Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Office Practice’ Category

Should I Tweet?

Posted by Dr. Vollmer on June 17, 2013

“You should tweet,” a colleague tells me. “Why?” I ask. “People wonder what you think,” she says. Do I want to be an internet personality? I ask myself. What is the difference between my blog and tweeting? Yes, I know that tweeting is “microblogging” and so they are different beasts, but do I have something to say in a limited number of characters? I suppose I could try tweeting and see what happens. I did not think I would post four days a week, but as it turns out. I do. I often do not know what I want to say until I sit down and say it. Before I started blogging, I could not imagine the pleasure in having a forum in which I could express ideas which have buzzed around in my head for over two decades. Indeed, there is often a sense of relief after I post. I have written something that I have wanted to express for so many years, but I had no audience. Now, the thought of my audience inspires me to discharge thoughts, agonies and concerns regarding the state of psychiatry, medicine, and psychoanalysis. So, how does tweeting add-on to this mission? I could comment on mental health tragedies that hit the news. I would enjoy that. My mind thinks in tweets, so I like the limitation in characters. On the other hand, would this blog suffer if I added tweeting to my working life? Maybe. I am surprised how much energy goes into posting, such that tweeting would also be consuming, despite the brief nature of the result. As we all know, it sometimes takes longer to be brief. Then, there is the issue of my narcissism. How will I feel if I have few followers? Do I want to subject myself to unpopularity? I think I can handle that. This blog has taught me that there is pleasure in writing, even if only one person reads it. As a person who came of age before the internet, few followers still amaze me, so my bar is low. Have I reached a conclusion? Nope. It is summer and so I will give myself time to contemplate.

Posted in Office Management, Office Practice, personal growth | 8 Comments »

Health Care Apps

Posted by Dr. Vollmer on April 18, 2013

  • Breath to Relax App Screenshot 2


In the “adapt or die” mode, part of moving into the next wave of health care changes is using applications to help patients understand and treat their ailments. Knowing which application to recommend to patients will be an important tool in the ever-expanding toolbox of treatment modalities. This application, pictured above, helps patients learn diaphragmatic breathing by showing a man lying on the ground with a book on his stomach, demonstrating that the book rises and falls with each deep breath, but not with shallow breathing. Deep breathing soothes anxiety, and is a relatively simple means of coping with stress in very powerful moments, such as learning about the Boston Marathon. Teaching people to breathe is that simple, elegant, intervention in which there are no negative effects. The smart phone allows people to teach themselves deep breathing in the privacy of their own space, along with the value of repetition, if need be. There is no doubt, that the smart phone will serve as both a health care passport, in which patients travel with vital medical information, along with serving as a  treatment tool, particularly for stress-related disorders such as anxiety or insomnia. This advanced technology thrills me beyond words. Only in my wildest dreams did I imagine such useful patient information to be so incredibly handy and useful. In this way, medicine is in an exciting era.

Posted in Anxiety Disorders, Apps, Office Practice, personal growth, State of Psychiatry, Technology in Medicine | Tagged: | 2 Comments »


Posted by Dr. Vollmer on April 17, 2013


Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.





Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.



Posted in Health Care Delivery, Medical Education, Office Practice, Primary Care, Professional Development, Professionalism, Psychiatry in Transition | 4 Comments »

Telephone: The Literal Connection

Posted by Dr. Vollmer on February 21, 2013

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…

Posted in Office Management, Office Practice | 8 Comments »

Power Outage

Posted by Dr. Vollmer on January 8, 2013


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.

Posted in Office Management, Office Practice, Psychotherapy | 2 Comments »

The Psychotherapy Image

Posted by Dr. Vollmer on December 6, 2012

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.

Posted in Media Coverage, New Media and Psychotherapy, Office Management, Office Practice, Psychotherapy | 5 Comments »


Posted by Dr. Vollmer on November 20, 2012

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.

Posted in Office Management, Office Practice, Professional Development, Psychotherapy | 2 Comments »

