on his schedule. And he would come up between pts to check on us if my mother wasn't home, so they saved on childcare as well (when we were about 8yrs old onwards).

Growing up, the ground floor was my dad's office. I don't think my father advertised that we lived above the office, so I think that could knock a few of your cons off your list. Just don't talk about where you live with pts. I'm sure they could work it out, especially if you live in a small town like we did. But it doesn't matter where you live, in small communities people talk and know where everyone lives. But we never had any problems with pts bothering us.

My father has explained to me that it started as a money saving venture. In addition to having only one car for a family of 5, for example, we'd turn off the heating upstairs and have the heat from the office keep us warm in the winter time. In this way, many of our utilities were business expenses. It wasn't lying because obviously my dad's office needed to be heated, but it saved on bills. If you sit down and think about it, I'm sure you can come up with a lot more ideas how to save money.

In summary, my dad having his office in our home was a great experience, and I hope to emulate it in years to come.

Great response! Thanks 🙂

 

[MissAmanda]

Having done private practice for over a year, I'd be open to having patients go to my home but only the ones that I've seen for several months in the office that have been cherry-picked to the point where I'd strongly believe they would in no way shape or form cause a problem in the home.

Yeah, this would be my concern too. I am not sure how one could cherry pick if they don't have an office outside of the home office, other than maybe a phone consultation/screening for patients? Not sure. But I can imagine there would be some patients (hostile or violent background, or poor personal-patient boundaries) that I would not want to know where I lived.

I wonder how things would be changed if it were a child psych office? How often would there be the problem of angry parents at your door, or parents in custody disputes threatening you in your house?

 

[nitemagi]

Often the office/entrance is from a different side of the house than the front door. Sometimes it even has a different address, based on a house on a corner. I've seen it landscaped properly by a former supervisor that it took me months to even notice it was part of another house.

 

[PsychBA]

I have always wondered if psychiatrists get paranoid from working with people with mental issues, especially people with addictions, psychosis, and those with personality issues, like psychopaths. It's like me becoming friends with the very people I avoid at work. Honestly, I don't think I would be able to sleep at night, always wondering if somebody followed me home or is planning to stab me or attack me in the office.

Given that predicting violence, even with the best assessment tools, is quite uncertain, I have no idea how people go about cherry picking patients to bring to their home.

 

[nitemagi]

I have always wondered if psychiatrists get paranoid from working with people with mental issues, especially people with addictions, psychosis, and those with personality issues, like psychopaths. It's like me becoming friends with the very people I avoid at work. Honestly, I don't think I would be able to sleep at night, always wondering if somebody followed me home or is planning to stab me or attack me in the office.

Given that predicting violence, even with the best assessment tools, is quite uncertain, I have no idea how people go about cherry picking patients to bring to their home.

My experience is the opposite. You become desensitized to issues over time. The avoidance you speak of is more of an issue for those without real exposure to psychopathology, and thus fantasizing, dramatizing, and catastrophizing the worst possible outcomes. Not that assaults don't happen, but the risk is still relatively small. People tend to like their psychiatrists 😉

Home treatment, as I mentioned before, was more common for those with psychoanalytic practices, which usually meant pre-screening for higher functioning individuals who wanted ongoing intensive frequent treatment.

 

[Sneezing]

I have always wondered if psychiatrists get paranoid from working with people with mental issues, especially people with addictions, psychosis, and those with personality issues, like psychopaths. It's like me becoming friends with the very people I avoid at work. Honestly, I don't think I would be able to sleep at night, always wondering if somebody followed me home or is planning to stab me or attack me in the office.

Given that predicting violence, even with the best assessment tools, is quite uncertain, I have no idea how people go about cherry picking patients to bring to their home.

Privacy is a fallacy in this era. Anyone with basic google skills can find where any 'public' figure lives, like a physician, and if that fails simply following one home will yield the same result. There no longer is privacy.

 

[Daedra22]

Privacy is a fallacy in this era. Anyone with basic google skills can find where any 'public' figure lives, like a physician, and if that fails simply following one home will yield the same result. There no longer is privacy.

I think this gets overlooked all the time. People think that because they take precautions like being unlisted in the phonebook, nobody can find them... but the internet makes basically all things public. You can't stop the information train. It is, of course, more work to search for a person's house to find out where they live. It's just not that much more work.

 

[psychphan]

There is no way in hell I would ever open a medical practice, especially a psychiatry practice, in my own home.

And I disagree, there is such a thing as privacy. There's a big difference in a a disgruntled patient tracking down a physician with an unlisted number/address than showing up at the place where he goes every month for his appointments.


If you're a fan of curb your enthusiasm you know this is a bad idea.

http://dctobc.com/2009/10/curb-your-enthusiasm-season-7-episode-4-hd-quality-streaming/

 

[JamesPhilly]

Often the office/entrance is from a different side of the house than the front door. Sometimes it even has a different address, based on a house on a corner. I've seen it landscaped properly by a former supervisor that it took me months to even notice it was part of another house.

Yep, we had all of those. Well, our house was obviously attached, but you couldn't tell if it there was office space or apartments above the office. And even then most people in the US would not assume that you lived above your office.

But like i said, a small town is small. You didn't need google 20 yrs ago to figure out where the town shrink lived, everyone knew information like that. And, they still do. You'd be wrong to think you're 'off the grid' just by having your number unlisted, and by staying off facebook.

