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

Big Data and Psychiatry - Moving Past the Mental Status Exam

I was a fan of big data before it became fashionable.  I was a high tech investor before the dot.com bubble and became very interested in high speed networking, especially the hardware necessary to move that data around.  Even before that information was publicly available, electrical engineers were using that equipment to rapidly download large amounts of data (GB) from satellites on every orbit.  As an investor, one of the early flagship applications was large telescopes.  I wrote an article on high speed networks and the medical applications - digital radiology and medical records back in 1997.  At about the same time I made the information connection.

As a college student, I got my hands on the Whole Earth Catalog.  That led me to my small college library and my surprise to find  that they had Shannon's  seminal work on information theory on the shelf.  I was even more excited when I learned about entropy in my physical chemistry course three years later.  Since then I have been searching without much success to look at what happens when two people are sitting in a room and talking with one another.

My entire career has been spent talking with people for about an hour and generating a document about what happened.  It turns out that the document is stilted in the direction of tradition and government and insurance company requirements.  It covers a number of points that are historical and others that are observational.  The data is basically generated  to match a pattern in my head that would allow for the generation of a diagnosis and a treatment plan.  The urgency of the situation can make the treatment plan into the priority.  The people who I am conversing with have various levels of enthusiasm for the interaction.  In some cases, they clearly believe that providing me with any useful data is not in their best interest.  Others provide an excessive amount of detail and as the hour ends I often find myself scrambling to get to critical elements before the hour expires (my current initial interview form has about 229 categories).  This basic  clinical interview in psychiatry has been the way that psychiatrists collect information for well over a century.  In the rest of medicine, the history and physical examination has become less important due to advances in technology.  As an example, it is rare to see a cardiologist these days who depends very much on a detailed physical examination when they know they are going to order an echocardiogram and get data from a more accurate source.

In psychiatry, other than information from a collateral interview and old records  there is no more accurate source of information than the patient.  This creates problems when the patient has problems with recall, motivation, or other brain functions that get in the way of describing their history, subjective state, or impact on their life.   The central question about how much useful information has been communicated in the session, the signal-to-noise considerations, and what might be missing has never been determined.  The minimal threshold for data collection has never been determined.  In fact, every information specialist I have ever contacted has no idea how these variables might be determined.

Information estimates have become more available over the past decade ranging from estimates of the total words spoken by humans in history to the total amount of all data produced in a given year.  Estimates of total words ever spoken range from 5 exabytes to 42 zettabytes depending on whether the information is stored as typewritten words on paper or 16-bit audio.  That 8,400 fold difference illustrates one of the technical problems.  What format is relevant and what data needs to be recorded in that format?  The spoken word whether recorded or typed is one channel but what about prosody and paralinguistic communication?  How can all of that be recorded and decoded?  Is there enough machine intelligence out there to recognize the relevant patterns?

An article in this week's Nature illustrates the relative scope of the problem.  Chris Mattmann makes a compelling argument for both interdisciplinary cooperation and training a new generation of scientists who know enough computer science to analyze large data sets.  He gives the following examples of the size of these data sets: ( one TB = 1,000 GB)

Project	Size
Encyclopedia of DNA Elements (ENCODE), 2012	15 TB
US National Climate Assessment (NASA projects), 2013	1,000 TB
Fifth assessment report by the Intergovernmental Panel on Climate Change (IPCC), due 2014	2,500 TB
Square Kilometer Array (SKA), first light due 2020	22,000,000,000 TB per year

That means that the SKA is nearly producing the total amount of information spoken by humans (recorded as 16-bit audio) in recorded history every year.   The author points out that the SKA will produce 700 TB of data per second and within a few days will eclipse the current size of the Internet!

All of this makes the characterization of human communication even more urgent.  We know that the human brain is an incredibly robust and efficient processor.  It allows us to communicate in unique and efficient ways.  Even though psychiatrists focus on a small area of human behavior during a clinical interview the time is long past due to figure out what kind of communication is occurring there and how to improve it.  It is a potential source of big data and big data to correlate with the big data that is routinely generated by the human brain.

George Dawson, MD, DFAPA

Dawson G.  High speed networks in medicine.  Minnesota Physician 1997.

Lyman, Peter, H. Varian, K. Swearingen, P. Charles, N. Good, L. Jordan, & J. Pal. 2003. How Much Information? Berkeley: School of Information Management & Systems.

Mattmann CA. Computing: A vision for data science. Nature. 2013 Jan 24;493(7433):473-5. doi: 10.1038/493473a.

Shannon CE.  A mathematical theory of communication. The Bell System Technical Journal 1948; 27(3): 379-423.