Telephone: The Literal Connection

Well, for those of you curious about my technological updates, here goes. My land line is going away, but my phone number (310-824-4912) remains. I will still be able to answer the phone, which is a part of my day which always surprises my callers. I am glad I can keep that. My leap forward is that now I will get messages in digital format, allowing me to have a written record of my calls, which I imagine will increase my efficiency, and yet, will not be a significant cost-saving. I also get more room on my desk, which I think means room for one more pile. What about the user interface, you ask? Well, that is interesting. Call me and you can hear the experience. You will hear my name, then hear music, and then hear my voice-mail  The music is new, and for those who feel like waiting an additional minute to get to my voice-mail is annoying, then there could be irritation. On the other hand, just ask me for my cell, or email me, and I will respond, so no need to fret about that minute. I am hopeful this is a win/win for all. Although I am known as responsive, I think this technological renovation will increase my turnaround time. My office, like our new world almost mandates, will be in my pocket. What’s next, you ask? E-calendaring and E-prescribing-now those steps are large! Stay tuned.

 

See also…http://shirahvollmermd.wordpress.com/2010/10/07/310-824-4912/

Power Outage

 

You missed me yesterday? I apologize for not doing my Monday posting. 11:00 am, in the midst of a session, the lights went out, the computer made an “annoying beep” my patient told me, with good humor. I said “I would turn off the beep, but I don’t know what is going on, so it is hard for me to turn it off.” The annoying beeps continued, to which I said “I think this is the computer telling us that it has a few more breaths left before it collapses entirely.” So it did. My phone worked, thank goodness, but email went away, and so my communication with so many of my clients instantly disappeared. I did my due diligence. I called the office management. I called the city. Daylight made it such that I could see in my office (thanks for my window), but my waiting room was pitch dark. It was a late night for me, so I thought that this could be really challenging as the sun goes down. At the same time, I wanted to believe, that in this major metropolitan area, my electricity would be up and running quickly, given that I work in a business area and the city of Los Angeles, would not want to lose business. Of course, as so many of you readers predicted, I could not have been more wrong. The daytime turned into evening, and so patient care was by lantern. Email would have to wait. This blog, sadly, was the last priority. With a few minutes in between clients, I could run to Kinko’s, across the street, to do a quick email scan for emergent situations, but then run back to my dark, and somewhat frightening office. The keypad to get into my building was also not working. The stairway to my office was dark, scary and dangerous. Another call to my landlord, only to find out it is the problem with the city of Los Angeles. A call to the city, proved little help. They said they were unaware of the problem. I knew my landlord was telling the truth, so I was left to believe the city was not on the ball. Meanwhile, my clients took it in good stride. I took the darkness to discuss Sigmund Freud. He wanted his patients not to see him (and lie on the couch) so that they could get in touch with their own minds, without the distraction of the therapist’s facial expressions. Perhaps our dark sessions were an opportunity to see if new things could be brought to light in the midst of this darkness. And what about those folks who rely on my email communication? Would they call me if they really needed an answer promptly? I am not sure. Would they feel frustrated that I am not responding to an important matter? Maybe. Should I quickly put on my email an outgoing message which instructs the patient to text or call me? Maybe, but I wanted to believe the problem would be fixed quickly. Should I get a smart phone so that I have backup email? Maybe. The sun set. The sun rose. Power was restored. Emails were attended to. The world was right again. Oh, did I mention that amazon sent me the wrong toner for my printer? That’s another story.

The Psychotherapy Image

http://www.nytimes.com/2012/11/25/magazine/psychotherapys-image-problem-pushes-some-therapists-to-become-brands.html?pagewanted=all&_r=1

Lori Gottlieb, the author of this NYTimes article talks about her experience transitioning from a journalist to a psychotherapist. She explains that “empty hours” are best met with marketing one’s practice to a specific need, as opposed to remaining generally interested in the internal psychic world. Have we arrived to a world where therapists need publicists? I wonder. Do we need to search for niche markets? I also wonder. This is a stimulating article which poses the question of supply and demand. Is there a demand for insight-oriented psychotherapy, or is the demand for a relatively quick-fix to a very specific problem? Does marketing one’s practice create a harvest from which to pick out more long-term patients? Does the publicity serve to overcome the inhibitions of psychotherapy, such that once the patient gets comfortable, a deeper experience can be had? In other words, does the promise of seeing a “specialist” give the patient permission to unleash one’s fantasy world? As usual, I have no answers, but only ideas and possibilities. As Ms. Gottlieb states, as our antidepressants go generic, there is much less direct to consumer advertising for medication, which may mean that there are less patients seeking mental health assistance. This, combined, with a variety of both licensed and unlicensed professionals seeking to help people guide their way through the messiness of adult life. The patient, suffering from ill-defined issues, is at a loss as to where to turn. The media, friends, relatives, and their primary care physicians, serve as referrals. The patient in pain trusts their referral source and then they land in an office, of which they do not know what will happen next. They could end up on medication, engage in long-term psychotherapy, engage in short-term behavioral techniques, or a combination of the above. There is no good algorithm. I am glad Lori Gottlieb brought this issue to her readers. I am left stimulated and confused.

