Shirah Vollmer MD

The Musings of Dr. Vollmer

The Patient Moves: Does The Treatment Have To?

Posted by Dr. Vollmer on April 6, 2012

Eka, a fifty-three year old woman, unemployed for six months, finally landed a job in Boston. Her husband and teenage children live here in Los Angeles, but this opportunity is too good to pass up, especially in this economy. Her husband works, but Eka is the main bread-winner. She takes the job and she enjoys her work. She bobs back to LA every four weeks or so and that seems to work out. In her travels to this coast, she fits me in for a “check-up,” as she calls it. “Maybe I should get a new doctor in Boston, ” she says, bringing up a conversation we have had many times. “Maybe that is a good idea,” I say, knowing that proximity is very important to the therapeutic process, but also thinking that with technology, that is not as important as it used to be. “Oh, but I don’t want to find a new doctor and start all over again,” she says, returning to our usual dance in this conversation. “Yes, but your life is moving more towards Boston and it seems like one day you might be moving there, so it makes sense to have some health resources there as well.” I say, pointing out that if she could identify a resource there, we could build a bridge to ease the clearly painful transition. “Yea, but there are so many things I have to do, finding a new primary care doctor just does not seem like a priority to me,” Eka repeats. “That is because you are healthy, but if you got sick, you would need to have someone you trust,” I say, pointing out the obvious, but at the same time knowing that since we now have hospitalists, most people who have medical emergencies do not see a familiar professional.

Eka and I meet face to face on a regular basis, so the ethics of me treating her, even though she spends substantial time on the other coast, are not in question. Yet, what if Eka pulled up roots in Los Angeles and she wanted to continue to see me as her physician? What if we only had phone appointments? Would I have to insist that she find a psychiatrist in her local area? When I trained, the answers to these questions were clear. Phone consultations, although acceptable on a short-term basis, were not ethically acceptable in the long-term. Now, with Skype, and the general globalization of our world, the answers are not so clear.

Eka and I ended as we always do. “Let’s continue to think about it,” I say, knowing that she is in a stable place. “Yea, too many other things in my life are changing,” she replies, reminding me that her kids are getting older and they are all hitting important developmental milestones. “So, it is on the back burner for now, but let’s keep this discussion going, as it is a very important question,” I say, making a plea for continuity on this topic. “Yea, I am pretty lucky to have a job, at my age, even though the location is not what I wanted.” Eka says with good cheer and a sense of self-confidence which felt good, without a touch of arrogance. “Yea, you should be very proud,” I echo.

6 Responses to “The Patient Moves: Does The Treatment Have To?”

  1. Jon said

    While Skype is not the same as being in the same room, it does seem to be a viable answer to Eka’s medium turn problem. I think this is well worth a try as an intermediate fix between finding an acceptable Boston replacement to good Los Angeles therapist. I encourage this use of modern technology, perhaps with the old fashion face-to-face meetings on occasion.

    • Thanks, Jon. As with all change, there is a lag between the change in technology and the change in the “standard of care” which is how these ethics are determined. Your point of view makes a lot of sense. Many places around the country are doing what they call “telemedicine” which means the patient is at home, talking to the doctor in a different location. Clearly, this has huge benefits for folks who live in rural areas. In psychiatry, this is new territory, mostly in terms of long-term psychotherapy. The loss of the “whole picture” is exchanged for maintaining continuity. This seems to me to be a dilemma, which for the time being, will be decided on a case by case basis. Thanks Again!

  2. Shelly said

    Shirah, what about Eka’s long-distance treatment troubles you? She comes routinely to your office and you see her face-to-face. Although her work brings her to the east coast, her family-base is still in Los Angeles. So what bothers you about continuing her treatment in the status quo?

    • That is a good question. I am concerned that if things were to go South, her work schedule makes it difficult for us to have face to face appointments in a crisis. Of course, we can have a telephone call or Skype, but nothing is as valuable as a face to face meeting. Thanks Again.

  3. I had avoided making a comment on this post mainly because I figured my opinions on this were probably “old fashioned and behind the times” in this fast paced, mobile world of ours. However I spend the morning yesterday with a long time close friend whose husband of over 50 years is in stage 4 cancer and has limited time to live. My friend volunteered the comment that “there is nothing like visiting face to face”, which confirmed how I’ve felt all along…be it with a friend, family member, psychoanalyst/psychotherapist, etc….nor do I understand these “long distance marriages or parenting via Skype ” either. If we humans get to “techie” in our relationships, we loose our human connectedness…emotion, facial expressions, eye contact, body language, and so on.

    So I guess the short answer here is that while psychodynamic therapy via phone or Skype might be OK for a short temporary basis, for the long haul there is no substitute for being in the same location….and that may require making some hard choices……just my opinion.

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