Phone Intakes

[FlowRate]

I was having some spirited discussion with my local psychiatry team today and I'm interested in opinions outside of my local bubble.

If you have a patient who's scheduled for a video intake but ends up having tech issues, do you do a phone intake or do you make the patient reschedule? Are there various situational factors that might change your decision (employment type, patient specifics, availability of next appointment, etc.)?

I have been doing phone intakes with patients, when we're not able to troubleshoot video issues, since the pandemic. It's not ideal and I ensure that I see the patient by video or, if it fails again for the first follow-up, in person by the second follow-up. I don't start controlled meds by phone. There are some situations in which I might insist on a patient coming in-person more urgently e.g. when I feel seeing the patient is likely to be more diagnostically relevant or if there are other risk factors.

I find the alternative of making someone go two months without care before the next available psychiatry intake appointment to be unpalatable.

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[mistafab]

I would in no circumstance do a phone intake.

I am still in residency so my opinion is not worth that much.

 

[Merovinge]

I do not feel that phone intakes meet the standard of care for an MD intake/evaluation. There are significant parts of the mental status exam that are completely unknowable by phone, even discounting the issues with rapport. While our intake take routinely completes evals by phone, none of our MDs do, as we are rightfully held to a different standard.

If you were doing this in the beginning of the pandemic when technology was sketchy I can absolutely see that being reasonable. Right now it seems preposterous to me.

As a wildly different and seperate concern, ff phone interviews are appropriate for intakes, I would be very worried about someone talking into a microphone and having AI parse through that. Seems like a fast path to technologic obsolescence.

 

[Celexa]

I absolutely swore off phone intakes once we had a vaccine and hold to that aggressively. Phone does not allow sufficient information for a quality assessment. I also will not continue with poor quality connection or if I do not have a good view of the patients face.

There are no circumstances which would change my mind or I would compromise. I have seen and experienced times when VIDEO visits vs in person clearly meant important information was missed with a ESTABLISHED patient. However I think there is much more benefit compared to risk in the cases of video follow ups. I will not do phone only and call it an actual appointment. Full stop.

 

[randomdoc1]

If the tech on the clinic side is set up correctly and the patient can't get it together to set up their video visit, it does tend to correlate with more pathology and higher risk factor for being inconsistent with following up with treatment planning or attending appointments altogether. Also, if they are using their insurance, most insurances do NOT pay for phone calls---your paycheck is likely taking a hit. Or if they do pay for phone calls, the rates I'd seen are 1/4 of that of a video visit. If you try to bill it as telehealth for a phone call, that's technically not a telehealth visit. It must be audio visual. So...technically insurance fraud, although insurance would have no way of proving you did a phone call instead of a video visit. But if you do get audited, note has to reflect what audio visual software was used.

 

[whopper]

No no and no.

Missouri (where I'm at) made a law for in-person or telemed only, but you will need to look up your own state's laws, some will not allow for a phone discussion. Some insurance companies will not pay for it. Even if the patient agrees to pay for it you could be accused of not following the standard of care if this case ever goes through some type of judicial review among other accusations such as did you really know this person was the person they clamed to be? How could you tell if this was phone only?

Also, and this is coming from doing this for years, the patients that often times give you plenty of headache BS are cut down by things such as having a no show fee or showing up in person at least the first visit. E.g. we make patients pay a refundable deposit if they want to be seen the first time. My BS I got to worry about from unreasonable patients went down big time since doing this and I noticed a dichotomy. The patients still giving me the headache BS are the ones we took in before I did this policy. You will likely get a lot more headache patients with the phone call first variety.

Everything else I got to say about this was said above. You will miss stuff on a phone only interview. Some of that stuff could be very important.

 

[claypigeon]

Phone call visits and intakes are imo well below the normal standard of care. So much so CMS looks to not even be allowing them 6 months after the official end of the pandemic.

I’d argue phone call intakes are currently at the low end of standard of care as enough physicians, mainly telehealth pill mills, do them but that’s a low standard. Hard stop on doing them and the only phone follow ups I do are for those who otherwise can’t access tech whom I have seen in person and think are otherwise reasonable candidates (therapy cases). I don’t like doing this even but think it’s better than them not getting care or transitioning to someone who doesn’t know them.

 

[FlowRate]

Appreciate the responses so far and interesting to see consensus thus far as well.

Some additional context--while billing kinda matters organizationally, it does not affect my pay at all. My understanding is 90792 can be billed if video tech didn't work out as long as the physician has capability to do AV. That's interesting to hear about CMS potentially changing course on this. ^

Would you outright refuse to continue a visit or would you opt to do something like spend the intake time allotted to gather additional history that day and schedule a f/u appointment to complete the assessment? (e.g. with time for pt to troubleshoot video or schedule face to face appointment.) I'd imagine for most, where this may not be compensated, this is probably a straightforward answer (not doing any additional assessment by phone since you may not be paid for it.)

