Solo Private Practice Folks: How do you handle coverage?

[DrPembleton]

A work friend and I both have been thinking more about transitioning from a large organization to private practice. One of the things I get hung up on is coverage. With a W2 in a large organization, I punch in at 8 and punch out at 4 with no worries about getting called on nights/weekends. How does this work in a solo private practice? My colleague was thinking that it's sufficient to use the crisis line or present to the ED outside of clinical hours and for the psychiatrist to return non-urgent calls within 24-36 hours. I'm a bit skeptical about this. What is the standard of care here? Similarly, how do you handle vacations?

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[Ironspy]

That’s how things are done in most outpatient (not just psych) practices. If I need med refills my cardiologist asks for 3 business days to fill. The office responds to non urgent questions within 1-2 business days and they direct me to call 911 for emergencies

 

[romanticscience]

I have an auto-attendant set up for my office's main phone #. There is an option for (1) existing patients or healthcare providers to reach me for an urgent matter (1.2) which rings my phone. There is also an option to be connected to the local crisis line. When I'm on an airplane, I replace this number with a colleague's.

Nearly all of my patients utilize my EMR's patient portal messaging feature. I put an "away" message on this after hours, on weekends, and on holidays. However, for a 2-hour window on these days, I do sign on to answer any messages.

People tend to appreciate my availability. Somtimes, I have to set boundaries with people who abuse it.

For context, I have a solo micro-practice (~200 active patients) with a psychotherapy focus. I consider this sort of availability part of a Good Psychiatric Management therapeutic model that I provide.

 

[TexasPhysician]

After-hours/weekends: If not an emergency, I don’t call back at all. Staff will handle on Monday. I call someone outside of an appointment maybe 2x/month. This is because I prefer to have staff schedule urgent patients for a same day or next day follow-up rather than call.

Vacation: You need coverage if not available (cruises, out of country). If solo, find another solo psych and take turns. Alternatively pay another psych to handle coverage.

 

[comp1]

This kind of thing is why I am very much W2 for life.

 

[Sushirolls]

Clueless academic medicine states 24/7 coverage is a must...

Real world standard of care from ARNPs to even a Big Box shop with several Psychiatrists / ARNPs I worked at, emergencies are managed by patients toing to ED or UC, phones are responded to only during business hours.

I provide an after hours number just for patients detailing for urgent issues, and not emergencies, and outline what emergency options are. 911, crisis line, ED, psychiatric units, etc. In like 4-5 years I've only been called 2-3x after hours. Called some times during hours, which I shunted to assistant to address and clarified with patients don't call that number during hours. None were emergencies. One was geriatric patient unaware of what the number was for. Another was anxious patient who their cold was serotonin syndrome. Another was patient thinking it was main office number.

I take my phone and lap top with me on vacation. I check 1-3x a day the computer for messages. Frequently the cell phone for any transcribed cell phone messages.

When out of country I stay near WiFi to respond to E messages, and coordinate with assistant to be one to call patients. Haven't yet had need to call a patient while out of country, but with WiFi based phone calls, not expecting to be an issue. Same thing, check messages twice a day, and if on other side of the planet, yes I'll get up in the middle of the night if needed to coincide with business hours here to do my 1-3x a day check.

When hunting in the middle of nowhere, I diligently must keep my cell phone charged, and whenever in random pockets of cell coverage I'll check messages/emails etc. Can't tell you how many times I've been sitting on a mountain top in rain storm freezing my arse off thumbing a response to assistant or patient. As much as I might want to hunt from before sunrise to after sunset, I typically have messages or longer things that need typed out [and not thumb/cell phone done] so I return to hunting camp for lunch to do work. Once I was on a ridge line on windy day, sounded like I was at the beach, but had trees getting blown down around me cracking and smashing. When I'm packing an animal out, I've found doing a work check is a great excuse to catch my breath and also get a water break. LOL

The biggest issue I've had, is I must keep my cell phone on when sleeping. Typically on vibrate. So I can hear phone ring in middle of night. So I do get some sleep disruption from rare spam callers. Biggest disruption is friends in different time zones texting when they are awake, I'm asleep, and not I get woken up by their text message vibrations. This is the thing I look forward to the most in retirement years - phone off at night.

