Safety/panic buttons in solo private practice?

[1edyfirel]

Starting a small cash-pay private practice, seeing pts both virtually and in-person. I'm renting an office two days a week, located in a fancy high-rise building in a very urban HCOL town. In residency (where I saw mostly medicaid) and in some county clinics/hospitals I've worked out, I had either panic buttons in the office I worked in, or carried around a panic button thing (inpatient). I know I'll be seeing a different clientele in my private practice, but it still makes me a little nervous. There are lots of other people in the building I'm in, but it's one of those high-rise kinda things. There is security downstairs mainly probably just to keep high and homeless people from waltzing in; not sure how connected they are to every individual office (though I'm going to talk to them about this next week).

Anything that people recommend in this situation? I was looking at the Ring doorbell panic buttons, thought something like that might work?

Appreciate any thoughts re safety in solo private practice operations.

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[luckybuck]

2nd amendment.

 

[calvnandhobbs68]

2nd amendment.

Weirdly enough, I actually don't disagree with this too much. If you're all alone in some office somewhere, even if it's in an office building, with a dangerous person who decides to bring a weapon to the appointment, what's a panic button going to do for you? Like, who is it even going to summon? You don't have "security", you're not in a hospital or clinic with their own security department and by the time the police get there, you're long gone.

This isn't without precedent:

Pa. doctor shoots patient who killed caseworker

Gunman with psychiatric history opened fire inside office at hospital near Philadelphia.

www.usatoday.com

 

[Sushirolls]

When I had staff and others subleasing we utilized the ring bell, you would see on counter top.
Hearing the bell, as walls were a pinch thin, would be que to lock door, not let anyone in, call cops. Or flee as fast you can and call cops.
That was as fancy as I got. Just make sure its not bumped. Had 2 false alarms, but were quick to pop out of office to declare "false alarm."

 

[PikminOC]

I hired a front desk person as I felt it was too unsafe to work alone

 

[Sushirolls]

This is an ideal 2A option.

If your hands are petite, or "less strong" and pulling the slide is too difficult with the Ruger LCP in .380 ACP above, then explore the Sig Sauer .380 ACP models. They have a much easier slide to work.

And as always, buy a gun, get an NRA membership.

At some point I'm going to buy a fashionable vest that is also bullet proof - and it will be a business expense - in recognition of the number psych and other healthcare professionals who are attacked. I'm excited about that. Some nice ones out there.

 

[1edyfirel]

Yeah, I'm surprised that I also don't totally disagree with the 2nd amendment suggestion (and I truly can't believe I'm saying that, but I'm also living in a state that has had two mass shootings the past 3 days, and the idea the killers were able to buy guns considering their backgrounds is insanity). And, yeah, I know panic buttons won't do much immediately, it's more of a panacea. Maybe I'll start with a taser? Idk, I wish this wasn't our world right now. But no front desk staff for now, it really is just me and an office.

 

[Sushirolls]

An employer is only going to be concerned about lawsuits. Whose gonna sue who and how much do they have to pay out - and not about your life; in the grand scheme of things.

When you are in solo private practice, you don't have to have your liberties to carry stripped away, and we are more concerned with staying alive and not downstream lawsuits. One of the lesser known perks of private practice. Carry or don't, up to you.

As a resident, I made it very clear to my family, in context of the number of death threats I had, that should I be killed at work, to sue the heck out of my residency or moonlighting gig, for not permitting concealed carry.

@1edyfirel its not our world right now... its always been our world. I've got storries of psychiatrists getting killed since the re-birth of the field in the 1940's. You look at world news there are stories of doctors in India getting killed by deranged family members of their patients.

 

[jbomba]

An employer is only going to be concerned about lawsuits. Whose gonna sue who and how much do they have to pay out - and not about your life; in the grand scheme of things.

When you are in solo private practice, you don't have to have your liberties to carry stripped away, and we are more concerned with staying alive and not downstream lawsuits. One of the lesser known perks of private practice. Carry or don't, up to you.

As a resident, I made it very clear to my family, in context of the number of death threats I had, that should I be killed at work, to sue the heck out of my residency or moonlighting gig, for not permitting concealed carry.

@1edyfirel its not our world right now... its always been our world. I've got storries of psychiatrists getting killed since the re-birth of the field in the 1940's. You look at world news there are stories of doctors in India getting killed by deranged family members of their patients.