Does knowing most patients (unless you think it's urgent) won't get any care for 2 months if you make them schedule a new full eval slot change your calculus at all? (F/u access is better, could see them back to complete assessment in a week or two.)

 

[randomdoc1]

Appreciate the responses so far and interesting to see consensus thus far as well.

Some additional context--while billing kinda matters organizationally, it does not affect my pay at all. My understanding is 90792 can be billed if video tech didn't work out as long as the physician has capability to do AV. That's interesting to hear about CMS potentially changing course on this. ^

Would you outright refuse to continue a visit or would you opt to do something like spend the intake time allotted to gather additional history that day and schedule a f/u appointment to complete the assessment? (e.g. with time for pt to troubleshoot video or schedule face to face appointment.) I'd imagine for most, where this may not be compensated, this is probably a straightforward answer (not doing any additional assessment by phone since you may not be paid for it.)

that patient would be out the door for me so fast. but I can only speak for myself.

 

[PsyDr]

1) There are several federal rulings that indicate that "audio only" is not equivalent to telemedicine or in person. This may create issues with liability.

2) CMS does not allow for "audio only" EM codes. This may create problems with billing.

3) There are some specific CPT codes for audio only appointments. I think they are only 15 minutes long.

4) I wouldn't want to defend that, if some patient commits suicide.

 

[Merovinge]

Phone call visits and intakes are imo well below the normal standard of care. So much so CMS looks to not even be allowing them 6 months after the official end of the pandemic.

I’d argue phone call intakes are currently at the low end of standard of care as enough physicians, mainly telehealth pill mills, do them but that’s a low standard. Hard stop on doing them and the only phone follow ups I do are for those who otherwise can’t access tech whom I have seen in person and think are otherwise reasonable candidates (therapy cases). I don’t like doing this even but think it’s better than them not getting care or transitioning to someone who doesn’t know them.

That's actually too bad because f/u phone call visits are actually super reasonable in some fields. My partner makes very good use of them to go over biopsy results within 1-2 days of them resulting (particularly when negative), makes people way less anxious then waiting for an in-person visit which often can take a week or two and then people are left reading MyChart pathology/radiology results out of context.

 

[comp1]

Lawyers are going to argue, it's what they do...but I'm betting there's a whole boatload of telephone only visits for psychiatrists still going on. I'd go so far as to guess the plurality of appointments with psychiatrists are telephone only. So it's kind of hard to say that it's way outside the community standard. I know my organization opposes phone only appointments and works against it. I also know that insurance companies are going to put up barriers, it's what they do. I also get that you lose a lot on the phone and I DEFINITELY agree anyone who can't get an AV or in person appointment going is likely to be challenging in other ways. Of course all of this is about appointments in general. Intakes are a little different and you might be able to argue a bit more about community or industry standards (still quite sure they are common in the community).

 

[claypigeon]

That's actually too bad because f/u phone call visits are actually super reasonable in some fields. My partner makes very good use of them to go over biopsy results within 1-2 days of them resulting (particularly when negative), makes people way less anxious then waiting for an in-person visit which often can take a week or two and then people are left reading MyChart pathology/radiology results out of context.

I think you can still bill the 9944x codes but reimbursement reverts back. So a perfect use for those type of scenarios but not for a regular visit

 

[FlowRate]

Lawyers are going to argue, it's what they do...but I'm betting there's a whole boatload of telephone only visits for psychiatrists still going on. I'd go so far as to guess the plurality of appointments with psychiatrists are telephone only. So it's kind of hard to say that it's way outside the community standard. I know my organization opposes phone only appointments and works against it. I also know that insurance companies are going to put up barriers, it's what they do. I also get that you lose a lot on the phone and I DEFINITELY agree anyone who can't get an AV or in person appointment going is likely to be challenging in other ways. Of course all of this is about appointments in general. Intakes are a little different and you might be able to argue a bit more about community or industry standards (still quite sure they are common in the community).

I'm not sure about other people, but there have been plenty of "video" visits where the patient has poor bandwidth/harsh lighting/poor quality camera where it'd be hard to argue that much was added beyond a phone call. I'd imagine there's also a spectrum of practice along what bar of quality people require of the video call in order to continue the appointment.

 

[Sushirolls]

Some states have laws about telephone encounters and billing and I'm aware of one state that says you can't do telephone encounter billings unless you previously had a signed consent saying those can be billed.

Insurance doesn't pay scat for no video encounters. So I will get at least 1 minute of video to muster up an MSE. Otherwise, I cancel the appointment and tell them to reschedule. I want to get paid, and I simply tell patients that, unless they are in the state with that weird law.