 

[Bartelby]

I have a very small private practice where the clinical care focuses mainly on psychotherapy patients. I provide my business cell phone number to all patients, which is just a Google Workspace number that rings directly to my cell phone. I am thus technically available 24/7. So far (in around two years) no one has called me with any overnight emergency. I also tell my patients that I respond to clinical messages by the next business day. Thus, even on vacation I log in each day Monday to Friday and respond to all messages in that single session (this takes around 15 minutes, sometimes less). I actually also cover my own Epic messages on vacation for my employed position because I find it much easier to respond to questions from my own panel than to cover and spend time sorting out how to respond to patients I don't know. By never asking others to cover my inbox, so far no one has asked me!

I believe that 24/7 availability *should* not be the standard of care, but I have not seen convincingly anywhere that it *is* not the standard of care. We are human beings who deserve to rest through the night, and anything that comes up at 3AM and could cause serious harm before the start of the next business day should be seen in an emergency room. With that said, I think that if your overnight and weekend coverage is a voicemail saying to go to the ER that there will certainly be people out there ready to make the case that this falls below the community standard of care. If anyone has real evidence addressing how courts would see that, I would love to see it.

But in brief, covering for yourself is one of the real downsides of private practice. It does mean you should not be intoxicated, unreachable, etc. in the unlikely event that a patient is urgently trying to reach you. On the flipside, you can pay another practice or a coverage company to provide coverage for your overnight/weekend calls, and I suspect doing so would be well within the standard of care. You can also find other practitioners in your area to rotate through this kind of call coverage.

 

[hamstergang]

For context, I have a solo micro-practice (~200 active patients) with a psychotherapy focus.

I'm sorry, but how would 200 patients with a psychotherapy focus be considered micro?

 

[Merovinge]

Clueless academic medicine states 24/7 coverage is a must...

Real world standard of care from ARNPs to even a Big Box shop with several Psychiatrists / ARNPs I worked at, emergencies are managed by patients toing to ED or UC, phones are responded to only during business hours.

I provide an after hours number just for patients detailing for urgent issues, and not emergencies, and outline what emergency options are. 911, crisis line, ED, psychiatric units, etc. In like 4-5 years I've only been called 2-3x after hours. Called some times during hours, which I shunted to assistant to address and clarified with patients don't call that number during hours. None were emergencies. One was geriatric patient unaware of what the number was for. Another was anxious patient who their cold was serotonin syndrome. Another was patient thinking it was main office number.

I take my phone and lap top with me on vacation. I check 1-3x a day the computer for messages. Frequently the cell phone for any transcribed cell phone messages.

When out of country I stay near WiFi to respond to E messages, and coordinate with assistant to be one to call patients. Haven't yet had need to call a patient while out of country, but with WiFi based phone calls, not expecting to be an issue. Same thing, check messages twice a day, and if on other side of the planet, yes I'll get up in the middle of the night if needed to coincide with business hours here to do my 1-3x a day check.

When hunting in the middle of nowhere, I diligently must keep my cell phone charged, and whenever in random pockets of cell coverage I'll check messages/emails etc. Can't tell you how many times I've been sitting on a mountain top in rain storm freezing my arse off thumbing a response to assistant or patient. As much as I might want to hunt from before sunrise to after sunset, I typically have messages or longer things that need typed out [and not thumb/cell phone done] so I return to hunting camp for lunch to do work. Once I was on a ridge line on windy day, sounded like I was at the beach, but had trees getting blown down around me cracking and smashing. When I'm packing an animal out, I've found doing a work check is a great excuse to catch my breath and also get a water break. LOL

The biggest issue I've had, is I must keep my cell phone on when sleeping. Typically on vibrate. So I can hear phone ring in middle of night. So I do get some sleep disruption from rare spam callers. Biggest disruption is friends in different time zones texting when they are awake, I'm asleep, and not I get woken up by their text message vibrations. This is the thing I look forward to the most in retirement years - phone off at night.

This is an incredibly detailed explanation for why human's are social animals and the value we can bring each other by forming relationships and helping one another. All the PP folks I know (which is many), have people that they share call with while on vacation, just letting patient's know that they are out of office for x amount of time and that Dr. soandso is covering.