India is like another planet with the kind of stuff that goes on there.

 

[whopper]

While I in general highly advocate for panic buttons I know more of mental health and handling acute situations more so than anyone I work with in my office so I just call 9-1-1. Everyone in my office is right by a phone and has a cell phone so this is a defacto-panic button given that we're not in a building with security.

 

[Fan_of_Meehl]

Starting a small cash-pay private practice, seeing pts both virtually and in-person. I'm renting an office two days a week, located in a fancy high-rise building in a very urban HCOL town. In residency (where I saw mostly medicaid) and in some county clinics/hospitals I've worked out, I had either panic buttons in the office I worked in, or carried around a panic button thing (inpatient). I know I'll be seeing a different clientele in my private practice, but it still makes me a little nervous. There are lots of other people in the building I'm in, but it's one of those high-rise kinda things. There is security downstairs mainly probably just to keep high and homeless people from waltzing in; not sure how connected they are to every individual office (though I'm going to talk to them about this next week).

Anything that people recommend in this situation? I was looking at the Ring doorbell panic buttons, thought something like that might work?

Appreciate any thoughts re safety in solo private practice operations.

.45 ACP

 

[Stagg737]

India is like another planet with the kind of stuff that goes on there.

Plenty of this stuff in the US to warrant consideration. I've worked with multiple attendings who have been stabbed by patients and a former attending at the program I did residency was shot in the face and killed by a patient's spouse who followed her home (years before I was there).

 

[Bartelby]

I helped set up panic buttons and mutual aid alarms for one organization I worked with. First, the two are different: mutual aid alarms ring so that other workers nearby can respond and help or summon help. Panic alarms route directly to police or security, summoning them with the presumption that something actively dangerous is underway (a patient physically attacking or with a weapon, for instance). Are you thinking of an alarm that rings to building security? An alarm that rings directly to the police in solo private practice is likely not possible. A mutual aid alarm would do little unless you get people near your office involved so that they would be aware of what to do.

Also, keep in mind that someone calling 911 is far better than hitting a panic button when able. When you hit a panic button, responding officers or security have no idea what they are walking into. They could be facing down anything up to and including an active shooter. If they have some sense (for instance from a colleague who places a call) of what they are dealing with it is far safer and less distressing for everyone involved.

I do some solo private practice work and I do not have any alarm or weapon in my office. In terms of an alarm, my building does not have security, and often I doubt there is anyone around who would hear a mutual aid alarm. I feel comfortable enough with this setup, but I am aware that it exposes me to some degree of risk. When I hear about patients who pose a high risk of violence, I will pass them up (in this setting, though not when working with larger systems) for that reason. Having a gun in your office could possibly protect you in some scenarios, but you need to think through the logistics of that carefully. Will it be locked? Will it be loaded? How will you access it if you are being actively attacked? Is there any chance a patient could get their hands on it if, for example, you have to step out of the room? How prepared are you to use lethal force if the need arises (because if you aren't, congratulations, you just handed your attacker a gun!)?

I do recommend learning basic self-defense. For instance, if someone is actively attacking you being able to at least attempt to fight back and escape. If the person is coming at you with lethal intent, for instance attacking you with a knife, this should include knowledge about how to respond. The self-defense that is taught in brief hospital seminars (such as raising your hands up in front of your face or trying to do elaborate wrist grabs and holds) is, I think, woefully inadequate. It is better to understand that in such situations your best bet for survival is to inflict an incapacitating injury; in other words, things like punching the throat, crushing a knee backward, gouging the eyes, etc. If truly faced with a life and death situation, the goal is to inflict such shocking injury that the person's full attention is consumed by it. That gives you an opportunity to escape. "When Violence is the Answer" by Tim Larkin is a helpful read for understanding what kind of mindset may be needed in cases where you face genuine violence with an intent to maim or kill.

It's good that you are thinking about these things. I feel comfortable enough practicing alone in what is at times a basically abandoned building. I plan to listen to my gut and avoid seeing (or continuing to see) people I am not comfortable with in that setting, and if all else fails I have done martial arts training that (I hope) would buy me a chance to escape. But short of something like an attacker with a firearm, being in a good organization with on-site security etc. is a safer setup. That is one of those intangible benefits of being with a larger organization to practice, and if you are going to work often with people who pose a serious risk for violence then I think settings like those are the better option.