If video is lagging or poor, I've reverted to phones only, but only after several minutes of Audio/Visual to justify for billing. I document the tech struggle in my Telemedicine documentation blurp.

I've had one cash pay patient who struggled with getting their internet and camera to work, and a few visits we did audio. But I also set a deadline like get it figured out by XYZ, and patient finally did. So even with being cash pay, we are getting telemedicine now.

 

[mistafab]

I would also consider your malpractice carrier. They may cover a provider doing "telemedicine" at a given site with specific criteria as to what that means. Who knows if audio-only is excluded or covered at this point post-covid. Wouldn't want to walk into something like that down the road.

That's beside the point that a phone intake is just bottom of the barrel care. A NJ doctor was indicted for fraud doing "phone intakes" and ordering DME for a telemed company. Lawyers successfully argued that there was no physical exam, and no doctor-patient relationship established. Guy was charged/sentenced and had to forfeit money.

I'm sure that specific case was beyond just terrible care, and likely did involve intentional fraud... But just providing a clear example of phone intake being insufficient in establishing Doc-Pt relationship in the eyes of the medicare - malpractice won’t help you there.

 

[Celexa]

Appreciate the responses so far and interesting to see consensus thus far as well.

Some additional context--while billing kinda matters organizationally, it does not affect my pay at all. My understanding is 90792 can be billed if video tech didn't work out as long as the physician has capability to do AV. That's interesting to hear about CMS potentially changing course on this. ^

Would you outright refuse to continue a visit or would you opt to do something like spend the intake time allotted to gather additional history that day and schedule a f/u appointment to complete the assessment? (e.g. with time for pt to troubleshoot video or schedule face to face appointment.) I'd imagine for most, where this may not be compensated, this is probably a straightforward answer (not doing any additional assessment by phone since you may not be paid for it.)

Does knowing most patients (unless you think it's urgent) won't get any care for 2 months if you make them schedule a new full eval slot change your calculus at all? (F/u access is better, could see them back to complete assessment in a week or two.)

It is false assumption, and a dangerous mental trap for a physician, to think that no care is always worse than bad care. The VAST majority of the time, as people have discussed above, pts inability to make it to appointments is reflective of a pathology that we should be conscious about and treating (through boundaries and structure) that is NOT helped by enabling. And I do not say this coming from a position of attempting to weed out or punish patients in challenging life circumstances. When I enacted these clear boundaries in my pracrice as a resident (clear definitions of what a phone call was acceptable for--requiring in person visits when clinically indicated or if the video quality was preventing me from providing the best quality of care) I didn't lose patients. They started doing the things that actually let me be a good doctor for them.

I never ended phone visits feeling I had done a good job. It was tremendously freeing to realize I could (and should) extricate myself from these lose-lose situations.

 

[hamstergang]

Would you outright refuse to continue a visit or would you opt to do something like spend the intake time allotted to gather additional history that day and schedule a f/u appointment to complete the assessment?

I would refuse to engage. I wouldn't want to start getting history on a patient and establish this relationship when are only interactions were on the phone. You also don't know that the issue will ever get resolved and unless you will just continue to do telephone visits, you now have only half an intake done and need to waste even more of the patient's time.

 

[comp1]

I would argue that in many cases, declining to see a patient via phone if inappropriate isn't really "no care." It can be very therapeutic boundary setting that could result in long term development of mature coping skills. It's more "care I can't bill for."

 

[annoyedpsychiatrist]

i agree and would not do phone intakes. Being able to see the person/how/how they present themselves/mannerisms/etc is often very useful for information.

 

[whopper]

Not specific to the question but always practice as if your specific encounter will be put under review. You practice in a way where say 10% doesn't meet up to standard, remember your records for usually up to 10 years can be dissected for review. You did something subpar, the enemy has 10 years to catch you, not that once.

I testified on a legal case 2 days ago where I had to dissect some other doctors' care and pretty much had no choice but to blow them out of the water in front of the state medical board cause there was a lot of indefensible treatment. In this case the person being treated by the other doctors was misdiagnosed and it led to that person losing his high-paying professional status, possibly permanently. The misdiagnosis went into the areas of 1-Not even seeing the patient in person or telemedicine and misdiagnosing, 2-Writing a letter the person cannot do the job to higher regulatory authorities based on a misdiagnosis, 3-Prescribing a patient a med that has a black box warning against the misdiagnosis in question but still doing it, then administering a test that patient bombed cause the med causes extreme confusion. 4-Using a test to justify the misdiagnosis where the doctors did not meet the minimum requirements to be allowed to administer the test (requires training and certification with the parent company that owns the test). Remember I've said on this forum about half the psychiatrists out there suck? A lot of them work day to day and nothing happens, but a few of them are put under the microscope from time to time.