 

[clausewitz2]

I'm with @Sushirolls . Has proven easier to just leave an auto response saying responses may be delayed compared to normal for such and such a period and then make a point of trying to log in briefly on a regular basis to deal with anything that's popped up. This has never taken more than 10-15 minutes at a go.

 

[comp1]

Wow, if a physician only got 3 after hours calls in 4 years...they must be amazingly good at selecting patients. That would be the first half of any given night at most big box shops.

 

[romanticscience]

I'm sorry, but how would 200 patients with a psychotherapy focus be considered micro?

I think I stole that description from direct primary care (DPC). I suppose a true micro practice in psychiatry is that of the psychoanalysts who see 13 total patients.

 

[clausewitz2]

Wow, if a physician only got 3 after hours calls in 4 years...they must be amazingly good at selecting patients. That would be the first half of any given night at most big box shops.

It's different when the patient population has not been socialized to believe that all problems must be resolved by an institution or larger system with no involvement or effort on their part. Folks seen in private practice tend to have had more experiences of their own efficacy in resolving difficulties and so have a much higher threshold to call. There are of course exceptions.

 

[finalpsychyear]

This kind of thing is why I am very much W2 for life.

Yes w2 is better lifestyle no question while 1099 you can hustle and probably retire in half the working years if one wanted.

 

[clozareal]

I think I stole that description from direct primary care (DPC). I suppose a true micro practice in psychiatry is that of the psychoanalysts who see 13 total patients.

13 patients may be a lot for psychoanalysts if they are seeing each patient 2-4 times per week.

 

[clozareal]

Yes w2 is better lifestyle no question while 1099 you can hustle and probably retire in half the working years if one wanted.

Business owners are willing to work 80 hours a week for themselves to avoid working 40 hours a week for someone else.

 

[finalpsychyear]

Business owners are willing to work 80 hours a week for themselves to avoid working 40 hours a week for someone else.

Pretty much. Most people won't want to work closer to 60hrs vs 40hrs even if it means 2x their income. I look at it as an opportunity cost to invest and escape the rat race in half the time. To me it's like a secret code in a video game that let's me move toward my goals twice as fast.

I still don't work nights or wknds clinically but i am often times doing something related to the business on the wknds that's for sure.
But I've always been the type to think why work average pace for 20 years if i can work sorta hard for 10 but still manage to enjoy myself

If the markets are on my side 2030 could be my swan song from medicine and i'd be mid 40s so i can still move.

 

[Sushirolls]

*My practice is about ~120 patients currently. Target is 300-400.
**I also have openings as a result of not being full and easy to just respond. Let's see each other in office I have openings as soon as 1, 2 days, etc.

 

[dl2dp2]

I think standard psychopharm practice (300 patients, etc) there's no after hour coverage or coverage is assumed by a call service that's not particularly helpful anyway, and emergencies are directed to the ER.

Smaller practices you might pick up after hours. Texts show up on my phone and people call me after hours or on weekends all the time and I almost NEVER respond unless they explicitly state emergency, which is extremely rare. In my almost a decade of practice, I can think of maybe a handful of instances. BPD patients have a hard time deal with this and proper boundaries are essential, but their calls are not emergencies and SHOULD wait for Monday morning.

Vacation coverage is necessary and you trade off with another PP psychiatrist.

 

[calvnandhobbs68]

This question comes up pretty frequently and different people approach this different ways.

There’s an answering service our group uses that takes calls and relays them to me after hours. It’s pretty infrequent and I have a pretty typical outpatient child psych panel where I see half hour visits every 1-3 months so several hundred active patients at any one time. I cover my own vacation although I haven’t gone out of the country yet….the calls are infrequent enough that it’s not really worth it to have to trade vacation coverage at this point.

I find the idea that we’re supposed to be available 24/7 ridiculous and again I think something psychiatrists agonize over for no good reason. Sure I’ll have some way to contact me after hours but doesn’t mean I’m gonna respond right away. We’re allowed to go have some drinks on the weekend and not be immediately coherent and available 24 hours a day. Most calls are either they should be going to the ER anyway or not actually urgent.

