Monday, March 23, 2020

Telepsychiatry - Day One

These are strange times.

For the past several years I have attended seminars on telepsychiatry. In Minnesota, we have an expert who has been doing it for a long time. He talks about the advantages of being an independent practitioner and using your own equipment rather than being a subcontractor. He has a definite method that includes seeing all of his patients in person at least once a year. His practice covers a large area that would otherwise probably not have a lot of psychiatric services. Over the years that I have been going to the seminars, I have thought about private practice and Telepsychiatry. I even looked at a storefront building at a shopping mall and fantasized about starting it up. But I am too close to retirement and there is a thing called tail coverage. That means if you carry malpractice insurance and retire you need to still pay the premium for two or three years into retirement in the event that you are sued.  That was a major deterrent and it seemed like I would just carry on in my current position until I decided to quit. And then the coronavirus and social isolation hit.

The transition to Telepsychiatry rapidly happened last Thursday. I was going about my day when my younger colleague told me that she was switching to Telepsychiatry this week. She encouraged me to get on board. Several people were critical to the effort and I was up to speed on the system by this weekend. I had to confirm that I had the computer power, bandwidth, and dropped frame rate consistent with software. I pulled up my schedule this morning and the main difference I was sitting at home looking at it on my big Mac Pro. I tested the camera and microphone. It produced a good image of me sitting in my home office and I was ready to go. What followed was a big glitch and some realizations about the visual aspects of psychiatry.

An initial series of emails let me know that the visual feed was not working. That essentially took out the software and as a replacement I was supposed to do telephone interviews. Hoping that they could get it up and running I moved the first patient new evaluation to the last slot in the daytime. There was some suggestion that only follow-ups should be seen as telephone interviews. I was concerned that patients would have to hold the telephone receiver for 45 to 60 minutes but was reassured that it would all happen over speakerphone. The locations were all secure and managed by our clinical administrator. When it became apparent that the visual feed would not occur I started doing new assessments and follow-ups strictly on the telephone.

In retrospect I found myself myself in an ironic position. For years I studied telephone switching both as a high-tech investor and as electronics hobbyist. I eventually got involved in communications theory. The engineering version of communications theory is highly technical and interesting but I have never been able to apply it to the clinical interview. The clinical interview is an exchange of information. There is always a certain noise level that varies significantly from person to person. That noise can occur strictly on the information being exchanged or various emotional levels that can add or subtract from the overall noise level. A good example would be a person who brings a lot of biases into the interview. As an example, I have had people slow the interview down or bring it to a halt just based on my physical appearance and how it was interpreted. Some of those people would be very explicit in telling me they could only work with a psychiatrist who had a certain religion, philosophical bent, or political affiliation. There was often speculation, that I did not meet the preferred categories. Interviews done without the visual channel, removed those factors.

I dictate all my valuations and follow-ups and have done that most of my career. Critical parts of what has become known as the Mental Status Exam are dependent visual assessment. A few examples of common bullet points include:

Appearance: I comment on whether the person appears to be alert, interactive, their overall grooming and hygiene, their eye contact and social demeanor. Where it applies I also comment on whether they appear to be intoxicated, distracted, potentially delirious, and in some situations whether they realize I am in the room with them.

Psychomotor: Hyperkinetic and hypokinetic movements and possible movement disorders need to be described. Psychomotor agitation and retardation as well as motor restlessness also need to be commented on. It is about a 40 foot walk to my office and the person’s gait also needs to be described.  Gait analysis is useful because of the association with dementias, neurological disorders, and medication side effects. It is also useful in assessing chronic pain patients. The commonest acute pain disorder I notice is gout due to its high prevalence in men of all ages. Specific movements require additional examination in some cases rating scales. For example if tardive dyskinesia is noted and AIMS (Abnormal Involuntary Movement Scale) can be done to determine a baseline score. There are additional rating scales for Parkinson’s, akathisia, tics, and dystonia.

Affect: Psychopathologists like Sims have pointed out the subtle differences between affect and mood. In his text for example he describes affect as “differentiated specific feelings directed toward objects”. Mood is described as “a more prolonged prevailing state or disposition”. He comments that both terms are used “more or less interchangeably”. Modern use is much more basic and it has to do with direct observation of the patient’s emotional expression, the specific context, and whether or not it may be consistent with an underlying phasic mood disturbance.  A common error I notice in many descriptions is that the time domain is omitted - people never seem to comment on the affective state over the course of the interview or the fact that the patient's affect appears to be completely normal - despite the assessment being done for a mood or anxiety disorder.

If you are interviewing people by telephone rather than Telepsychiatry, you don’t have access to any of those three critical domains as well as other parameters that might be important. For example, vital signs, focal physical examination, and the overall determination about whether or not a patient may be physically ill or critically ill just based on their appearance.  There is also a pattern matching aspect to psychiatric diagnosis. After psychiatrist has evaluated hundreds or thousands of patients, certain patterns are evident that can facilitate diagnosis. The most obvious one is delirium. It has always been a mystery to me why that diagnosis is so difficult for a lot of people to make. Once you have seen a few delirious people, the pattern seems obvious. Other findings are much more subtle. An example might be a patient appears to be in pain but also does not want to disclose the source of that pain. It could be a self-inflicted injury or injury from intimate partner violence. Those findings would be very difficult to pick up over a telephone interview.