 

[allantois]

The best defense is an ounce of prevention e.g. screening out patients with history of violence from your practice (especially if it does not have security) or seeing them via telehealth only

 

[Candidate2017]

Panic buttons, weapons, bullet resistant vests, receptionists, and screening out bad seeds all have their flaws individually. You probably need to use all of those options as part of a layered system. Meanwhile, someone will look up your clinic hours at your cash pay clinic and burgle your house within 8 minutes while you're safe at work.

I hired a front desk person as I felt it was too unsafe to work alone

Like the Pennsylvania story, the commotion of a receptionist getting attacked is probably the best first alert warning system to allow you to unlock, load your double barreled shotgun and fire two blasts in the air as recommended by Uncle Biden. That should do it, no need for an "AR-14".

At some point I'm going to buy a fashionable vest that is also bullet proof - and it will be a business expense - in recognition of the number psych and other healthcare professionals who are attacked. I'm excited about that. Some nice ones out there.

Why stop at one? Might I suggest an entire wardrobe to suit different occasions, a la John Wick. I'd imagine a knife and spike rated vest for inpatient work, and everything in between all the way up to level IV steel plates for outpatient rural America, Chicago, or Houston.

 

[TexasPhysician]

Panic buttons to outpatient psych is probably worthless.

I’ve had my office alarm go off triggering a police response, and I’ve called police 3x for office related issues including aggression. If I was truly in danger, there is 0% chance police would arrive in a reasonable time with a panic button.

If staff are in the office/nearby, screaming would be more effective. People are conditioned to want to help when someone yells for help. When an alarm sounds (fire or otherwise), I start looking for an exit.

My office has locks between the waiting room and clinic rooms that only lock from the patient side. Im never there alone. I have a license to carry even though that is no longer needed in my state.

 

[clausewitz2]

Always comes to mind in these discussions:

The Last Psychiatrist: Bad At Math

 

[calvnandhobbs68]

Like the Pennsylvania story, the commotion of a receptionist getting attacked is probably the best first alert warning system to allow you to unlock, load your double barreled shotgun and fire two blasts in the air as recommended by Uncle Biden. That should do it, no need for an "AR-14".

That’s not at all what happened you should actually read the case. The patient and his caseworker both went to the doctors office for who knows what reason (patient may have been threatening the caseworker or pissed off or something), patient pulls out a gun on both of them, there’s a short commotion, then patient shoots at the case worker and the doctor, doctor shoots back, critically injuries the patient and suffers a graze wound. Tragically the case worker died.

And yeah you probably reduce your risk by screening patients and not seeing patients alone with a risk of violence, but for instance within this past year I’ve had a kids dad covertly threaten me that I was “gonna be sorry” for treating his kid without his consent (which I did not need as mother had sole legal and medical custody….which is why this was a conflict). I work within a larger office but he knows where it is. Now I try to me more careful about trying to screen for disagreement between parents ahead of time but yeah.

 

[Fan_of_Meehl]

Panic buttons to outpatient psych is probably worthless.

I’ve had my office alarm go off triggering a police response, and I’ve called police 3x for office related issues including aggression. If I was truly in danger, there is 0% chance police would arrive in a reasonable time with a panic button.

If staff are in the office/nearby, screaming would be more effective. People are conditioned to want to help when someone yells for help. When an alarm sounds (fire or otherwise), I start looking for an exit.

My office has locks between the waiting room and clinic rooms that only lock from the patient side. Im never there alone. I have a license to carry even though that is no longer needed in my state.

When seconds count, the police are only minutes away

 

[dl2dp2]

Starting a small cash-pay private practice, seeing pts both virtually and in-person. I'm renting an office two days a week, located in a fancy high-rise building in a very urban HCOL town. In residency (where I saw mostly medicaid) and in some county clinics/hospitals I've worked out, I had either panic buttons in the office I worked in, or carried around a panic button thing (inpatient). I know I'll be seeing a different clientele in my private practice, but it still makes me a little nervous. There are lots of other people in the building I'm in, but it's one of those high-rise kinda things. There is security downstairs mainly probably just to keep high and homeless people from waltzing in; not sure how connected they are to every individual office (though I'm going to talk to them about this next week).

Anything that people recommend in this situation? I was looking at the Ring doorbell panic buttons, thought something like that might work?