A colleague of mine who is excellent was also involved in the case and (THANK GOD) his work was excellent. E.g. he followed all the requirements and didn't misdiagnosis. Only wrote down that at that moment the patient appeared confused but that he couldn't diagnose other than an NOS diagnosis because he only saw him once and mental status can highly shift over time. He was able to dodge the bullet.

You study criminals, it's not the 1 act where they get caught. It's usually after they've been doing it a long time cause then they leave enough of a trail of breadcrumbs. You make something a common practice for yourself and this goes on for years? Not good even if you are a prick who deserves to not practice. Even for the evil bad doctor, if they're smart, they won't practice this way if only for self-preservation.

 

[calvnandhobbs68]

Nope, no phone only appointments at all. The patient should be testing the connection to see if it's feasible BEFORE the appointment. Not our fault if they didn't do that. I tell patients if they can't figure out how to do video appointments, we should be seeing each other in person.

I don't even do phone followups at this point, much less intakes. People know how to use Zoom/Doxy/Google Meet/whatever, they did it for 2 years. I would also personally argue it doesn't meet standard of care at this point. Emergency scrambling to figure things out during COVID when there was also high risk to in person visits in general, sure, not now.

 

[FlowRate]

1) There are several federal rulings that indicate that "audio only" is not equivalent to telemedicine or in person. This may create issues with liability.

2) CMS does not allow for "audio only" EM codes. This may create problems with billing.

Psychiatric News

psychnews.psychiatryonline.org

Medicare apparently approved audio-only telemental health on a permanent basis.

There is also an interesting equity argument in favor of the practice (commented on in the article.)

 

[whopper]

Medicare apparently approved audio-only telemental health on a permanent basis.

I heard about this but never saw verification. If Medicare accepts it, it becomes arguable as a standard of care treatment. I still wouldn't recommend it.

Wrote after someone posted after this one (so it'll appear as an edit). I wrote in another forum that a place I worked at wanted to do something where I didn't know it was legal. It was a direct thing where all these changes in practice led to what I'm calling COVID legal confusion. The state of Missouri specifically writes laws, and the state said this so several times-they want the state laws to be compatible with federal laws. The problem being with so many changes some doctors don't know if a practice that was allowable while COVID was going on is still legal, or is it now illegal? Missouri law stated telephone meetings are no longer allowable, but Medicare allegedly says it's allowable, and Missouri stated they work to be compatible with the Federal Laws. So then WTF is going on here?

While the situation with the clinic I worked at wasn't the same exact thing it was darned close. Too many changes to the law, we don't know if the new laws nullified prior ones, we asked the state, no one from the state knew. We hired a lawyer, they couldn't tell after dozens of hours of working on this issue but they sure as heck gave a big bill. The DEA told us it was a state issue so they couldn't give us an answer. So my final answer as medical director was if we didn't know we weren't going to do it, and then the clinic replaced me which was fine with me.

 

[Sushirolls]

Equity... give it another year or two, and equity and it's comrades inclusion and diversity will be a 4 letter word.

 

[FlowRate]

Equity... give it another year or two, and equity and it's comrades inclusion and diversity will be a 4 letter word.

I'll put it in terms that you might find appealing: some farmers live far away from cities with psychiatrists, don't have high speed internet access, and aren't so great with new fangled electronics. They might appreciate mental health access via a technology that they are familiar with (the phone.)

 

[Sushirolls]

I'm deep in farming country. I don't have sympathy.
Farmers can drive. They have trucks. People even have commuter cars that sip gas.
People commute 45-90 minutes to work, or horse round ups, or whatever.
The older I get the less I buy into woes of rural or whatever 'disenfranchised community' is the flavor of the day.
People know you live in XYZ location its not going to have every thing.
Star link exists now. Satellite internet had existed even prior to starlink. This rural community had a ton of existing line of sight towards the beamed internet options on par with cable internet.
The fact our country is trying to push this idea that access needs to be in BFE Caucasian farm town, or the East Cleveland poverty area is mind boggling.
East cleveland... hop on the bus, go several city blocks and you are at the doorsteps of the Cleveland Clinic.
BFE farm town... drive ... like you do for everything else.

People will drive hours for their cardiologist. But hesitate for the Psychiatrist or other specialist? Really, is the issue access to care or more their priorities? Should the country be pushing policy and agenda and after agenda saying we need XYZ in farm town? Or in the criminal/gang heavy side of town?

Perhaps, the interior of Alaska has rural villages and people who just truly don't have the technology, are outside starlink coverage. That is about the only place I would buy the argument of phone services under any reason or political lingo of the day.

Convenience or personal priorities are the real issues of accessing health care, at the level of the patient. Not providers, docs or tech we use. People aren't victims of whatever. People are making choices.