It’s something that you see variably in all other specialities too, even those that supposedly have “after hours” lines. My wife paged OB after hours for decreased fetal movement (an actual semi urgent concern) and got a call back like 4+ hours later by whoever was supposed to be “on”.

 

[splik]

The answer is, it depends. This is not just about the standard of care. It is also about what, if anything, your medical board thinks, and if you accept insurance. However, the standard has certainly evolved over time. There was a time when you were in fact expected to have 24/7 cover. This was what was taught in residency, and it was in part influenced by a forensic psychiatrist called Bob Simon who is now long dead and I would argue this idea has died with him.

Some insurance companies will stipulate in your contract that you do provide 24/7 coverage for your practice. If so, then you are in breach for not doing so. That is not really such a big deal but it is a liability issue if there is a bad outcome and you have deviated from your contractual obligations in a malpractice suit.

In California, the medical board is quite explicit that directing patients to the ER out of hours is in fact appropriate coverage for physicians. This may not be the case in all states, so you want to familiarize yourself with what your state medical board says. Most do not have any position on this matter.

Finally, you need to know what kind of practice you want to have. If you have a lot of high needs, higher acuity patients, then you do need to have appropriate out of ours coverage. If you are more selective about the patients you take then you do not. The important thing is to:
1. screen patients for your practice appropriately. This should be a continuous process, and you should terminate and refer out any patients who you are unable to meet their needs.
2. Clearly outline in your practice policies what your out of hours policies are. This should also make it clear what the expectations are about responding.
3. It is usually a good idea to make clear to patients (in writing and during sessions) that is NOT appropriate to send messages or emails about SI or other urgent matters.
4. When patients are in crisis, make clear expectations of your availability and contingency plans.
5. Redirect patients to the ER, 988 or other resources on your auto replies and voice mail when you are not available.
6. If the patient has a therapist, collaborate with the therapist and agree that they should be the first port of call for crises. Bear in mind you are still the "captain of the ship" and could be held responsible for the conduct of the therapists so try not to work with crappy therapists.

For those with cash practices and especially for concierge practices, you want to consider how much access/availability you have as part of your premium offerings. Patients may be paying more for that access and availability so you want to be clear about that and set appropriate expectations.

In my practice, I do accept a higher number of patients in crisis, recent hospitalizations, suicidal behavior and personality disorders than the average solo practice. Because I see patients on a regular basis, it is unusual for me deal with calls and messages after hours/at the weekend. When it happens it usually the same pts. This will prompt a conversation about increasing the frequency of treatment, or referral to a higher level of care (e.g. PHP, residential, hospitalization).

 

[Stagg737]

After hours/weekends/brief holidays ER/crisis for emergencies and 2-3 days for non-urgent response is pretty standard everywhere I've seen.

To those in true solo PP: what do you do when you go on longer (week or more) vacation? Do you log in or make calls every couple of days? Do you just tell patients you're gone from x-y dates and to take care of anything before that and otherwise good luck? Do you just not take vacations?

 

[Sushirolls]

I'm in true solo. See my post above.

 

[Dr. Pookie]

I am leaning towards covering for myself like @Sushirolls. Change voicemail prompt to let patients know I'm away and will respond to all portal messages on Tuesdays and Fridays. Low-acuity medication practice with a small panel of psychotherapy cases.

One issue I recently came upon is that of controlled substance prescriptions while abroad. My understanding is that this is not permitted by the DEA. Thus, for a prolonged vacation abroad, I plan to run through my patient census and authorizing any upcoming refills for controls prior to leaving. Does anyone do anything differently for controls (in the case that a refill is needed before the next follow-up for whatever reason)?

 

[clausewitz2]

I am leaning towards covering for myself like @Sushirolls. Change voicemail prompt to let patients know I'm away and will respond to all portal messages on Tuesdays and Fridays. Low-acuity medication practice with a small panel of psychotherapy cases.

One issue I recently came upon is that of controlled substance prescriptions while abroad. My understanding is that this is not permitted by the DEA. Thus, for a prolonged vacation abroad, I plan to run through my patient census and authorizing any upcoming refills for controls prior to leaving. Does anyone do anything differently for controls (in the case that a refill is needed before the next follow-up for whatever reason)?