Appreciate any thoughts re safety in solo private practice operations.

In this very specific scenario, I think your concerns are overblown.

Some states you'd have to worry more about gun violence, but patient selection is key. Work on common sense. Panic buttons are not fast enough to react to actual problems of this nature.

 

[Fan_of_Meehl]

Always comes to mind in these discussions:

The Last Psychiatrist: Bad At Math

Every time I see stories like these, I'm glad I don't have to prescibe medications (as a psychologist). My hat is off to all of you prescribing providers; you more than earn your money dealing with this and it is only getting worse.

All I have to offer is the 'blood, sweat and tears' opportunity for people to work on themselves (psychotherapy). Never heard of anyone being shot over withholding the opportunity to set measurable goals or complete a sleep log.

Of course there is some risk with clients coming in demanding particular diagnoses, letters, accommodations, service lizards, etc.but nothing to the degree of what you all face when people are withdrawing from drugs of abuse and see you as the obstacle to getting more of the same.

 

[TexasPhysician]

When seconds count, the police are only minutes away

Sometimes hours.

 

[TheRightMedication]

There is literature about this, right? I may try to dig it up later but to my knowledge-

1. Non-Predatory violence isn't random - there is a continuum from verbal agitation, to physical agitation, to violence. If your patient is ramping up, end the encounter. Call for help. Anything but sit there while it accelerates.

2. Being alone or isolated is dangerous, both in the moment and over time with an ongoing threatening patient.

I have a martial arts background and dabble in the 2A world, and I claim some authority in saying the core of self defense is paying attention. If it's come down to whether you have a panic button, whether you know kung fu, or what caliber you carry, many opportunities to avoid or diffuse the situation have passed, and it is officially too late.

 

[TheRightMedication]

I would add something for medical students and residents- if your gut tells you youre in danger, or if you recognize a patient moving towards aggression, get the heck out of there. Inpatients can be seen later. Outpatients can be rescheduled.

You're not stuck.

 

[allantois]

At any rate the way this country is going we may soon only feel safe doing telehealth from home and never leaving the house..

 

[allantois]

When seconds count, the police are only minutes away

Uvalde school shooting

Nineteen children and two adults were killed in a shooting at Robb Elementary School in Uvalde on May 24, 2022. It is the deadliest shooting ever at a Texas public school. We’re covering the aftermath of the shooting and the policy discussions that have followed.

www.texastribune.org

 

[FlowRate]

if your gut tells you youre in danger

This is how I avoided the multiple attempts patients made to hit me during training. If your spidey sense says stay 10ft away and standing, then that's what you should do.

Re: panic buttons. If we were talking about the security I was used to just down the hall from our inpatient unit and outpatient clinic in one of the hospitals that I worked at then yea, panic button is a great idea. They'll be there with 4+ large, strong people who are trained to do restraints within 30 seconds.

My outpatient clinic technically has security but they're more the "check that people aren't doing inappropriate stuff and call police if something does happen" type. I'm not sure how much they'd actually try to help if I pushed my panic button but my assumption is they wouldn't help at all.

 

[TheRightMedication]

At any rate the way this country is going we may soon only feel safe doing telehealth from home and never leaving the house..

There is no safety. What happens when people pull back from their duty?

Uvalde school shooting

Nineteen children and two adults were killed in a shooting at Robb Elementary School in Uvalde on May 24, 2022. It is the deadliest shooting ever at a Texas public school. We’re covering the aftermath of the shooting and the policy discussions that have followed.

www.texastribune.org

That is what happens.

I will show up and do my job even when it's not "safe," and I expect others to do the same. I am not brave - no, I am cowardly. I merely fear unrestrained evil and entropy most of all.

 

[allantois]

There is no safety. What happens when people pull back from their duty?



That is what happens.

I will show up and do my job even when it's not "safe," and I expect others to do the same. I am not brave - no, I am cowardly. I merely fear unrestrained evil and entropy most of all.

I can do a decent job providing good services via telehealth or screening out violent patients as it stands if that’s what you mean. I don’t feel like we have to shoulder the burden of caring for violent individuals who have unrestricted access to lethal weapons thanks to our government. I’m generally more concerned about being involved in a road rage incident (my area has seen multiple drivers being shot at by enraged drivers) than I am by workplace safety

 

[forchinet121]

Panic buttons to outpatient psych is probably worthless.