 

[Celexa]

I'm deep in farming country. I don't have sympathy.
Farmers can drive. They have trucks. People even have commuter cars that sip gas.
People commute 45-90 minutes to work, or horse round ups, or whatever.
The older I get the less I buy into woes of rural or whatever 'disenfranchised community' is the flavor of the day.
People know you live in XYZ location its not going to have every thing.
Star link exists now. Satellite internet had existed even prior to starlink. This rural community had a ton of existing line of sight towards the beamed internet options on par with cable internet.
The fact our country is trying to push this idea that access needs to be in BFE Caucasian farm town, or the East Cleveland poverty area is mind boggling.
East cleveland... hop on the bus, go several city blocks and you are at the doorsteps of the Cleveland Clinic.
BFE farm town... drive ... like you do for everything else.

People will drive hours for their cardiologist. But hesitate for the Psychiatrist or other specialist? Really, is the issue access to care or more their priorities? Should the country be pushing policy and agenda and after agenda saying we need XYZ in farm town? Or in the criminal/gang heavy side of town?

Perhaps, the interior of Alaska has rural villages and people who just truly don't have the technology, are outside starlink coverage. That is about the only place I would buy the argument of phone services under any reason or political lingo of the day.

Convenience or personal priorities are the real issues of accessing health care, at the level of the patient. Not providers, docs or tech we use. People aren't victims of whatever. People are making choices.

Lol I know we don't vote the same but we sure agree a lot when it comes to clinical work. That hypothetical rural farmer is going to be at notably high risk assessing over the phone. What if their "depression" or "fatigue" is due to an untreated and/or unstable medical condition? I've been consulted on patients IN the hospital for "anxiety" who were literally hypoxic. You trust the patient to triage themselves appropriately? Old dudes are notoriously not the most forthcoming about suicide--there's so much communicated in face and body language to actually get at the risk.

I don't buy the equity argument and I don't buy the patient preference argument. Patients might want phone interviews when offered choices. Patients want all sorts of things that are bad for them or are poor care. This is no different.

 

[Sushirolls]

@Celexa I'm not pro phone. I'm saying, people need to figure out their tech or go into the office.
I'm critiquing the medical establishment of constantly pushing access to care, to even allow just a phone to count as means for an encounter.
*except perhaps interior Alaska

 

[Celexa]

@Celexa I'm not pro phone. I'm saying, people need to figure out their tech or go into the office.
I'm critiquing the medical establishment of constantly pushing access to care, to even allow just a phone to count as means for an encounter.
*except perhaps interior Alaska

Yes? I was agreeing with you...

 

[Sushirolls]

Cool!
High five [hand is up]

 

[Celexa]

Cool!
High five [hand is up]

 

[Stagg737]

Concur with the mob. No telephone intakes.

I do telehealth only for outpatient (nearest patient is 3+ hours away). I will not do phone-only intakes. I've had enough intakes turn into situations where I've had to send the patient to the ER or send police for a wellness check that I'm not willing to have these appointments via telephone. I will allow patients that I have seen several times to convert a video appointment to phone if the connection sucks after trying to get video to work. If it's problems on intake, it's not acceptable. This is why I have the MA who works with me set up the video portion before I even join. If it's an intake and the connection is terrible, we reschedule before I see them.

Does knowing most patients (unless you think it's urgent) won't get any care for 2 months if you make them schedule a new full eval slot change your calculus at all? (F/u access is better, could see them back to complete assessment in a week or two.)

If they're in such crisis that they can't wait a month or two to reschedule, then they need to go to the ER for further assessment.

 

[forchinet121]

The views of SDN I don’t think are reflective of the community standard to be honest..many people around me are doing telephone only appointments especially with low SES patients it’s much better than nothing

 

[forchinet121]

Concur with the mob. No telephone intakes.

I do telehealth only for outpatient (nearest patient is 3+ hours away). I will not do phone-only intakes. I've had enough intakes turn into situations where I've had to send the patient to the ER or send police for a wellness check that I'm not willing to have these appointments via telephone. I will allow patients that I have seen several times to convert a video appointment to phone if the connection sucks after trying to get video to work. If it's problems on intake, it's not acceptable. This is why I have the MA who works with me set up the video portion before I even join. If it's an intake and the connection is terrible, we reschedule before I see them.



If they're in such crisis that they can't wait a month or two to reschedule, then they need to go to the ER for further assessment.

Not sure how a video would help you versus phone to send someone to the ER, I routinely do telephone only and have sent people to the ER before I simply call 911 and tell the police their address

 

[Stagg737]

Not sure how a video would help you versus phone to send someone to the ER, I routinely do telephone only and have sent people to the ER before I simply call 911 and tell the police their address

You can actually visualize the patient and often see their surroundings, it's still not as good as in-person but better than telephone. I've had patients who were chronically psychotic where I wouldn't have called for a wellness check by phone as I wouldn't have been aware of the feces/disorganized behaviors of the patients if I couldn't see them. Additionally, you can at least do a partial AIMS via video, pretty tough to do if you can't see them though. I did telephone only for some patients as a resident at the VA during the start of COVID and seeing the condition of some of these patients a couple of months later in-person was shocking.

