More New Ways to Communicate

A few weeks ago I asked, Is It Time to Give up on the Phone?, bemoaning the challenges our increasingly complicated and varied modes of communication present. Here I add alternatives that arguably increase the complexity and opportunities for dysfunction, but at the same time allow workarounds when other modalities fail.

Fax
How did I forget? I use a fax service that, for a reasonable monthly fee, assigns my own private fax number and allows me to send and receive via Internet. Received faxes appear in my email inbox as .pdf files. I can even receive a document in .pdf format, print it to a .jnt (Windows Journal) file, sign it with the stylus on my tablet pc, print back to .pdf format with CutePDF Writer (a free download), and fax it back, all without paper. One patient who had lost his phone actually did cancel his appointment via fax.

Videoconfernce
Of course videoconferencing via Skype, Google Video Chat, or other such service makes for a nice alternative to the voice only phone, but users can also send text messages. The chief limitation for me comes from the fact that I usually do not leave Skype running unless I have scheduled a patient contact. The notifications whenever someone signs distract me. Phone-based videoconferencing services like Tango depend on an operating telephone, so they do not add much.


Google Voice
This free and flexible service offers the capability of customizing an outgoing message to an identified caller. I almost tested this a couple weeks ago with the patient I mentioned in the earlier post who apparently was unable to access voicemails I had recorded. I could have recorded a message specifically for him containing more or less the same information I had left on his voicemail. The same capability used to "block" unwanted callers. Once you have identified a caller you want blocked simply so indicate through your Google Voice contacts list. The caller then encounters a message that says something to the effect that the number is no longer in service. An accommodating DEA agent actually confirmed for me that this works very nicely. (I recorded a custom outgoing message for a patient yesterday after several failed attempts to contact him by phone.)

Another more mundane feature probably available in one guise or another to many cell phone users actually allowed me to communicate with the patient mentioned above. Between Google Voice, my software-as-a-service contact management vendor, and my Android phone I am able to send unidentified callers as well as selected identify callers (usually all of my patients) directly to voicemail without ringing the phone. However, in the case of this particular patient I had not yet set his contact for immediate forwarding, so shortly before I intended to record a special outgoing message for him the phone rang identifying him, and, of all things, I actually picked up the phone and answered the old-fashioned way.

Google Wave
Google has indicated it plans to abandon the service in the near future. However, just yesterday it occurred to me that it might offer a solution to a different problem. I like to be able to hand my patients information at the end of a visit. Most commonly this would relate to a new medication I have just prescribed. However, I also like to be able to provide a business card when I refer someone to a psychotherapist or primary care physician. (I could write down the name and phone number, but the patient could never read it, and I always seem to run out of cards.) Since these kinds of information, as well as information about specific mental disorders, reside on Web pages, I would like to be able to efficiently provide the patient with a link. Google Wave appears to offer the capability of establishing a private forum for myself and the patient where I might post URL's for future reference by the patient. Since one can also leave messages or use a Wave for real-time text and even video chat, it could also serve in place of the telephone in a pinch. Furthermore, I can envision, with the patient's permission of course, inviting the patient's psychotherapist and primary care provider into the Wave.

Each of these modalities carries risks and benefits. In particular I wonder about the privacy and security of Wave. However, like with other modalities, we can always manage the content of the conversation in such a way as to maximize privacy. And as with other modalities such as e-mail, a written agreement can go a long way toward assuring that patient and physician understand rules and expectations.

After all, as far as I know it's still okay, even under HIPAA, to smile at the patient when you see him in public.

The Best Treatment or Just the Most Expensive?

$600 an Hour for Treatment

No, $600 for a 45 minute psychotherapy session.

On July 7, 2008 The New York Times published an article (Age of Riches: Challenges of $600-a-Session Patients by Eric Konigsberg) describing the psychotherapy practices of psychiatrists Michael Stone and Byram Karasu.

At first read this looks like another story about the wealthy getting the best treatment. Not necessarily. This article tells us a little about what is probably a very unrepresentative sample of the rich and famous but raises many questions about the practice of psychiatry, or at least the practice of some forms of psychotherapy.

The article begins with an example in which Dr. Karasu criticizes a “therapist” for encouraging a patient to go ahead with an expensive purchase despite his misgivings rather than “explore” the patient’s anxiety. He labels the purchase as a manifestation of an “addiction” involving “excesses and consumption.”

The average psychiatrist today may charge more than $100 for a medication management visit that may last five minutes. Cram 12 of those into an hour and you easily exceed Dr. Karasu’s fee. Of course it takes many more patients to fill your practice. Or fewer psychiatrists can treat the same number of patients, depending on your perspective. The $600 fee is exorbitant, and indeed few can afford it, especially twice a week, but the economic law of supply and demand determines how high a fee such a professional can command.

Regardless of fees much of importance is conspicuous by its absence. There are references to treatment, neurosis, patients, doctors, and psychoanalysis, but there is no mention of illness, of mental disorder. The rich “patients” described in the article seem to want only help for life problems, for “unhappiness or emotional anguish,” or just someone to talk to.

If this is not just an example of the richest patients buying the best doctors, we need to look further for an explanation. Perhaps it is the rare wealthy narcissist (Narcissism also afflicts the poor and can lead to failure.) who gravitates to a treatment that is expensive, if easily afforded, and makes him feel special. Perhaps these doctors are no better than the next “therapist” at helping them, but they may become skilled in attracting them to and keeping them in “therapy” even when they fail to “make progress.”

Sometimes many of us like to think all that money and success would not have made us happier anyway, and indeed the wealthy suffer from many of the same mental disorders as the rest of us. Antidepressants and other medications, and psychotherapy methods like cognitive behavior therapy, effectively treat most mental disorders today. The notion of “neurosis” was long ago abandoned by the diagnostic manual of the American Psychiatric Association, but psychoanalysts, Freudian and otherwise, cling to it stubbornly. The few who seek psychoanalytic psychotherapy from the likes of Drs. Stone and Karasu may be less ill and more in search of someone to listen. They may even like the idea of a “treatment” that can go on for years, regardless of whether it is effective.

Ambivalence about whether to bid $8 million for a painting is not likely a manifestation of a mental disorder, nor is the success of “treatment” likely to hinge on whether to give the patient permission to buy rather than force him to explore his anxiety. The mentally ill, wealthy or not, deserve effective treatment. The worried well are all too happy to pay someone with lofty status to listen to their complaints. Psychoanalysts like Drs. Stone and Karasu need only a few such patients to fill their practices.

If you are wealthy and need treatment that works, find a family or cognitive behavioral psychotherapist, or take psychiatric medication. They work just as well for the wealthy as for the rest of us.