I agree with Daedra and Sneezing: even in cities there really isn't complete privacy, either now or before. I googled my psych attending, just to see what other positions he held, and I got a copy of his deed from a sheriff's sale. Things like that are part of public record that you cannot suppress. Hell, the mods on SDN can tell by your IP address where you live and/or work.

Now, I wouldn't have my suboxone clinic downstairs. But a normal psychiatrist's office? I'm telling you, as a kid I loved it, and my dad did too. I'd like to hear about other peoples' experiences.

 

[whopper]

I am not sure how one could cherry pick if they don't have an office outside of the home office, other than maybe a phone consultation/screening for patients?

There really is no way until you've seen a patient at least a few times. Some patients, you don't find out until later, are very dysfunctional people. It's one thing to have to call the police to your office, it's another thing when it's in your family's home while a psychotic person decompensates there.

I've seen people that are millionaires be high-maintenance and even more frustrating than poor patients with a long criminal record. Higher SES, I've found out, draws out different, though just as frustrating problems if not even more so than lower SES. There is no way to tell in a manner I'd consider it worth the risk of bringing someone in my home until I got to know the patient well.

Definitely don't do any Suboxone practice out of your home unless again, they've been cherry picked. Out of all of my Suboxone patients (about 40), I can only think of 2-3 that I'd consider for that.

A business model I was considering doing was eventually opening up my own private practice, and cherry pick patients for the home. I'm currently strongly considering leaving my current job situation and working for the university where I attended fellowship to focus more on teaching and research. It's not about the money. In actuality, at least for several months, I'll be earning a heck of a lot less. It's more about an oppurtunity to work side-by-side with some of the world's top psychiatrists and learn more.

 

[MissAmanda]

How would a child psych practice change things?

 

[nitemagi]

There really is no way until you've seen a patient at least a few times. Some patients, you don't find out until later, are very dysfunctional people. It's one thing to have to call the police to your office, it's another thing when it's in your family's home while a psychotic person decompensates there.

I've seen people that are millionaires be high-maintenance and even more frustrating than poor patients with a long criminal record. Higher SES, I've found out, draws out different, though just as frustrating problems if not even more so than lower SES. There is no way to tell in a manner I'd consider it worth the risk of bringing someone in my home until I got to know the patient well.

Overall I'd agree with this. This is part of the deception that higher functioning individuals are somehow more stable psychiatrically, when really they're just together enough to stay out of the hospital (sometimes because they're just articulate). I've seen this rationale applied to not hospitalizing, and end up in situations like a suicide. Higher SES or apparent functionality doesn't equate with low maintenance, or requiring less surveillance.

 

[whopper]

How would a child psych practice change things?

I'd feel the same way. While I'm not a child psychiatrist, I do have a few child patients. Even if the patient isn't bad, the parent can be. Many child patients have psychiatric problems due to problematic parents. You might not have a child decompensate in your office, but you may have a parent that you suspect is an alcoholic blow up becuase you refuse to do a particular treatment.

 

[Daedra22]

I think telepsych may be the answer to this thread...

>.>

 

[PsychBA]

My experience is the opposite. You become desensitized to issues over time. The avoidance you speak of is more of an issue for those without real exposure to psychopathology, and thus fantasizing, dramatizing, and catastrophizing the worst possible outcomes. Not that assaults don't happen, but the risk is still relatively small. People tend to like their psychiatrists 😉

Home treatment, as I mentioned before, was more common for those with psychoanalytic practices, which usually meant pre-screening for higher functioning individuals who wanted ongoing intensive frequent treatment.

Thanks for your input. I had always wondered how psychiatrists can just go to work without either building some serious muscle, knowing martial arts, or carrying a gun. I just have my bachelors and a few years of research so excuse my naivety. But I just keep thinking that if I am a psychiatrist, something bad gonna happen to me quite often. Like that an addict who is desperate enough may lounge at me if I don't give him what he wants or that a person with psychosis might suddenly think that I'm working with FBI one session and try to stab me or follow me home after I'm shopping. Or a psychopath, who looks like a nice guy and is a real charmer, gonna break into my home. Or some narcissistic fellow, who is high functioning but maybe later loses his job or his looks and despite looking like the perfect patient, a year into therapy, have a psychotic decompensation and start going into an uncontrollable rage and start throwing things at me and injure me.

Damn TV shows and my crazy imagination

 

[Sneezing]

Odds are still rare enough to not lose sleep at night. MR, antisocial, and dementia/delirium are still the more likely causes of getting hurt.

addicts - if they are really desperate they will go to where they know where the drugs are. You aren't it. If they are in active withdrawal they need an immediate fix, and you aren't it.
Psychosis - likey the paranoia already included you before the office visit, so why go to the doctor you suspect is feeding information to the FBI? So you can confront them and risk letting the Feds know you know that they are watching you and turned your shrink against you? Not likely.

 

[kugel]

so why go to the doctor you suspect is feeding information to the FBI? So you can confront them and risk letting the Feds know you know that they are watching you and turned your shrink against you?

But what if they know that you know that I know that you know?
http://www.youtube.com/watch?v=U_eZmEiyTo0

 

[whopper]

Odds are still rare enough to not lose sleep at night.

Agree, but what odds are you willing to put in the place where you and your family reside?

I agree that the odds are still very low that something bad will happen in your home office, but given that for most people, the home is a sacred place, I wouldn't take that risk unless again the patient was cherry-picked.

In pretty much every outpatient situation I've seen, expect to have to call the police to the office on the order of every few months.

 

[DD214_DOC]

I think telepsych may be the answer to this thread...

>.>

👍