A couple of examples come to mind when I think of critically ill patients who did not come to see me because they were critically ill. The first was a patient who looked the whitest I had ever seen a person. I asked him if he was physically ill and he denied it. I asked him about possible causes of blood loss and that was also denied. He did eventually allow me to order a complete blood count. I got the results back his hemoglobin was extremely low and when I called him - he did acknowledged some symptoms of G.I. blood loss and agreed to go to the emergency department. He was subsequently found to have a gastric ulcer. In another case I was talking with the patient appeared to be physically ill. He seemed to have some abdominal distress. He allowed for a limited exam of his abdomen and appeared to have right upper quadrant pain and tenderness. He was also referred to the emergency department and had acute cholecystitis and required surgery. Both of these scenarios depend on how the patient actually looks to the psychiatrist and that is why the visual presentation is so important.

Many people think that psychiatry is an exchange of words. A common myth these days is that these words allow people to be grouped into diagnoses based on other sentences and phrases. A discussion between two people is always much more than that. When a psychiatrist is in the room the discussion is between two people one of whom has memories of tens of thousands of important patterns and findings that mean something. A significant number of those patterns are visual rather than strictly verbal.

I have lost count about how many times a rapid visual diagnosis played a critical part in the diagnostic process. When I see a patient with serotonin syndrome or neuroleptic malignant syndrome or malignant catatonia - I am not running down the diagnostic criteria in my head. I am thinking that they are critically ill probably have a specific diagnosis - but I have to get them somewhere fast where they can receive the necessary supportive care while that diagnosis is clarified and treated. Most of that is a visual process based on what I have seen in the past. In most cases, the diagnosis occurs in seconds to minutes.

I thought the telephone interviews went well. My notetaking was as intense as ever. I am looking at an average of about six pages of handwritten notes that I base my dictations on. But I know the process can be much better. Telepsychiatry is superior to telephone psychiatry, and I hope to find out how close it is to a face-to-face interview.

Hopefully that visual feed will be there tomorrow.

George Dawson, MD, DFAPA


  1. I have spent the last few weeks doing dry runs and beta testing different platforms. Not just the free versions but the subscription versions on short-term trials. Thera-link, Doxy and Zoom (HIPPA) are the big ones and Simple Practice is a comprehensive scheduling and billing and management suite. I couldn't really beta test the last one because of how it was set up. Thera-link and Zoom is expensive and I could be wrong but I don't think there's anyway to keep someone from barging in your appointment if they click their link at the wrong time. So far the winner is Doxy. They have a virtual waiting room and you have to affirmatively invite them into the chat (three and four way works) and the price is right too. I completed a 3.5 hour forensic eval on Thursday with examinee and a Cantonese interpreter in different locations and it went well except for a couple of minor audio hiccups. These were solved by a simple reload. The examinee had nothing but an iPhone and it dropped only once. The other thing is that Doxy doesn't require an app to download, you just have to tap a link. It worked well on 3G as well as Wifi. Small sample size but so far so good. You want to do at least ten trial runs with staff before using it in practice for all of these. Some kind of exams are unsuitable including neuropsychiatric.

    Everyone is using Zoom for everything now and I fear that will be a crowded series of servers. I'm noticing that phenomenon on Netflix streaming downloads lately. I think the niche programs are better for that reason.

    Make sure you have consents, a BAA agreement with the provider and tell everyone to charge everything or plug it in beforehand. Some of these services have stores where you can buy a blue screen to attach to the back of your chair to make the background more neutral and not reveal too much in the home.

    Let me know what you think as I'm not proclaiming any kind of expertise but thinking out loud here. Everything I'm writing is based on heuristics and experimentation.

    Simple Practice may be a good way to go if you want to start all over.

    I have a feeling that houses with granny shacks or detached living areas are going to be especially desirable in the future. It's a lot to ask everyone to be quiet at home for extended periods of time.

    1. Thanks for the comprehensive review!

      I was interviewed on Zoom for a podcast and found it to be an impressive interface. The host sent me a link and within seconds I was up and running. I can appreciate your concerns about their recent popularity and what that might mean for their infrastructure. I have also been advised that their HIPAA compliant version with the necessary licenses is quite expensive.

      I am on Mend software though a corporate network. It seems like a capable system. The main issue seems to be people logging on with their Smartphones instead of using a standard workstation in our clinic. The standard workstation provides better security and imaging. A lot of people are concerned about eye contact but on a large screen, camera placement at the top of the screen does not detract from the illusion of direct eye contact through the monitor.

      Another interesting issue that has come up as a result of the pandemic is the relaxation of telemedicine/telesychiatry regulation including the interfaces that are now acceptable. The following paragraph was interesting:

      "Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency."

      It will be interesting to see how the post-pandemic telemedicine landscape shakes out. Unless there were gross confidentiality problems with the excepted applications, there would not appear to be a reason to charge hundreds of dollars a month for other commercial packages.

      Looking forward to your updates and I will definitely look at Simple Practice.

    2. The free version of Doxy only allows you to send links by email. The thirty dollar a month version allows you to send by text, which I think is imperative because emails get lost in junk files or ignored. I think Doxy is good if you already have your billing and scheduling in place.

      My case on Thursday was med-legal which doesn't require HIPPA but I did it anyway. Might as well for the one time you make a mistake and assume something isn't under HIPPA but it really is. It's like COVID itself, asymmetric risk, the cost of being wrong is a lot greater than the benefit of being right.