The views of SDN I don’t think are reflective of the community standard to be honest..many people around me are doing telephone only appointments especially with low SES patients it’s much better than nothing

I saw a fair number of patients in a previous clinic whose docs were "seeing them by phone" for months. Based on the diagnoses and meds from the docs doing that, seemed like they were either terrible psychiatrists or just missing a lot of things they shouldn't have been. Sometimes something is better than nothing. Sometimes it causes far more harm. It's the same argument used to justify mid-levels providing care with minimal training. I just don't agree.

 

[FlowRate]

If they're in such crisis that they can't wait a month or two to reschedule, then they need to go to the ER for further assessment.

There are many psychiatric conditions that suck to live with that would benefit from not having to wait two more months to start treatment, when they already waited two months for the intake appointment where their video setup didn't work. That doesn't mean they need emergency care.

 

[splik]

Before med school, I volunteered as a counselor on a youth hotline. There is a specific skill set that goes along with doing telephone interviewing and counseling. If you don't have it, you won't be able to be effective doing phone assessments. If you have it, you can do a lot via telephone.

A lot of things can't be done via telephone but in some settings you probably can see straightforward cases over the phone. my friend does community psychiatry and has been telephone only since the beginning of the pandemic. Zoom not an option for many of these patients. That is quite challenging as this includes alot of pts with schizophrenia, bipolar, intellectual disability etc but it's the only way they are going to get care.

CMS has said you can do audio only for 90792 now so the federal government acknowledges you can do an audio only psych diagnostic evaluation. Is it the ideal? No. But its not a bad option for a lot of people.

I did telephone staffing on C/L early on the pandemic. The patients had been seen in person overnight by a resident, but I called the patient on the phone to staff them. Was actually very effective for many patients. I wouldn't do this for delirious pts, catatonia etc, but pts with adjustment reactions, demoralization, depression, safety evals, substance use disorders and even capacity evals it worked quite well. Also some patients will tell you stuff over the phone that they wouldn't tell you via zoom or in person. It's like lying on the couch.

I've also done parts of forensic evals telephone only and they were accepted by the federal courts.

 

[forchinet121]

You can actually visualize the patient and often see their surroundings, it's still not as good as in-person but better than telephone. I've had patients who were chronically psychotic where I wouldn't have called for a wellness check by phone as I wouldn't have been aware of the feces/disorganized behaviors of the patients if I couldn't see them. Additionally, you can at least do a partial AIMS via video, pretty tough to do if you can't see them though. I did telephone only for some patients as a resident at the VA during the start of COVID and seeing the condition of some of these patients a couple of months later in-person was shocking.


I saw a fair number of patients in a previous clinic whose docs were "seeing them by phone" for months. Based on the diagnoses and meds from the docs doing that, seemed like they were either terrible psychiatrists or just missing a lot of things they shouldn't have been. Sometimes something is better than nothing. Sometimes it causes far more harm. It's the same argument used to justify mid-levels providing care with minimal training. I just don't agree.

If a psychiatrist is causing far more harm seeing a patient, the reason is not because it’s a telephone encounter. He would’ve caused harm regardless of the encounter type. Telephone encounters in my experience have been adequate as the alternative is no care and I know I can provide better care to someone via a phone than no care at all. Telling someone you’re not going to see them because they don’t have video is a bit much for a lot of patient populations but everyone is free to do as they wish

 

[allantois]

I love hearing from patients about their previous psychiatrist who they’ve never seen; only talked to on the phone for 5 mins at a time; and who supplied them with their Adderall for never before diagnosed ADHD

 

[Celexa]

If a psychiatrist is causing far more harm seeing a patient, the reason is not because it’s a telephone encounter. He would’ve caused harm regardless of the encounter type. Telephone encounters in my experience have been adequate as the alternative is no care and I know I can provide better care to someone via a phone than no care at all. Telling someone you’re not going to see them because they don’t have video is a bit much for a lot of patient populations but everyone is free to do as they wish

I had a patient in residency. Old guy with bad OCD and depression. History of hospitalizations. At times the OCD was so bad he lost a ton of weight between fears of contamination and time spent on compulsions.

Its Covid and he only had the phone. Always says he feels the same and the same is always terrible. Made some med adjustments. Unsurprisingly no change. He's reluctant to come in. But I had inherited him on a LOT of meds. I'm not gonna monkey around anymore without more information.

