House Calls

The other day, I was scooting around a Google map of Manhattan, trying to find The Doughnut Plant, which makes the best coconut cream yeasted doughnut ever. And as I was virtually strolling along 23rd street, I saw this:

House Call Psychiatrists. Hmm. I couldn't help checking out their website.

From their home page:

House Call Psychiatrists is a network of board certified and licensed psychiatrists with extensive experience making psychiatric home visits.  They are available 24 hours a day, 7 days a week for convenient and private house calls within Manhattan, Brooklyn, Queens and North Jersey.

House Call Psychiatrists offer a unique and high level service in the convenience of your home, office or hotel room. They are able to address most psychiatric issues in a timely and private manner avoiding other urgent care centers and hospital emergency rooms.

There's an interesting idea. It's a bit different from TalkSpace, a texting therapy service which I posted about previously. Some of the things I didn't like about TalkSpace were that it's not in-person treatment, and there's no delayed gratification like there is when you have to wait for your appointment.

But these are house calls. So you do have to make an appointment, even if it happens to be in the middle of the night. And it is in-person.

Here's some more information.

There are 7 psychiatrists on the team, all men. A general psychiatrist, two addiction psychiatrists, a bipolar specialist, a geriatric specialist (who doesn't seem to be board certified in gero-psych, so I guess that's why they don't call him a geropsychiatrist), a community psychiatrist, and an anxiety specialist.

Thinking about the "extensive experience making psychiatric home visits," I'm skeptical. How would they get that extensive experience? I can remember my pediatrician coming to my house, but nothing since then-who makes house calls anymore?

"Our psychiatrists have been making house calls for many years on Assertive Community Treatment (ACT) teams which are home-based psychiatric outreach programs.  They are also psychiatric emergency room physicians with admitting privileges to..."

ACT house calls seem very different to me than the house calls they're talking about here. For one thing, ACT is a team, and sees patients as such. Here, my impression is that this is 1 to 1 care. For another, most patients in ACT treatment can't afford the $500 fee that House Call Psychiatrists charge. Or $1000 from 8pm to 8am.

I'm trying to understand the model. I assume they cover for each other, and that someone is always on call.

All the the psychiatrists seem to have separate private practices that provide more typical office visits. Some of their websites indicate that they will also make house calls, but at the $500 rate, rather than their regular rates, which are less. Does this mean that the House Call Psychiatrists only see established patients? I don't get that impression.

They also offer to see patients in their hotel rooms, which implies that they may be visiting NYC, and therefore not established patients.

The house call services provided are:

This makes me wonder about liability. If they provide crisis intervention and safety checks, then they may end up seeing a patient they don't know who is suicidal. What if that patient needs to be hospitalized but refuses to go? One of the individual psychiatrist's websites states that he does make house calls, but that, "A home visit should not replace calling 911 if you are having an emergency." That confuses me.

My fantasy about this model is that some wealthy person feels like he needs to see a psychiatrist, but he is either visiting NYC, or lives here but doesn't want to go to anyone's office. I imagine this as happening in the middle of the night, with patients who suffer from insomnia (they state they treat sleeping difficulties), or who are having panic attacks. Or maybe it's during the day, but it's some CEO who wants his shrink to come to him.

I'm really not sure what to think about this model. I know I wouldn't make house calls with my patients, but my practice has a certain nature that doesn't lend itself to this model. Also, I don't fancy wandering into a stranger's hotel room in the middle of the night, knowing that there's a psychiatric problem.

Home visits are a great idea for patients who function poorly and would be lost to care if they weren't followed by an ACT team, for example. But patients who can afford $500 fees presumably function fairly well. (Incidentally, no insurance is accepted, and the fee is prepaid at each visit via credit card.)

I think that for one-off panic attacks, home visits are probably not a good idea, because they maintain the message that the patient can't manage on his own and tolerate some delayed gratification, similar to TalkSpace.

For naltrexone injection or genetic testing, maybe it does make sense for the shrink to come to your office.

For ongoing therapy, I don't know. Is there some benefit to making time during the day to travel to the shrink's office? Is there a power struggle that gets settled by default when the shrink comes to you? Does it violate the important frame of a treatment to have it in your home, or does it just create a different frame?

I have a lot more questions than answers. What do you think?

New App-Pager

I saw an ad on the subway today for a new app called, "Pager". You download the app, input your info, and then you can report any symptoms you might be having, and get a doctor to make a house call within 2 hours.

That's right! The new innovation in medicine is house calls.

The app was designed by the same people who brought you Uber, the taxi summoning app. Which makes sense. In case you're interested, and I must say I'm intensely interested in this, here's a Wall Street Journal article about Pager from back in May.

But today was the first ad I'd seen for it, and I ride the subway every day.

I did the instant chat thing with Michelle from Pager when I checked out the site, because I was curious about a few things. Here are the screen shots:

Okay, so it's not foolproof, but they do have some way of addressing safety concerns.

I asked about safety because I remember my doctor making house calls when I was a kid, but this was someone with whom my family and I had a long-established relationship. Not a stranger.

I asked about Gyn just to be challenging. And I asked about Psych to see what they would say, and if I could potentially work there one day. Not that that's my current plan, but I do think this is a much more promising venue than telemedicine. These are real medical visits, with real physical exams. Wounds can be sutured, school physicals dealt with, flu shots given, labs ordered and followed up, prescriptions written.

I was thinking about this in comparison with Urgent Care centers, and for reasons I  can't really justify, I prefer this system. I somehow have the sense that if I walk into an urgent care center, I'll end up dealing with someone who has less training and knowledge than I do, and I'll be frustrated and walk out. I'm not sure why a doctor working for Pager would be any different, except that, at least according to the WSJ article, doctors do this to supplement their incomes, and to avoid the frustration of working at insurance based clinics. Somehow that seems more reasonable, or at least more in line with my approach. But I'd be interested to hear other people's thoughts.

Pager is $50 for a call or text that does not require in-person follow up, $199 for a weekday house call, and $299 for a weekend/evening house call. I believe it's only available in Manhattan, currently. I'm also not sure what the time limit is for a house call. Pager will provide you with appropriate bills to submit to insurance.

The site seemed reasonably responsible in weeding out emergencies, which was reassuring. It also seemed really suitable for someone visiting NYC and staying in a hotel.

Is this the future of medicine? Surely not the future of Psychiatry-house calls are kinda off limits for the way I practice. But Pager has an option for telemedicine, so maybe it could be tele-psychiatry, with an option for in-person follow-up if necessary. Sounds confusing, but better than run-of-the-mill distance psychiatry.

I did download the app. It required my name (false), email, cell number, and photograph, which it claims to need. It requires a credit card to set up an appointment, but not for plain old registration. I entered my office location, but I couldn't figure out how to access a list of local doctors without entering my current symptoms. Maybe I'll try that out.