Moviedoc is thinking about two of the same things that I am:

• Could I do more telepsychiatry at home and think about making part time arrangements for office space rather than full time ones?
• If I only have part time office space, how do I handle emergencies where I really feel I should see the patient, not just talk or video Skype him or her?

He does ask one question though, that I think that I know the answer to. He wants to know a good way to manage scheduling office space online. I would suggest webcalendar on some hosting provider. The security is easy to set up, and although it isn’t customized for mobile phones, it really makes it easy to coordinate scheduling among people who have to do this already, as long as you make a couple of ground rules for how to use it.

Up until now, one of the key issues for me was that I sometimes need to see someone for an emergency visit, and, because my office and my residence are within walking distance of each other, I’ve seen patients, at various times, on every day of the week.

Last week something happened that made me realize that I don’t  need access to an office seven days a week. I needed to have a session with someone and just did telepsychiatry from my home office rather than my practice office.

I think it may be a little in the future, but I can see a time when I might be able to handle more and more of my emergencies by Skype rather than having to go into my office.

This is a little tricky because some emergencies are clearly better handled face-to-face rather than via Skype, but my experience last week made me realize that as telepsychiatry develops, a different business plan might make more sense for my practice. Right now, my office is sitting empty most of the time, and I can see how a group of psychiatrists doing telepsychiatry could easily get together, rent some space for face-to face-visits with  individual patients, and do more and more of their work out of their home rather than their practice office. The default could be telepsychiatry, with office visits no longer being the norm.

Rent is a pretty significant part of my overhead, and cutting it by 50%, say, would really be something worth thinking about.

Psychiatrists (and mental health workers in general) have always had a somewhat different relationship to hospitals and other institutions than other professionals. A surgeon pretty much has to have some relationship with a hospital, and can’t really do surgery without some kind of team behind him or her. Mental health work is different. The institution doesn’t tend to do much for psychiatrists seeing outpatients (as opposed to inpatients) other than feed them patients and, ideally, do enough work for the psychiatrist to justify the overhead that the institution adds.

I’ve been in a lot of situations where the overhead from the institution (rules, regulations, meetings, visits from JHAHO, fees for administrative services, poor collection policies) far far exceeded the value they brought to the outpatient setting.

I’m not trying to say that institutions don’t provide some value on the inpatient side, because clearly they do, but one of the best things about a solo private practice with no employees other than myself is that my overhead is much less than I think it would be if I were attached to some institution.

Telepsychiatry might just bring that overhead down some more. I need to think about setting up my home office a little better than it is….