I’ve had my office alarm go off triggering a police response, and I’ve called police 3x for office related issues including aggression. If I was truly in danger, there is 0% chance police would arrive in a reasonable time with a panic button.

If staff are in the office/nearby, screaming would be more effective. People are conditioned to want to help when someone yells for help. When an alarm sounds (fire or otherwise), I start looking for an exit.

My office has locks between the waiting room and clinic rooms that only lock from the patient side. Im never there alone. I have a license to carry even though that is no longer needed in my state.

Do you have a gun on you while interviewing patients?

 

[Fan_of_Meehl]

I would add something for medical students and residents- if your gut tells you youre in danger, or if you recognize a patient moving towards aggression, get the heck out of there. Inpatients can be seen later. Outpatients can be rescheduled.

You're not stuck.

I second this. I'd rather have 10,000 patient cpmplaints than one broken rib.

 

[TheRightMedication]

I can do a decent job providing good services via telehealth or screening out violent patients as it stands if that’s what you mean. I don’t feel like we have to shoulder the burden of caring for violent individuals who have unrestricted access to lethal weapons thanks to our government. I’m generally more concerned about being involved in a road rage incident (my area has seen multiple drivers being shot at by enraged drivers) than I am by workplace safety

I didn't mean to say you can't do a good service remotely. I spoke more to the afraid-to-leave-home bit.

 

[Bartelby]

I would also mention that in solo private practice, one way to decrease violence is by practicing a slower-paced and high-quality type of medicine. Image you need to fill one hour of weekly clinical time for a four-week month. Simply from a risk perspective:

Scenario 1 - You fill that time with a single weekly psychotherapy patient. You have an excellent working relationship with this patient, and due to your frequent meetings you are highly attuned to changes in their condition that might suggest risk for violence. When disagreements in perspective about treatment come up, you have ample time to discuss and process these issues and any feelings that arise around them.

Scenario 2 - You fill each hour with three 20-minute medication management slots, for patients who you see every three months on average. In the four-week month, you see a total of 12 such patients. You see them far less often and know far less about their condition because you conduct only brief check-ins. Your rapport, while typically good with these patients, is more tenuous in some cases because you don't have the time to dive into some of the issues the patient cares about. Just by the odds, some of these 12 also feel they should be getting controlled substances or certain benefits such as certification of disability, emotional support animal letters, etc. You may disagree with them, and by virtue of appointment length there is much less time to really process and discuss these sensitive topics.

While the above are both somewhat on the extremes for the purpose of illustration, from the perspective of risk to you I think it is obvious why the single patient in psychotherapy poses a lower risk than seeing the 12 medication management patients in the same time. Part of the beauty of solo private practice is being able to set your own pace and provide more intensive / high-quality care than you might in many systems. That different practice style can also be used to your advantage with regard to risk and may make up for the lack of on-site security, a crowded building with colleagues available, and other institutional support.

 

[clausewitz2]

I would also mention that in solo private practice, one way to decrease violence is by practicing a slower-paced and high-quality type of medicine. Image you need to fill one hour of weekly clinical time for a four-week month. Simply from a risk perspective:

Scenario 1 - You fill that time with a single weekly psychotherapy patient. You have an excellent working relationship with this patient, and due to your frequent meetings you are highly attuned to changes in their condition that might suggest risk for violence. When disagreements in perspective about treatment come up, you have ample time to discuss and process these issues and any feelings that arise around them.

Scenario 2 - You fill each hour with three 20-minute medication management slots, for patients who you see every three months on average. In the four-week month, you see a total of 12 such patients. You see them far less often and know far less about their condition because you conduct only brief check-ins. Your rapport, while typically good with these patients, is more tenuous in some cases because you don't have the time to dive into some of the issues the patient cares about. Just by the odds, some of these 12 also feel they should be getting controlled substances or certain benefits such as certification of disability, emotional support animal letters, etc. You may disagree with them, and by virtue of appointment length there is much less time to really process and discuss these sensitive topics.

While the above are both somewhat on the extremes for the purpose of illustration, from the perspective of risk to you I think it is obvious why the single patient in psychotherapy poses a lower risk than seeing the 12 medication management patients in the same time. Part of the beauty of solo private practice is being able to set your own pace and provide more intensive / high-quality care than you might in many systems. That different practice style can also be used to your advantage with regard to risk and may make up for the lack of on-site security, a crowded building with colleagues available, and other institutional support.

