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Taking an extended leave: What to do before you go
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Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.1 However, an anticipated leave allows for advanced planning that can help ease transfer of care.
A smooth transition
Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.
It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.
Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.
Disclosure
Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.
Reference
1. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992;47(3):82-84.
Discuss this article at www.facebook.com/CurrentPsychiatry
Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.1 However, an anticipated leave allows for advanced planning that can help ease transfer of care.
A smooth transition
Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.
It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.
Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.
Disclosure
Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.1 However, an anticipated leave allows for advanced planning that can help ease transfer of care.
A smooth transition
Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.
It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.
Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.
Disclosure
Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.
Reference
1. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992;47(3):82-84.
Reference
1. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992;47(3):82-84.
How to prepare patients for your maternity leave
Although a psychiatrist’s pregnancy can disrupt the continuity of a patient’s care, it also may be a catalyst for patients to address key therapeutic issues. Working with patients in advance can help ensure that they take advantage of this unique therapeutic opportunity.
How a patient reacts to a psychiatrist’s pregnancy depends on the patient’s personality structure and personal experiences,1 the depth of his or her relationship with the doctor, and how the psychiatrist addresses her pregnancy in the therapeutic context. For example, patients who fear abandonment may act out in unconscious anger at the clinician.1 They may create crises that demand the doctor’s attention, call more often or schedule more appointments than usual, miss appointments, or stop engaging therapeutically. Previously compliant patients may stop following treatment recommendations, including taking prescribed medication.
In contrast, many patients may react warmly to news of their psychiatrist’s pregnancy. They may ask questions about her family life and the baby. Although in some cases these warm feelings may be a patient’s attempt to defend against resentment of the pregnancy, often they can be taken at face value. Patients who are mothers may identify with and feel increased solidarity with pregnant physicians.2 Pregnant patients may feel greater comfort with pregnant psychiatrists, assuming that the clinician may be more closely attuned to their treatment needs.
Pregnant psychiatrists should explore the meaning of their pregnancies with patients. A clinician may be reluctant to do so because she fears her patients may become angry or because of fatigue associated with pregnancy. However, failing to explore what the pregnancy means to patients may prevent them from taking advantage of an opportunity to work through conflicts,2 such as sibling rivalry1 or body image issues for patients with eating disorders. It also can bring up issues related to sexuality, parenthood, and fertility.1
Pregnant psychiatrists should set a date by which they make all patients aware of the pregnancy.2 This will allow time to explore the meaning of the pregnancy and to plan for how the patient’s treatment needs will be met during the leave.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Although a psychiatrist’s pregnancy can disrupt the continuity of a patient’s care, it also may be a catalyst for patients to address key therapeutic issues. Working with patients in advance can help ensure that they take advantage of this unique therapeutic opportunity.
How a patient reacts to a psychiatrist’s pregnancy depends on the patient’s personality structure and personal experiences,1 the depth of his or her relationship with the doctor, and how the psychiatrist addresses her pregnancy in the therapeutic context. For example, patients who fear abandonment may act out in unconscious anger at the clinician.1 They may create crises that demand the doctor’s attention, call more often or schedule more appointments than usual, miss appointments, or stop engaging therapeutically. Previously compliant patients may stop following treatment recommendations, including taking prescribed medication.
In contrast, many patients may react warmly to news of their psychiatrist’s pregnancy. They may ask questions about her family life and the baby. Although in some cases these warm feelings may be a patient’s attempt to defend against resentment of the pregnancy, often they can be taken at face value. Patients who are mothers may identify with and feel increased solidarity with pregnant physicians.2 Pregnant patients may feel greater comfort with pregnant psychiatrists, assuming that the clinician may be more closely attuned to their treatment needs.
Pregnant psychiatrists should explore the meaning of their pregnancies with patients. A clinician may be reluctant to do so because she fears her patients may become angry or because of fatigue associated with pregnancy. However, failing to explore what the pregnancy means to patients may prevent them from taking advantage of an opportunity to work through conflicts,2 such as sibling rivalry1 or body image issues for patients with eating disorders. It also can bring up issues related to sexuality, parenthood, and fertility.1
Pregnant psychiatrists should set a date by which they make all patients aware of the pregnancy.2 This will allow time to explore the meaning of the pregnancy and to plan for how the patient’s treatment needs will be met during the leave.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Although a psychiatrist’s pregnancy can disrupt the continuity of a patient’s care, it also may be a catalyst for patients to address key therapeutic issues. Working with patients in advance can help ensure that they take advantage of this unique therapeutic opportunity.
How a patient reacts to a psychiatrist’s pregnancy depends on the patient’s personality structure and personal experiences,1 the depth of his or her relationship with the doctor, and how the psychiatrist addresses her pregnancy in the therapeutic context. For example, patients who fear abandonment may act out in unconscious anger at the clinician.1 They may create crises that demand the doctor’s attention, call more often or schedule more appointments than usual, miss appointments, or stop engaging therapeutically. Previously compliant patients may stop following treatment recommendations, including taking prescribed medication.