Laid down the law and said you must come in person. Pt shows up in person. Surprise--he IS better! Not in self report, of course. Still all eeyore. But he's put on weight, doesn't have any major skin lesions from OCD overwashing, and in the room with isn't put out enough anxiety to power a small town.

I would never have known I was on the right track with the med adjustments if I hadn't gotten an in person assessment. Short of mind reading, I would never have gotten crucial clinical information without SEEING the patient. And I absolutely could have done more harm then good--based solely on what he was saying, the logical moves would have been to keep making med changes and I likely would have blown right past something that actually was helping and never known it.

This is not a one off experience. I understand why in some cases, a phone follow up may be better than no follow up. It's not my practice but I get it. But I simply cannot believe that phone intakes or longitudinal phone only care is good care. In a stable pt it might allow for sustaining care for a while, but when things destabilize it'll go back to being poor care.

 

[forchinet121]

I had a patient in residency. Old guy with bad OCD and depression. History of hospitalizations. At times the OCD was so bad he lost a ton of weight between fears of contamination and time spent on compulsions.

Its Covid and he only had the phone. Always says he feels the same and the same is always terrible. Made some med adjustments. Unsurprisingly no change. He's reluctant to come in. But I had inherited him on a LOT of meds. I'm not gonna monkey around anymore without more information.

Laid down the law and said you must come in person. Pt shows up in person. Surprise--he IS better! Not in self report, of course. Still all eeyore. But he's put on weight, doesn't have any major skin lesions from OCD overwashing, and in the room with isn't put out enough anxiety to power a small town.

I would never have known I was on the right track with the med adjustments if I hadn't gotten an in person assessment. Short of mind reading, I would never have gotten crucial clinical information without SEEING the patient. And I absolutely could have done more harm then good--based solely on what he was saying, the logical moves would have been to keep making med changes and I likely would have blown right past something that actually was helping and never known it.

This is not a one off experience. I understand why in some cases, a phone follow up may be better than no follow up. It's not my practice but I get it. But I simply cannot believe that phone intakes or longitudinal phone only care is good care. In a stable pt it might allow for sustaining care for a while, but when things destabilize it'll go back to being poor care.

So if that patient couldn’t come in you believe better care would be for him to stop getting any meds and seeing you at all?

 

[whopper]

Whenever the patient expects me to know what's going on without giving me enough information, I tell them, "if I could read minds I'd be in a casino once a week."

 

[Celexa]

So if that patient couldn’t come in you believe better care would be for him to stop getting any meds and seeing you at all?

Again, as I said above, this is a false choice. He certainly said he couldnt come in many times! He had every seeming legitimate reason in the book. I didn't threaten to cut off the meds. I told him, I cannot make changes without seeing you. I told him outright, I am worried we will not be able to make the right decisions about your care without seeing you. If we had gotten out to the time span on which he hit our clinics policies for discharge, I would have talked candidly about that. He came in for the next appt after I told him he needed to--because that's what the majority of these patients do when you exercise positive therapeutic boundaries, regardless of what they said previously.

Allowing the patient's illness to drag down their care is collaborating with it. If you yourself view that boundary is a punishment or transgression or a failure, that comes through. Of course that isn't a therapeutic frame. But coming from a place of care and compassion, centered on genuinely providing the best care within your power for the patient--it's one of the most powerful tools we have.

 

[forchinet121]

Again, as I said above, this is a false choice. He certainly said he couldnt come in many times! He had every seeming legitimate reason in the book. I didn't threaten to cut off the meds. I told him, I cannot make changes without seeing you. I told him outright, I am worried we will not be able to make the right decisions about your care without seeing you. If we had gotten out to the time span on which he hit our clinics policies for discharge, I would have talked candidly about that. He came IN for the next appt after I told him he needed to--because that's what the majority of these patients do when you exercise positive therapeutic boundaries, regardless of what they said previously.

Allowing the patient's illness to drag down their care is collaborating with it. If you yourself view that boundary is a punishment or transgression or a failure, that comes through. Of course that isn't a therapeutic frame. But coming from a place of care and compassion, centered on genuinely providing the best care within your power for the patient--it's one of the most powerful tools we have.

So you think there aren’t patients who legitimately can’t come in? Or can’t afford to get video? I don’t know about your patient but this is not a false choice for a lot of people

 

[Celexa]

So you think there aren’t patients who legitimately can’t come in? Or can’t afford to get video? I don’t know about your patient but this is not a false choice for a lot of people

I worked with a HEAVILY medicaid population in residency. Everyone had smart phones. The only people who didn't were a small slice of geriatrics, and quite frankly if they lived by themselves and could neither get on video with assistance from someone else or couldn't get in, they almost always weren't safe to be living by themselves and outpatient wasn't the right level of care anymore.

