Telepsychiatry Is a Team Sport

[[{"type":"media","view_mode":"media_crop","fid":"25037","attributes":{"alt":"telepsychiatry","class":"media-image media-image-right","id":"media_crop_6832179568061","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2230","media_crop_rotate":"0","media_crop_scale_h":"251","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Telepsychiatry is a team sport. To run an effective practice, you need skilled people on-site with the patients. The on-site staff needs to be able to do more than just get the patient into the correct room and call the psychiatrist. The on-site staff needs to be able to assess the things that you, as the telepsychiatrist, would not be able to assess: Does the patient smell of alcohol? Did he or she interact with the staff at the front desk, or with the other patients in the waiting room, in such a way that you should be made aware? Is there a family member in the waiting room who should be included in the appointment? Does the patient have a medication list that needs to be deciphered? Does the patient’s behavior suggest that there might be a safety concern, either for himself or for the staff? Are there physical signs that you might notice in person that might not be evident on video, such as rash or exophthalmos? The level of training and expertise of the on-site staff needs to be clearly understood by the treating physician.

We need to be aware, also, of the increased stress that the staff who are actually with the patients feel: in telepsychiatry, the psychiatrist is not on-site to help if some difficult event occurs. It may be the psychiatric nurses and aides who tackle the patient when a crisis occurs, but the team still sees the psychiatrist as the one who ultimately needs to make critical treatment decisions.

Telepsychiatry is good for psychiatrists. It offers the possibility of working from home, and of working somewhere warm in the winter and somewhere that’s not too hot in the summer. It gives psychiatrists an opportunity to rejuvenate their careers in an interesting fashion, and to become proficient with a new set of skills using new technology. It may be that telepsychiatry will increase the shrinking pool of available psychiatrists, since some psychiatrists may choose to practice longer if telepsychiatry allows them to accommodate their own physical limitations as they age. Telepsychiatry may also allow younger psychiatrists to work more hours if the option of working from home creates greater flexibility for child care or a more satisfying ability to interact with family during the day.

Is telepsychiatry good for patients?

All else being equal, I believe that having a psychiatrist on-site, in person, in the room, is better for most patients than having a telepsychiatry session with a psychiatrist. (Of course, for some patients it will not make a difference; other patients may feel that telepsychiatry is less threatening than a live interview.) Telepsychiatry is enjoying a boom, but that is primarily, in my opinion, because there is a shortage of psychiatrists. If there were a surplus, I believe the demand for telepsychiatry would be much smaller.

A relevant question is whether telepsychiatry for a rural clinic is better than the grand tradition of the traveling, itinerant psychiatrist who spends a day or two at a time, in person, in small clinics, traveling from small town to small town on a regular schedule. The answer, at least for most patients, is that telepsychiatry is better for the psychiatrist, but not necessarily better for the patient. One exception might be in very sparsely populated rural areas, where a patient might have to travel long distances even to get to a rural clinic. In that situation, a telepsychiatrist might be able to see a patient in a very small town-a town too small to support even an occasional full day of psychiatric time-perhaps by videoconferencing into the patient’s home.

Consider the costs

Telepsychiatry is costly. In addition to the videoconferencing equipment, a telepsychiatrist needs two offices: one for the psychiatrist, and one for the patient. A telepsychiatrist also needs someone to be on-site and available to the patient at all times. If you have one technician or nurse at the patient end of the interaction, and that person calls in sick, goes on vacation, or even just goes to lunch, your practice will grind to a halt. You need a backup staff on the patient end.

You also need ongoing IT support-a little if you are lucky, but a lot if you are not! To minimize the risk of canceling patients because of a technology issue, your IT support needs to be readily available. Having a nurse with extensive mental health experience available at the patient end of the interaction is highly desirable and addresses many of the concerns raised by having the psychiatrist off-site.

Prescriptions can be handled by using an electronic prescribing service, such as Allscripts. Controlled substances that require a written prescription involve more effort, including a combination of calling prescriptions into a pharmacy and mailing written prescriptions.

Implications for the doctor-patient relationship

Should telepsychiatrists videoconference into a patient’s home, allowing the patient to be seen without even leaving his home? Can we use telepsychiatry to re-create the home visit that was such a tradition of doctors in the past? Perhaps there are patients who would benefit, but it seems as if telepsychiatry into a patient’s home might be a very different kind of interaction than what we are used to. Going to the doctor’s office, negotiating the reception desk and the waiting room, and sitting in a professional office must surely have significant meaning in the therapeutic relationship. Seeing a patient in his home via videoconferencing also involves the complicated issues of the home environment: privacy, technical equipment, the patient’s feelings about the psychiatrist being “present” in his home, and the expanded potential for disruptions.

I recently decided to retire from my full-time telepsychiatry position with the VA and return to my previous full-time job as the Health and Human Services psychiatrist for Sheboygan County, Wisconsin. I will be on-site for at least half the year at Sheboygan County, and doing telepsychiatry for Sheboygan County from someplace warm for the rest of the year.

There are, undoubtedly, psychiatrists who will thrive doing telepsychiatry from home full-time; my experience has taught me that I am not one of them. Full-time telepsychiatry is a diet that is a bit too rich for me; tiramisu is delicious, but not tiramisu for breakfast, lunch, and dinner! I am looking forward to working with my colleagues at Health Human Services again, live!

Disclosures:

Dr Knoedler reports no conflicts concerning the subject matter of this article.