In contrast, many patients may react warmly to news of their psychiatrist’s pregnancy. They may ask questions about her family life and the baby. Although in some cases these warm feelings may be a patient’s attempt to defend against resentment of the pregnancy, often they can be taken at face value. Patients who are mothers may identify with and feel increased solidarity with pregnant physicians.2 Pregnant patients may feel greater comfort with pregnant psychiatrists, assuming that the clinician may be more closely attuned to their treatment needs.
Pregnant psychiatrists should explore the meaning of their pregnancies with patients. A clinician may be reluctant to do so because she fears her patients may become angry or because of fatigue associated with pregnancy. However, failing to explore what the pregnancy means to patients may prevent them from taking advantage of an opportunity to work through conflicts,2 such as sibling rivalry1 or body image issues for patients with eating disorders. It also can bring up issues related to sexuality, parenthood, and fertility.1
Pregnant psychiatrists should set a date by which they make all patients aware of the pregnancy.2 This will allow time to explore the meaning of the pregnancy and to plan for how the patient’s treatment needs will be met during the leave.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Sensible use of e-mail in clinical practice
As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.
Advantages
For you, e-mail’s advantages include:
- decreased “phone tag” with patients
- ability to respond to requests at your convenience
- an automatically generated medical record1
- easy distribution of handouts and references to patients, eliminating the need to store paper copies.
E-mail’s advantages for patients include:
- increased satisfaction and participation in care
- convenience
- better understanding of instructions that can be reread vs verbal information that might not be recalled.
For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.
E-mail guidelines
Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:
- a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes2
- a breach of duty that results in harm to the patient.
Don’t diagnose or treat by e-mail
Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.2 This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.
For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.
For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.
Set e-mail boundaries
Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.3
Table
6 strategies to minimize liability when using e-mail
| Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people |
| Avoid establishing new patient-physician relationships via e-mail |
| Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency |
| Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information |
| Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive |
| Include e-mail in the medical record |
| Source: Reference 3 |
Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.
1. Spielberg AR. On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA. 1998;280:1353-1359.
2. Recupero PR. E-mail and the psychiatrist-patient relationship. J Am Acad Psychiatry Law. 2005;33:465-475.
3. American Medical Association. Guidelines for physician-patient electronic communications. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml. Accessed June 11, 2009.
As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.
Advantages
For you, e-mail’s advantages include:
- decreased “phone tag” with patients
- ability to respond to requests at your convenience
- an automatically generated medical record1
- easy distribution of handouts and references to patients, eliminating the need to store paper copies.
E-mail’s advantages for patients include:
- increased satisfaction and participation in care
- convenience
- better understanding of instructions that can be reread vs verbal information that might not be recalled.
For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.
E-mail guidelines
Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:
- a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes2
- a breach of duty that results in harm to the patient.
Don’t diagnose or treat by e-mail
Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.2 This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.
For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.
For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.
Set e-mail boundaries
Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.3
Table
6 strategies to minimize liability when using e-mail
| Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people |
| Avoid establishing new patient-physician relationships via e-mail |
| Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency |
| Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information |
| Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive |
| Include e-mail in the medical record |
| Source: Reference 3 |
Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.
As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.
Advantages
For you, e-mail’s advantages include:
- decreased “phone tag” with patients
- ability to respond to requests at your convenience
- an automatically generated medical record1
- easy distribution of handouts and references to patients, eliminating the need to store paper copies.
E-mail’s advantages for patients include:
- increased satisfaction and participation in care
- convenience
- better understanding of instructions that can be reread vs verbal information that might not be recalled.
For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.
E-mail guidelines
Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:
- a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes2
- a breach of duty that results in harm to the patient.
Don’t diagnose or treat by e-mail
Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.2 This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.
For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.
For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.
Set e-mail boundaries
Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.3
Table
6 strategies to minimize liability when using e-mail
| Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people |
| Avoid establishing new patient-physician relationships via e-mail |
| Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency |
| Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information |
| Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive |
| Include e-mail in the medical record |
| Source: Reference 3 |
Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.
1. Spielberg AR. On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA. 1998;280:1353-1359.
2. Recupero PR. E-mail and the psychiatrist-patient relationship. J Am Acad Psychiatry Law. 2005;33:465-475.
3. American Medical Association. Guidelines for physician-patient electronic communications. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml. Accessed June 11, 2009.
1. Spielberg AR. On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA. 1998;280:1353-1359.
2. Recupero PR. E-mail and the psychiatrist-patient relationship. J Am Acad Psychiatry Law. 2005;33:465-475.
3. American Medical Association. Guidelines for physician-patient electronic communications. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml. Accessed June 11, 2009.