Residency was in a big city but like Sushi I also have connections and experience in more rural settings. I accept that frequent visits can be out of reach--certainly there are many people who I understand cannot make weekly in person therapy visits, for example--but outpatient medication appointments? Neither video or in person, ever? Nope.

 

[MedMan80]

Did it during the pandemic, hated it, stopped it about a year ago. Sucks having to reschedule folks 4-6 weeks away if tech fails but it is what it is.

 

[annoyedpsychiatrist]

Not sure how a video would help you versus phone to send someone to the ER, I routinely do telephone only and have sent people to the ER before I simply call 911 and tell the police their address

These are some of the intakes I have had of recent (over past 30 days)

1. New onset psychosis in a 67 year old female. Severe paranoia, disorganization, possibly AH. Previously healthy, acute onset of 2 months. She barely even spoke, had to get most of the info from the family. She was previously president of the homeowners association and very active. There was suspicion of CJD, given other details of the case.

2. Late onset bipolar in a woman in her 50s, with severe baseline irritability. Previously was also healthy.

3. Patient with reported schizophrenia who is deaf and mute.

4. First break psychosis in a 21 year old

5. First break psychosis in a 19 a year old

6. 66 year old woman where there was concern for neurocog disorder vs ADHD that was never formally diagnosed

7. Woman in her 30s with a broken wrist that I happened to observe, which gave me more insight on her living situation


Doing strictly telephone visits with my intakes last month would have been a disaster. Would have missed the ability to observe gait/movements in patient number 1, wouldnt have been able to observe number 2s demeanor, would have missed that there was a little EPS in number 4, wouldnt have seen the wrist in number 7, wouldnt have been able to really see for myself how disorganized the lady was in number 6.

If your patients are very mild and its a simple case of starting zoloft I suppose I can see the argument for phone intakes but for the patients Im getting I think phone intakes would just not work out and id miss way too much. I hate when people always bring up access to care, because thats the same argument that people use to justify expansion of NPs. We should specify "access to care" and say "access to quality care" because I would argue that care following below the standard of practice isnt always better than no care.

 

[forchinet121]

These are some of the intakes I have had of recent (over past 30 days)

1. New onset psychosis in a 67 year old female. Severe paranoia, disorganization, possibly AH. Previously healthy, acute onset of 2 months. She barely even spoke, had to get most of the info from the family. She was previously president of the homeowners association and very active. There was suspicion of CJD, given other details of the case.

2. Late onset bipolar in a woman in her 50s, with severe baseline irritability. Previously was also healthy.

3. Patient with reported schizophrenia who is deaf and mute.

4. First break psychosis in a 21 year old

5. First break psychosis in a 19 a year old

6. 66 year old woman where there was concern for neurocog disorder vs ADHD that was never formally diagnosed

7. Woman in her 30s with a broken wrist that I happened to observe, which gave me more insight on her living situation


Doing strictly telephone visits with my intakes last month would have been a disaster. Would have missed the ability to observe gait/movements in patient number 1, wouldnt have been able to observe number 2s demeanor, would have missed that there was a little EPS in number 4, wouldnt have seen the wrist in number 7, wouldnt have been able to really see for myself how disorganized the lady was in number 6.

If your patients are very mild and its a simple case of starting zoloft I suppose I can see the argument for phone intakes but for the patients Im getting I think phone intakes would just not work out and id miss way too much. I hate when people always bring up access to care, because thats the same argument that people use to justify expansion of NPs. We should specify "access to care" and say "access to quality care" because I would argue that care following below the standard of practice isnt always better than no care.

I agree, I definetly don’t think it’s a good fit for all patients but a significant amount of patients will benefit from an audio only appointment and I do not believe that is below the standard of care and do believe it is better than the alternative.

 

[FlowRate]

Doing strictly telephone visits with my intakes last month would have been a disaster. Would have missed the ability to observe gait/movements in patient number 1, wouldnt have been able to observe number 2s demeanor, would have missed that there was a little EPS in number 4, wouldnt have seen the wrist in number 7, wouldnt have been able to really see for myself how disorganized the lady was in number 6.

Those are all great case examples of why "strictly phone intakes," as if that was planned or your exclusive option forever, isn't what we're talking about. I'm talking about whether some initial assessment by phone is preferable to no care at all when a patient has issues getting video to work. In the cases you gave, I'd gather some history (and collateral if the family was available) by phone and then slot the patient into a f/u slot within a week or two to complete the assessment (either face to face if I don't have confidence they can fix their video issues or video and emphasize that they need to get it fixed and review with our IT service that will do test runs with patients.) The alternative is making those new onset psychosis patients wait 2 months to get a full intake slot.

And in my setting, I'm paid for all of this. Well, I'm also paid if they no-show or if I use their video issues as an excuse to not have a visit. But I'd rather patients actually get timely care.