Telepsychiatry: First Week in the Trenches

In spite of the minor mishaps of my first week, outlined below, it has become clear to me that telepsychiatry can be a viable, valuable, and timely addition to our psychiatric lives and that of our patients.

Telepsychiatry, from home
I begin my first week of my new job as a full-time telepsychiatrist, working for the Green Bay VA Hospital in Green Bay, Wisconsin.

Day 1
The basement, my new office, is far colder than I ever imagined. I have donned a Polartec® jacket for warmth. My fingers are tingling. I’m thinking of putting on a knit cap. When I turn on the electric baseboard heater, which we have never used in our 17 years in the house, things start to warm up.

Then, I sense the strong smell of something burning. Then, the fire alarm system goes off-not just in the basement, but throughout the house-after I had dutifully linked all the fire alarms in the house to go off at once! I hear the footsteps of my obviously startled son and his girlfriend, home from Texas, on the floor above me as the alarm wakes them. Fortunately, there are no open flames.

Later, while seeing a patient, I realize that there is a stream of warm air coming from the side of the laptop on the right side of my desk. Slowly I start to slide my hands towards the warmth as I talk, hoping to warm up my freezing fingers. I suddenly realize that the patient can tell I’m doing something with my hands, but he can’t tell what I’m doing, because my hands are outside of his field of vision. An awkward moment of silence occurs. I slowly pull my hands back towards me. Grist for the mill.

Day 2
I must not look into the mirror very often. In a small window in the corner of my monitor, as I talk with my patients, there is some old guy who seems abnormally animated staring at me. Wait! That’s me, looking back at me! What happened? The last time I looked at myself, I had a lot more hair and I looked at least 15 years younger! This is not pleasant. I also notice that I have a tendency to lean towards my patient when I talk-something I was unaware of until now.

When I lean in on my telepsychiatry system, my head suddenly looms large and fills the screen that the patient sees. It must look like Shrek coming out of the woods. I consider whether my patients might enjoy having 3D glasses so my head will appear to bulge out into the room towards them. It might work as a sort of a Rorschach test, to better assess their startle response.

Day 3
I’m considering writing a movie script, a sort of sequel to “Home Alone,” about a psychiatrist whose parents accidentally leave him home alone. (Wait, that won’t work!)

It’s frighteningly quiet here when I’m not seeing a patient. I think up a ruse, and call the nurse I used to work with, ostensibly with a valid question. I think she sees through me. She’s probably thinking: “Here we go. He’s been home alone for less than a week, and he’s losing it.” I’m fearful that she might be correct.

I’ve always known that interacting with other staff was a big part of my job satisfaction, but that fact is being driven home with painful clarity. I start flipping through the job ads at the back of Psychiatric Times. Prison psychiatry is looking like a viable option for the first time ever. At least there would be someone to talk with!

Day 4
I realize I forgot to shave yesterday morning, and didn’t notice until this morning. Is that it? Is that the beginning of the decline? Will they find me some day looking like Howard Hughes, unshaven, fingernails growing in long curves back into the pads of my fingers? How long will it take the technician on the other end of the system to recognize that I’ve gone over the edge?

There’s a shortage of psychiatrists, I tell myself: I can probably keep working even if I start wearing pajamas and carry a teddy bear to my basement office. I’ll get a short stool to prop the teddy bear up, just under the line of sight of the camera. He can keep me company. It will be good to not be alone.

Day 5
I’m painfully reminded of the old adage: Be careful what you ask for-you might get it! Taking this telepsychiatry job, and leaving the warm comfort zone of my old job, has been like jumping off a cliff; heading off to college; hopping a freight car. It’s a big shake-up at a time when I could have coasted along for another 5 or 10 years and never even dusted off my office bookshelf. It’s the kind of thing I sometimes encourage my patients to do: get out of your comfort zone.

I can feel the stress this change causes, but I keep telling myself this is how we move forward.

Of course, as a psychiatrist, I know jumping off a cliff doesn’t always turn out well. Sometimes you land on a new ledge filled with new challenges. Sometimes you . . . don’t land on a new ledge filled with new challenges. I time the mail delivery perfectly to get a chance to chat with the letter carrier. “How’s the new job?” she asks. “Too early to tell,” I respond, deciding that honesty is the best policy. “Too early to tell.”

Postscript
Despite the growing pains of my first week, I have come to discover that telepsychiatry serves to address the lack of access to psychiatric care that is such a problem for so many patients.

The limitations of the current technology do not affect the key elements of good psychiatric care, which in my opinion are the ability to

•form a strong therapeutic alliance
•successfully understand what the patient is thinking and feeling
•collaborate and develop an ongoing and flexible treatment plan

On the one hand, the technology can present a barrier; on the other, I have found that patients have been intrigued by the novelty, and that the technology should not and does not prevent an experienced clinician from being fully engaged.

Disclosures:

Dr Knoedler left his “Comfort Zone” job as Medical Director of Sheboygan County Health and Human Services in Sheboygan, Wisconsin. He is now a full-time Telepsychiatrist for the VA Hospital in Green Bay, Wisconsin.