The Lull

Posted by Dr. Vollmer on August 9, 2012

“My work as an interior designer is really slow right now. I have never been this slow,” Marjorie, fifty-three tells me with some fear and anxiety in her voice. “Maybe you can enjoy the lull?” I say, offering her a new way to see her situation; a way with excitement as opposed to negativity. At the same time, I am sensitive to not dismissing her fears. “Gee, I never thought of it as a ‘lull’ ” Marjorie says, as if my word choice was shocking to her. “The problem, of course, is that if I knew for sure that it was a lull, then that would be one thing, but I have no way of knowing if this is a lull or if this is my new pace.” Marjorie explains the uncertainty of her business. “Well, maybe it is a lull, until you decide that it is lasting longer than you would like, at which point you decide to do more marketing.” I say, again wanting to be sympathetic to her fears, but also wanting her to expand her point of view to see the positive in something in which she usually can only see the negative. “You mean that I should set a date to end my lull?” Marjorie asks with confusion. “Sure, why not? At that date you will either have gotten busier, in which case it was a lull, or if you did not get busier, then you could mobilize to action.” I say, understanding that referral based businesses are hard to control. “Lull, like lullaby, could be a soothing time,” I say, expanding on my word choice. “Yea, but I am a long way from feeling comforted. I really have to think about this.” Marjorie says, with some hope that with cognitive reframing, she can feel more relaxed. “Uncertainty is tough, and some things in life are more uncertain than others, ” I say, stating the obvious, but also stating that by choosing to be self-employed, she has signed up for this kind of anxiety. “Yes, I have agency,” Marjorie says, acknowledging her life choices which lead her to these ‘lulls’. “I do pick my poison and I like this more than I like working for other people,” Marjorie reassures herself. “So, enjoy the lull,” I say, uncharacteristically being very directive. “Easy for you to say,” she responds with humor and hostility. “Just kidding,” she quickly says, knowing that there was hostility in her voice. “I will sing myself lullabies and that will remind me to enjoy the lull,” Marjorie says, as if to reassure me that she has been paying attention. “If the lullabies make you go to sleep, I hope you wake up refreshed,”  I say, staying with our word play. “Me too,” Marjorie says as she leaves, seemingly more relaxed than when she came in.

Posted in Office Practice, Psychoanalysis, Psychotherapy | 2 Comments »

Do Child Psychiatrists Still Play With Kids?

Posted by Dr. Vollmer on April 25, 2012

I have a new job-a volunteer job, that is! On July 12, 2012, I will begin teaching “Clinical Practicum,” which is a six month child psychotherapy course to first year child psychiatry fellows at UCLA. I will have seven students with varying degrees of interest in doing child psychotherapy. “Can I give my students articles to read?” I ask, my new boss. “You can do whatever you want,” she tells me with a smile. I am excited to walk into an environment in which psychopharmacology is the dominant modality, with the hope, that maybe, just maybe, I can remind my students, budding professionals, that listening and explaining are still valuable skills. Maybe, I can encourage play. By that I mean, maybe I can inspire them to play with their patients as a way of getting to know them.

I have a goal, but my question to myself is how best to achieve that goal. We can read and discuss articles. I can talk about my clinical experience, by disguising identifying features in order to preserve privacy.  If I choose that path, should I pick one patient and go into depth about his treatment, or should I discuss vignettes of multiple patients? I can have them bring in their clinical experience, and we can have a group supervision group where we share ideas about how to get into the inner workings of both the child and his/her family. If I have the child psychiatry fellow bring in a case, then should I divide up the 26 weeks among seven fellows so that everyone has an equal opportunity? Should I limit the class to the treatment of pre-pubertal kids, since treating adolescence is a very different skill set? The best path is not clear to me.

I need to connect with them in a way which expands their experience, but does not seem “outdated.”  I fear that they will see the idea that one must  spend a lot of time with a child and his family before plunking down a diagnosis  as “unrealistic.” To help them see that understanding and explaining is a journey contradicts the notion that parents need immediate answers to their concerns about their child. On the other hand, this is a University, so a multiplicity of ideas should be embraced by both students and faculty. I hope that my exploration of different ways to approach this class will be in line with my goal that different approaches all have value. The more one learns, the more tools one can draw upon. This is a simple notion, but even in the most open minded families, I mean institutions, this idea gets lost. Am I too grandiose to think that I can bring back a discussion of family dynamics to a scene which is so heavily based in neurobiology? Or, do I need that grandiosity to enter into this adventure? As always, I welcome your thoughts.

Posted in Career Dilemmas, Child Psychiatry, Office Practice, Pediatric Psychopharmacology, Play, Professional Development, Psychiatry in Transition, Psychotherapy, Teaching | 2 Comments »

A Psychiatrist’s Assistant?

Posted by Dr. Vollmer on September 5, 2011



  I thought for a moment, then I thought a bit longer, and I decided to hire a temporary assistant to help me with phone calls, emails, and faxes. Of course, I briefed them on the essential tenet of confidentiality, although I was still concerned about keeping the privacy of my practice. At first, I felt relief. My assistant was prompt, responsible and reliable. He wrote down every detail: no complaints there. Yet,  suddenly, I realized that I missed out on important clinical information. I was no longer hearing the tone of the person who left a message. I was no longer hearing how the person worded their request. Instead, I got a very concise, distilled, version of what they were trying to communicate. Oh, not another trade-off, I said to myself. Yet, indeed it is. Not only does an assistant give greater threat to confidentiality, it also takes away all the little clues I receive from retrieving my own messages and scheduling my own appointments. I have always valued the personal aspect of my practice. I have my own office. I, most of the time, am the only one who listens to my voicemail. The responsibility is welcomed, given the closeness that gives me to my work. In my twenty-one years of private practice, I have always known that. Given my recent experiment, I know it now in a deeper way.

Posted in Office Practice | 2 Comments »

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