Scenario 3 - fill the hour with 2 30-minute appointments with patients with a median follow-up time of one month. In a four week month you will see eight such patients, but these are certeris paribus the same patients you saw in this hour last month. It will take you longer to get to the point of having the kind of feel for the patient that you get if you are seeing someone for weekly psychotherapy but also you actually can get into topics the patient cares about, especially if you can swing closer f/u's PRN if both of you feel there is a topic that needs to be addressed at length. YMMV but even people who are pissed at me about not giving them a controlled substance or an ESA letter tend to be less heated about it when I can tell them no and then spend 25 minutes explaining why I am saying no.

Mostly what I'm trying to say is you don't necessarily have to be doing all psychotherapy all the time in PP to significantly mitigate these sorts of risks.

 

[PikminOC]

Cops don't prevent crimes like this.

 

[smalltownpsych]

Panic buttons, weapons, bullet resistant vests, receptionists, and screening out bad seeds all have their flaws individually. You probably need to use all of those options as part of a layered system. Meanwhile, someone will look up your clinic hours at your cash pay clinic and burgle your house within 8 minutes while you're safe at work.



Like the Pennsylvania story, the commotion of a receptionist getting attacked is probably the best first alert warning system to allow you to unlock, load your double barreled shotgun and fire two blasts in the air as recommended by Uncle Biden. That should do it, no need for an "AR-14".



Why stop at one? Might I suggest an entire wardrobe to suit different occasions, a la John Wick. I'd imagine a knife and spike rated vest for inpatient work, and everything in between all the way up to level IV steel plates for outpatient rural America, Chicago, or Houston.

Just wanted to point out that if you give two warning shots with a double barreled shotgun, wouldn’t you be out of ammunition? 😉 Wasn’t sure if you were taking a poke at Joe Biden or not so just wanted to clarify. 😁

 

[Candidate2017]

Just wanted to point out that if you give two warning shots with a double barreled shotgun, wouldn’t you be out of ammunition? 😉 Wasn’t sure if you were taking a poke at Joe Biden or not so just wanted to clarify. 😁

"I know you're wondering did I fire one blast or three blasts. I kinda don't remember myself. But this is an AR-14 shotgun, the most powerful handgun in the world. Do you feel lucky, punk? Do you?"
- Uncle Joe

 

[Desired Member]

Starting a small cash-pay private practice, seeing pts both virtually and in-person. I'm renting an office two days a week, located in a fancy high-rise building in a very urban HCOL town. In residency (where I saw mostly medicaid) and in some county clinics/hospitals I've worked out, I had either panic buttons in the office I worked in, or carried around a panic button thing (inpatient). I know I'll be seeing a different clientele in my private practice, but it still makes me a little nervous. There are lots of other people in the building I'm in, but it's one of those high-rise kinda things. There is security downstairs mainly probably just to keep high and homeless people from waltzing in; not sure how connected they are to every individual office (though I'm going to talk to them about this next week).

Anything that people recommend in this situation? I was looking at the Ring doorbell panic buttons, thought something like that might work?

Appreciate any thoughts re safety in solo private practice operations.

Disclaimer - no experience with private practice. However, it seems reasonable to me to prescreen patients by having a couple appointments with a new patient via telehealth before considering meeting them in person. I feel like that would allow one to root out ASPD, drug seeking, HI, command AH to kill, etc type patients and if you did get a patient like that, you could see them only via telehealth or fire them if they threatened you, etc. Of course, this would not completely negate risk. I agree with talking to building security and asking them what services they can provide.

 

[allantois]

Disclaimer - no experience with private practice. However, it seems reasonable to me to prescreen patients by having a couple appointments with a new patient via telehealth before considering meeting them in person. I feel like that would allow one to root out ASPD, drug seeking, HI, command AH to kill, etc type patients and if you did get a patient like that, you could see them only via telehealth or fire them if they threatened you, etc. Of course, this would not completely negate risk. I agree with talking to building security and asking them what services they can provide.

That doesn't seem practical. Patients who like to come in person such as elderly often have a hard time figuring out telehealth. On the other hand, offering telehealth probably makes one more secure in a way