Telepsychiatry - Week 7

It is week seven of telepsychiatry.  Things have been going reasonably well. I am as productive doing telepsychiatry as when I was sitting in an office. The constraints are becoming more evident as time goes by and I have the opportunity to confirm some of them with colleagues.   I have about 50-minute commute one way and doing telepsychiatry saves me that time every day. That is about 50 hours of time saved in the past 7 weeks. I also don’t have the additional expenses of purchasing food, coffee, and snacks at the workplace and that is a significant savings as well as the gasoline costs.

It is very convenient to sit in your office all day, click a tab, and immediately see your next patient. I do get notifications of people are running late but that is rare. The photo at the top of this post is what my desk looks like. The Mac Pro is the large monitor in the background. That is what I use for the telepsychiatry software. It is a high-resolution monitor with good sound quality but it is only as good as the monitor and sound quality on the other end. The small Dell laptop in front is what I use to access the VPN and secure networks and all of my previous notes. I only have access through this computer. The Surface Pro on the far right provides access to everything else I need including FDA package inserts, UpToDate, NLM searches, drug interaction software, an outside lab server that contains all the lab results on patients I am seeing, and the searches I need to locate a patient’s primary care clinic and psychiatrist. That is the information I commonly access during sessions with patients.  It turns out I am a lot faster with the additional computers than working on one computer in my office.

I have a number of documents that I present to patients in interviews that I have posted on this blog.  When I use web casting software for work related conferences, I have the option of posting material from Word, Excel, or PowerPoint right in the working field.  So far, I do not have that capability in my telepsychiatry software and I will be a lot more comfortable when I can do this. One of the critical documents is my standard list of psychiatric medications. It does prompt recall of many more medications than most people can recall spontaneously. 

I put up an earlier post on some of the limitations of telepsychiatry visits. I have had some further observations on that issue some of which have been confirmed by colleagues. Complex movement disorders for example are difficult if not impossible to assess in a telepsychiatry visit. The one I am thinking of was a combination of spasticity from a known neurological diagnosis, possible dyskinetic movements, and possible chorea. Asking a patient about their subjective experience of movements is useful to some degree but not absent an examination. I made the provocative suggestion to some colleagues that “telepsychiatry is not real psychiatry” to point out that there are both favorable and unfavorable consequences.

One of the unfavorable consequences is that telepsychiatry is not universally accepted by patients. With the recent security problems in a popular teleconferencing platform people are more aware than ever of this issue and how it may affect personal discussions with a psychiatrist. There seems to be a general belief that everyone accepts security risks as the cost of doing business but that is not true. There are some people who refuse telepsychiatry visits. There are others who go along but are obviously anxious about it and may not disclose sensitive material. It is an issue that should be explicitly discussed especially if the patient is obviously stressed or the information flow in the interview seems restricted. I had one colleague state that his practice of psychodynamic psychotherapy was going well with telepsychiatry visits. Another variable may be whether the psychotherapy started before telepsychiatry or not.

Even though it is a different kind of psychiatric assessment it does tend to expand the horizon. I started to think about seeing people anywhere in the United States or the rest of the world. I started to think about people I would see from rural Minnesota who would have to drive 150 miles to see me, until they eventually decided it was too inconvenient. Now I can potentially see them immediately right at their home. My mind wandered to the current pandemic and a recent story about depression and suicide in physicians who are on the front lines. I could potentially volunteer my time and help these colleagues.  A critical question is what are the barriers to that kind of practice or volunteerism? A good place to start is looking at an ideal telepsychiatry practice in the state of Minnesota. In that practice a very highly-respected psychiatrist has been a consultant to several southern Minnesota counties for years and has provided their psychiatric care. He has a very well-defined model that includes seeing patients only in clinic settings after they had been roomed and their vital signs have been determined. He has nursing and clinical staff on the other end who know the patients well.  He also sees everyone in his practice on an individual basis every year. His computer system and software are state-of-the-art and high definition. I have seen him give two presentations on his practice, but until the pandemic it never thought I would be using that model.

For now, I will consider a pared down model that would allow volunteer psychiatrists help their colleagues in the current and subsequent pandemics. The first consideration is licensing. Currently physicians are licensed in their own states and that license is not typically allowed treatment in a neighboring state. The only exception I am aware of is licensing through the Veterans Administration for physicians working in that system of care.  A central licensing body or state waivers could potentially bypass state licensing in this situation. It would also allow a large number of retired or semi-retired psychiatrists to volunteer their services. Some of those psychiatrists have let their licenses expire or in some states there is a active but retired status.

The second issue is malpractice. One of the deterrents to opening a private practice or transitioning to a private practice prior to retirement is malpractice insurance and tail coverage. Tail coverage is malpractice premiums that carry it on in retirement, until the window for civil litigation has expired. That would typically involve a two or three year malpractice premium payment during retirement with no associated income. Some states make an exception to malpractice insurance for volunteer physicians. I would argue that consultation to front-line physicians is a priority not only in terms of medical care but also national security. I would suggest that volunteer psychiatrists in this model should be indemnified by the federal or state government.

The third problem is centralized documentation. All clinical encounters should be documented - even in the case of free volunteered care and those records need to be confidential. I would argue for a central authority that would record and house those records. Ideally there would be access to an electronic health record so that any necessary prescriptions could be routed to the appropriate pharmacy.

All three of those prerequisites are considerable obstacles to a volunteer psychiatric workforce. The United States has a government facilitated private system of care that is dominated by large healthcare companies. Their networks are largely expensive and exclusive. The Veterans Administration is a good example of a government run system with its own information technology and networks. It may be a potential system for the addition of the elements necessary for a volunteer telepsychiatry workforce in the event of national emergencies. One of the issues made apparent by the current pandemic is a lack of public health readiness in the country. A volunteer telepsychiatry workforce may seem like a good idea right now but what happens when the pandemic ends? I would suggest that the infrastructure and volunteers could still be effectively used in areas where there were shortages of psychiatrists or after natural disasters when care for people with ongoing mental illness is disrupted. In order for that to occur, there need to be substantial changes in government philosophy and creating systems that are more people centric than business centric. The system like the one I am suggesting would not survive as a football for the two-party system.

If I think of an ideal science-fiction approach to telepsychiatry the possibilities increase greatly. I can envision a time where psychiatric appointments can occur anywhere or when a psychiatrist posts their availability online and see people who sign in. My current system displays all of the necessary legal documentation at the first visit. I think that all the details of what is necessary for telepsychiatry informed consent are still not clear at this point. Standard wrist worn activity monitors at some point could post the relevant vital signs in the physician’s software. Billing and payment is always an issue. In the past 20 years I have not really seen any progress in that area. There is no reason why a physician visit should not be as easy to pay as buying a mocha at a coffee shop.

I have some concerns about abuse of the format. It would be fairly easy to set up a prescription mill to prescribe stimulants, benzodiazepines, and opioids. Those operations certainly exist today and there are many ways to get those drugs from nonmedical sources. Confidentiality is a potential problem. If there is a telepsychiatry visit at home are there going to be other people listening or recording what occurs on the patient end? That does not occur in an office setting but I see it as a potential problem if the patient end of the visit is at home rather than a clinic.

Those are some of my thoughts after week seven of telepsychiatry. Despite the limitations I do think it is effective. If it wasn’t, I would have stopped by now and in this era of a pandemic of uncertain length - retired.

George Dawson, MD, DFAPA

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