For what it is worth, the restriction on controlled substances from outside of the United States appears to have been part of the package of proposed DEA rules for telehealth controlled substance prescribing from early last year that went down in flames. I would not be surprised if it is not revived, but in any event we should have plenty of notice of this.

 

[smalltownpsych]

I have been running a therapy practice for a couple of years. It's cash pay so i offer increased availability with an after-hours phone and some select patients can text me directly, and I always have plans for patients with higher needs. Had a psychiatric NP in practice for a period of time and the after-hours phone was ringing off the hook. Most of the time, it was due to poor planning around refills and not exactly a crisis. I work with a very high acuity population and also have a relationship with a crisis intervention team if patients need extra support as a step prior to hospitalization. That is a costly service though so only a few patients utilize that, but it is one way to keep people out of institutional settings.

 

[ObsequiousAplomb]

I'm one of the early solo people here. I have 30 patients, though 6 of those are weekly therapy. I gave as many people as necessary paper prescriptions with "do not fill until" dates on them at their last appointment. I'm taking my work phone with me but only checking it once per day. It gives me push notifications (which will be silent, in the background) if I get a portal message. I have in my policies that I take vacations from time to time so they should never expect a rapid response to portal messages, we discuss emergency / contingency plans at initial appointment and subsequent appointments. Honestly, none of these people ever reach out to me in crisis. If they do, it's to schedule an appointment. They're all used to psychiatrists with much longer spaces in their schedules between available appointments. They never seem to notice when I don't have available hours for 6 days in a row. Maybe they just think I'm busier than I am. The weekly people all get a heads up that the appointment will be cancelled a while in advance.

 

[TexasPhysician]

The most common issue that I’ve seen with this is board complaints. Say a bipolar patient lost their medication and calls for an urgent refill. It is probably appropriate to refill it. Patient calls and leaves a VM. If on a cruise for a week or out of the country, there needs to be a way to address this.

If this patient files a board complaint, many psychiatrists would find that ignoring this for a week is below the standard of care. If you can check this and send a refill from wherever you are, I don’t see an issue.

 

[calvnandhobbs68]

After hours/weekends/brief holidays ER/crisis for emergencies and 2-3 days for non-urgent response is pretty standard everywhere I've seen.

To those in true solo PP: what do you do when you go on longer (week or more) vacation? Do you log in or make calls every couple of days? Do you just tell patients you're gone from x-y dates and to take care of anything before that and otherwise good luck? Do you just not take vacations?

I’m basically solo for coverage purposes, the group is mostly therapists with a couple other adult psychiatrists who are also independent contractors and we don’t cover for each other at the moment. I use their answering service (which is basically just a service that takes a message and then calls me) for after hours calls.

I just cover myself during vacations. My admin assistant still takes messages and I check them about once a day. It’s honestly not even worth it at this point to “trade” routine coverage with someone else because I’m rarely somewhere where I can’t check internet once a day and tell my assistant what to do with messages she needs to respond to and do whatever refills come up. Even cruises you can usually buy packages that include enough internet that you can login to an EMR and refill meds.

I agree that totally leaving patients high and dry for a week is a bad look but again there are plentyyyy of practices that barely respond to refill messages when they’re in the office much less on vacation.

 

[Stagg737]

So basically check-ins to address messages and give refills while on vacation. For someone like me who loathes inboxes/messages this sounds awful. Dealing with messages about medication side effects or SI would just stress me out when I'm supposed to be caring for myself and spending time with family. Hard pass.

 

[Merovinge]

So basically check-ins to address messages and give refills while on vacation. For someone like me who loathes inboxes/messages this sounds awful. Dealing with messages about medication side effects or SI would just stress me out when I'm supposed to be caring for myself and spending time with family. Hard pass.

Completely agree, which is why people trade coverage with colleagues in PP. You want to have folks in your circle to bounce cases, legal issues, etc off of anyway. Even filling out a paper script or adding someone to your Erx is a few minute endeavor on a work day vs taking a break from the world that is needed on vacation.

