Cell phones work so well, most of the time, and afford such convenience in casual use, that we risk failure to recognize their substantial limitations, especially when used in conjunction with voice mail, for communicating with patients in critical or emergent situations when 911 services might serve them better.
Use of any kind of telephone may be inadequate for even routine psychiatric care and psychotherapy, much less for the difficult and critical task of emergency assessment and intervention which demand face to face communication. The physician responding to a phone call from a patient after hours might be enjoying the effects of a second glass of wine, embroiled in conflict with a teenage child, or otherwise in flagrante delicto. Voice mail allows you to delay contact with the patient until you can focus your full attention on the call, and your surroundings will not distract you.
Caller ID adds to the complexity: If the patient has set her phone to block unidentified callers, the physician must choose whether to expose his cell or even home telephone number.
Cell phones can easily be carried in pocket or purse. They can also easily be dropped, drowned (Web pages instruct us how to revive a phone dropped in the toilet.), borrowed, broken, forgotten, hidden, hurled, left, lost, silenced, stolen, stepped on, turned off, and ignored. Their batteries can die. The signal can be distorted, unintelligible, interrupted by a second call, or dropped completely. You may forget to switch the phone back on after leaving a place where cell phones must be switched off. You may not hear the ring tone because of ambient noise or feel the vibration if the phone is not next to your body. You may forget to switch from one alert mode to the other after changing modes, in a meeting or theater. As I write this a cell phone belonging to I know not whom rings in vain on a desk in my office suite, probably forgotten by a patient. In poor coverage areas the phone may not ring at all. Bluetooth headsets and other hands-free devices can further complicate matters, and, contrary to myth, may not improve safety when used while driving.
If your patient calls, and you do get both the message and the call back number, but cannot use your cell phone, do not count on using a pay phone. The number of pay phones in the United States diminished by about two thirds between 1998 and 2007. You may not know the location of a pay phone, and finding one in an urgent situation could take an hour or more. If you borrow someone else’s cell phone your lack of familiarity with its operation could compound the problems, and the phone may retain a record of your patient’s number.
Voice mail, too, can compromise communication. The message may be interrupted or unintelligible. The caller may not leave the correct call back number, or any number at all. Some phones will tell you the caller’s number but only if it is not blocked. The caller may not finish recording a critical message, interrupted by a limited recording time, or you may stop playback before you have heard the entire message, thus failing to hear critical information. The caller who just leaves a message for you to call them back may decide to stay off the phone awaiting your return call instead of calling 911. Whether this means a few minutes for you to pull your car to the side of the road or 50 minutes to finish a psychotherapy session, the resulting delay in seeking immediate help from another source may result in disaster. In theory “call waiting” features should help, but either doctor or patient might accidentally drop a call, particularly during a crisis. You may try to leave a message only to hear, “I’m sorry, but the person you have called has a voice mail that has not been set up yet. Good bye.” or, “This mailbox is full.”
Some cell phones may alert you only to the first voice mail message leaving you unaware of messages recorded subsequently. Even when returning a call to a patient claiming to need an urgent response the physician may encounter the patient’s outgoing message. His voice mail may or may not accept a message, and even if you can record your message, phone tag and repeated delays may ensue.
In contrast to cell phones the use of 911 is straightforward, consistently and rapidly accessible, and its reliability may be limited only by that of the caller’s phone. Regardless of the time of day the 911 operator is likely alert and focused on the job. Enhanced 911 services can even tell emergency personnel the location of the caller, critical information if the patient has reported a dangerous act or intent or in any situation where the patient needs assistance but cannot provide his or her location.
Psychiatrists should afford their patients limited telephone access outside of normal business hours, but not for emergencies. If you do use a cell phone to talk to a patient, do not do so while driving or where others can hear your conversation. When retrieving voice mail always finish listening to each message before you end the call. Do not delete messages until the next business day. Preserve your professional boundaries and keep your cell number private by forwarding to your cell phone calls directed to your office number.
Unless you can return every emergency call within a few minutes let 911 handle them, and add to the outgoing message on your office voice mail a warning to hang up and dial 911 for all emergencies (not just medical emergencies) so your patients will know not to wait for your return call.
(This is a considerably shortened and toned-down version of an article I wrote in response to a piece by Robert I. Simon, MD that appeared in the February, 2008 Psychiatric Times. In his article he criticized the use of "hang up and dial 911" messages and extolled the virtues of the cell phone. One wonders if he ever actually used one himself. Interestingly, too, Clinical Psychiatry News declined to print the article after I explained what prompted me to write it. Thank heaven for blogs.)