Unknowable

Trina, fifty-six, a physical therapist in private practice for twenty-two years does not understand how her business works. She has great referral sources, but the flow of her practice changes “wildly,” she says. “Sometimes I have no time to myself, whereas other times I think I am going out of business,” she says, with palpable anxiety and uncertainty about her future. “I have many colleagues and they have the same experience, except for them, they make these false attributions, like blaming the economy.” Trina says, explaining that her perspective is that her business plods along at a rate which is not simply explained by market forces. “There is no way to get a handle on the supply and demand aspect of what I do,” she says, with a sound of frustration that she cannot control her world. “Well, let’s assume it is unknowable, what does this mean to you?” I ask, wondering how she manages this anxiety. “It means to me that I have to understand that my business is vulnerable in a way that I may never fully comprehend.” Trina says with resignation. “When you hear your colleagues talking about how the economy is hitting their practice and you don’t see it that way, how do you cope with that?” I ask, wondering about how she deals with not finding colleagues who share her point of view. “First, I think they are saying that to make themselves feel better. Maybe their practice is down because someone is guiding them to someone who they feel is doing a better job. That is always a possibility. It is hard to go down that road. It is hard not to take it personally and feel that a low practice is secondary to poor work, so it is comforting to know that the force is external instead of internal. No one ever says that their practice is down because they are not good at what they do, but I am sure many people feel that. We, in private practice, get so vulnerable because training programs that offer additional certification can seduce us into believing that if we just could use one more machine then our practice would flourish. Of course, that may be true, but it may also be a way for these training programs to make more money. It is so hard to know. Other people feel the key to building a practice is marketing, so they spend a lot of time and energy trying to package their practice, but it is not possible to know if that is helpful, or the tides are turning on their own. You cannot do a randomized control trial to see what the key ingredients to building a practice. I think this is why a lot of physical therapy students are looking at a place like Kaiser, where there are no business worries. I could not do that because then I would have a boss, and you know me enough to know, that as much as I hate thinking about how vulnerable I am, I also do not like the idea of working for someone else.” Trina explains to me why she copes with this uncertainty. “So, living with the unknowable in private practice seems better than living with the knowable of having a boss while being employed.” I say, articulating her dilemma. “That is exactly right. Life is unknowable. This is just one more thing,” Trina says poetically.

A Television in the Waiting Room?

   Magazine subscriptions-so yesterday. Now, as I understand it, I can subscribe to visual content which can be displayed in my waiting room on a screen that looks like a television; the content can be updated on a monthly basis, for a fee. Maybe I could get advertisers and cut my costs down? Would I have “shows” on diet and exercise or on mindfulness for better mental health? Maybe I could make my own “content” and sell my product to other psychiatrists for their waiting rooms? A revenue stream, as my business colleagues might suggest. The ethics? What is the problem? Is it any different from choosing my clothes or my hairstyle? Patients will have an opportunity for projection as well as an opportunity to guess my conscious and unconscious motivations on how I make my decisions. Now-for the obvious question-why don’t I just put my blog on the television in my waiting room and then I can be sure of full disclosure? This would be an interactive experience, like a home DVR or a personal computer. They could roam around my blog/website and learn about me while they wait for me. Wait, this is no different from those clients who have smart phones who do this on their own steam, or maybe I should say, on their own dime. Yea, but to put my blog/website on the big screen; maybe that changes the message. Maybe that touts my narcissism a bit too much. Luckily technological change comes slow for me. Like a wireless internet for my office, or a smart phone,  I am going to think about it. Change is hard.

Office Management

“Do you charge when someone calls you to ask for a refill?” a colleague asks me. Once again, I feel the contradictory pulls of my older colleagues who would say “no way” and my younger colleagues who would say “time is time”.  Do I bill like a lawyer or an accountant who charges for their time or do I bill like an old-time physician who charges for a service? Or, as one would imagine, is there some combination of service and time which goes into this fuzzy world of billing? Emails take time. Phone calls take time. Faxes take time. Prior authorizations, letters for insurance, letters for school, they all take time too. Sure, billing for my time makes sense. Time is limited. I have to figure out a way to use it most efficiently and effectively.  On the other hand, there is a service aspect to what I do, which would get lost if every minute was “on the clock”. It is a tough question. I have to think about it.

Cleaning the Office

     Seven years from the last visit, the time charts have to be stored, except when it is a child, in which case it is seven years after the client turns eighteen. So, chart thinning is a yearly ritual. New psychiatry  graduates have a different plan. Many are paperless. There are no charts; patient information is digital. This means no file cabinet. All papers are scanned into an electric file; then the paper is shredded. Back-ups are digital as well. Space requirements go way down. Security issues change. Whereas I worry about a fire, my newly minted colleagues need to be concerned about an electromagnetic pulse which can wipe out electronic data. I peruse old files, looking through pictures, hand-drawn,  as well as photographs. I touch them. I turn them over. I feel nostalgia, remembering when a patient handed me something they wanted me to keep. I am no technophobe, but I  appreciate touching documents; turning pages stimulates reverie. Maybe sitting at my computer, reviewing old files would do the same thing, but I don’t think so. There is something nice, almost sweet, about holding a paper, seeing the writing, in assorted colors, pop out, as I sort through old charts. I embrace the digital age, but not for everything.