 

[Candidate2017]

So basically check-ins to address messages and give refills while on vacation. For someone like me who loathes inboxes/messages this sounds awful. Dealing with messages about medication side effects or SI would just stress me out when I'm supposed to be caring for myself and spending time with family. Hard pass.

My resident clinic was like a solo PP because the staff was useless. To cut down on getting swamped with messages, I explained to patients how to contact me (phone only) and when to expect a reply, my refill policies, what benign side effects to expect, side effects for which they need to go to the ER, and symptoms of decompensation requiring, you guessed it... going to the ER. I got less than 10 afterhours calls, the majority related to covering other residents. The 3-4 afterhours calls from my panel was mainly new patients very anxious about possible side effects from the Lexapro 5 mg they started today, or that one patient on a benzo taper who always asks for early refills.

It's our job to explain what is an emergency and what to do. At the end of the day, 24/7 coverage is silly. No one calls their cardiologist in the middle of the night for chest pain. If the cardiologist is getting called, it's because he's in the cath lab. Me, what am I gonna do? Hey, double up your Lexapro to 10 mg stat, and I'm coming in to H&P you!

If someone is abusing the system, then they need to be therapeutically discharged and form a relationship with the local Big Box shop wher they can be appropriately serviced by a "therapist" who shoots the breeze and a "provider" who writes whatever the patient wants.

 

[calvnandhobbs68]

So basically check-ins to address messages and give refills while on vacation. For someone like me who loathes inboxes/messages this sounds awful. Dealing with messages about medication side effects or SI would just stress me out when I'm supposed to be caring for myself and spending time with family. Hard pass.

Yeah just depends on what you want to do and how needy your patient population is conditioned to be but you have to cover that stuff somehow. I maybe get one or two messages the whole week I actually have to do anything about besides tell my admin assistant to tell them to schedule an appt or is just a refill thing I do in my eRx.

Not worth it from my end to have to trade off with someone else with possibly a totally different practice style in terms of availability for patients or neediness of patient population. I also have no problem spending the day chilling out and not worrying about messages lol. Everyone has their own preference with this though.

 

[ObsequiousAplomb]

So basically check-ins to address messages and give refills while on vacation. For someone like me who loathes inboxes/messages this sounds awful. Dealing with messages about medication side effects or SI would just stress me out when I'm supposed to be caring for myself and spending time with family. Hard pass.

I get that.
One of the benefits to private practice is the ability to screen out patients who would ruin a vacation like that. With the right panel, this type of thing is rare enough that it's not upsetting. At least for now. This is a lesson I'm currently learning the hard way.

 

[Dr. Pookie]

I’m basically solo for coverage purposes, the group is mostly therapists with a couple other adult psychiatrists who are also independent contractors and we don’t cover for each other at the moment. I use their answering service (which is basically just a service that takes a message and then calls me) for after hours calls.

I just cover myself during vacations. My admin assistant still takes messages and I check them about once a day. It’s honestly not even worth it at this point to “trade” routine coverage with someone else because I’m rarely somewhere where I can’t check internet once a day and tell my assistant what to do with messages she needs to respond to and do whatever refills come up. Even cruises you can usually buy packages that include enough internet that you can login to an EMR and refill meds.

I agree that totally leaving patients high and dry for a week is a bad look but again there are plentyyyy of practices that barely respond to refill messages when they’re in the office much less on vacation.

Have you ever had issues with sending controls while outside the US? For example, when you're on a cruise? I'm not sure why this would be an issue - especially if you have an established relationship with patients receiving controls and did at least one in-person evaluation. I didn't even think this was a potential issue until I read the DEA 2023 proposed telemedicine report. It seems silly to try and get coverage from another psychiatrist just to refill controls...

 

[calvnandhobbs68]

Have you ever had issues with sending controls while outside the US? For example, when you're on a cruise? I'm not sure why this would be an issue - especially if you have an established relationship with patients receiving controls and did at least one in-person evaluation. I didn't even think this was a potential issue until I read the DEA 2023 proposed telemedicine report. It seems silly to try and get coverage from another psychiatrist just to refill controls...

I’m not sure how anyone would know unless you had an EMR or prescription program that restricted that for some reason…it’s not like the program tells the pharmacy your current location.

 

[Ironspy]

Have you ever had issues with sending controls while outside the US? For example, when you're on a cruise? I'm not sure why this would be an issue - especially if you have an established relationship with patients receiving controls and did at least one in-person evaluation. I didn't even think this was a potential issue until I read the DEA 2023 proposed telemedicine report. It seems silly to try and get coverage from another psychiatrist just to refill controls...

A number of eRx platforms do not work outside the US. You can use a vpn

 

[Stagg737]

Yeah just depends on what you want to do and how needy your patient population is conditioned to be but you have to cover that stuff somehow. I maybe get one or two messages the whole week I actually have to do anything about besides tell my admin assistant to tell them to schedule an appt or is just a refill thing I do in my eRx.

Not worth it from my end to have to trade off with someone else with possibly a totally different practice style in terms of availability for patients or neediness of patient population. I also have no problem spending the day chilling out and not worrying about messages lol. Everyone has their own preference with this though.

I get that.
One of the benefits to private practice is the ability to screen out patients who would ruin a vacation like that. With the right panel, this type of thing is rare enough that it's not upsetting. At least for now. This is a lesson I'm currently learning the hard way.

Sure. I'd be willing to bet that plenty of PPs screen out disaster patients who end up at academic programs, CMHCs, or pill mills. It's probably the nature of the outpatients I've worked with (VA, CMHC, telehealth consultation for the rural half of a state) but I can't imagine not having at least a couple of patients at a time who aren't high maintenance. Even with decent screening. I've encountered plenty of patients who looked and sounded fine and then 3-4 appointments in the baggage starts getting unloaded. Where I've been at coverage by and for others has basically been answering basic questions, following basic instructions from previous notes (sure, increase the Remeron to 15mg...), or telling them to go to the ER.

My resident clinic was like a solo PP because the staff was useless. To cut down on getting swamped with messages, I explained to patients how to contact me (phone only) and when to expect a reply, my refill policies, what benign side effects to expect, side effects for which they need to go to the ER, and symptoms of decompensation requiring, you guessed it... going to the ER. I got less than 10 afterhours calls, the majority related to covering other residents. The 3-4 afterhours calls from my panel was mainly new patients very anxious about possible side effects from the Lexapro 5 mg they started today, or that one patient on a benzo taper who always asks for early refills.

It's our job to explain what is an emergency and what to do. At the end of the day, 24/7 coverage is silly. No one calls their cardiologist in the middle of the night for chest pain. If the cardiologist is getting called, it's because he's in the cath lab. Me, what am I gonna do? Hey, double up your Lexapro to 10 mg stat, and I'm coming in to H&P you!

If someone is abusing the system, then they need to be therapeutically discharged and form a relationship with the local Big Box shop wher they can be appropriately serviced by a "therapist" who shoots the breeze and a "provider" who writes whatever the patient wants.

Sounds like you were fairly lucky in residency. I spent extensive time explaining things to patients (to the point that attendings said I was excessively thorough) and still dealt with almost daily messages. My clinic also became notorious as the resident clinic with a disproportionate number of Cluster B patients, but still. I agree that 24/7 coverage is completely unnecessary for psych and if there's and "emergency" they need to just go to an ER. That doesn't stop patients from trying to call though, and maybe it's just because I'm C/L at a large academic center but I've had plenty of inpatients tell me they were admitted after calling their doc after hours and being told to go to the ER.

I'll also push back a bit on the last point. Probably has to do more with the big box shops where I'm at (almost) all being academic centers, but what you're describing sounds more like the CMHCs that are basically run by NPs and 3-4 PPs that are the local candy shops.

 

[calvnandhobbs68]

A number of eRx platforms do not work outside the US. You can use a vpn

That's true. TunnelBear is free for 2GB of data a month which is plenty for eRx scripts and even EMRs.

 

[SmallBird]

After-hours/weekends: If not an emergency, I don’t call back at all. Staff will handle on Monday. I call someone outside of an appointment maybe 2x/month. This is because I prefer to have staff schedule urgent patients for a same day or next day follow-up rather than call.

Vacation: You need coverage if not available (cruises, out of country). If solo, find another solo psych and take turns. Alternatively pay another psych to handle coverage.

How much?