Adventures in telepsychiatry

I had an interesting phone call and email conversation the other day. It  came to nothing–I didn’t feel that I could help the patient with her problem whether face to face or via telepsychiatry, but it made me think about how much telepsychiatry changes the way medicine is going to look in the future.

The request for telepsychiatry was from a U.S. citizen living in another country. When I got the initial message, I was tempted to just say “no,” but the more I thought about it, the more perplexed I got.

Put aside, for a moment, the issue of licensing. I  don’t know what the laws are regarding telepsychiatry in another country right now, and don’t want to become an expert.

What made me think a bit is that I have occasionally treated people who were temporarily out of the country. For example, I’ve had patients who were on extended business trips, visiting their family in another country, or away for an exchange program. I’ve sometimes given someone six months of medications in this situation, even though I usually don’t do that for a variety of reasons.

I’m not sure whether or not this counts as “practicing medicine” in another country. Certainly, I’ve never thought so. Usually, the patient is getting someone here in the U.S. to pick up the meds and ship the meds to them.

As far as I know, this kind of accommodation gets done all the time, and no one has ever told me it was wrong. I guess you could argue that the patient should get care in the other country, but that may not happen, or it may not go well, especially in psychiatry.

So here’s the puzzle. Let’s say I take care of a student, he goes on a junior year abroad, and I write for continuing his antidepressants, with his mother handling the meds here in Maryland. If I have a brief phone conversation or an email exchange with the student while he’s away, I think I’m within the standard of care. Suppose I have a telepsychiatry session with this student while he’s away. Am I now practicing medicine in another country or doing something illegal? It’s seems like I’m doing a more careful job for my patient, not a sloppier one.

It’s surprising how few technical difficulties my patients have had with Skype, but there have been a few.

With one exception, all the technical troubles any of my patients have encountered have been the very first time that they’ve set up Skype. Although I tell everyone to test it out before they try it for their first appointment, the problem is that some of the people I see don’t know anyone to Skype with other than me. It’s hard to test the system without someone else to help.

I’ve tried to address the problem by now asking people to make one quick Skype call to me before their first appointment if they can’t test things with someone else. Although this wastes a little of my time occasionally, it really hasn’t been that much of a burden (I’ve done this two or three times,  and it never took more than 10 minutes to get everything working.)

The one exception was a problem that turned out to be really hard to fix. My patient had borrowed one of my loaner webcams, got this webcam to work without a problem, and then decided to buy a new webcam for himself. He installed the software for the new webcam, but it wouldn’t work. He did try to call me, but Skype wasn’t working at all. We did the session by regular phone after it was clear that something was wrong and after we had wasted about 10 minutes trying to fix it.

The problem was that he had not de-installed the software from the loaner webcam before installing the software from the new webcam, and that messed up everything until he uninstalled both sets of software (complete with the usual 10 reboots it tends to take Windows to do these things) and re-installed the software for the new webcam.

I’ve actually only had one video call go south in the middle of the session–the person was in a place with a lot of electronics, and I suspect that the problem was on her end, not on mine, but I guess you never know.

So, the score right now is one failed session and 30 minutes of “technical support” time in what have to be 100+ sessions, at least. Not too bad in my opinion. I probably spend as much time keeping my printer working.

One of the characteristics of any part of medicine that I’m aware of is that the work tends to be “bursty,” meaning there is seldom a steady flow of work. Instead, work is often crazy busy for a while, and then not-so busy, then crazy busy again, and so on.

Throughout my medical life, I’ve been in lots of circumstances where crazy busy times have led to some hair-raising experiences. Sometimes there’s some backup (like in a hospital during the day), but a lot of times there isn’t. When I was a resident in the ER, it wasn’t that unusual for me to be responsible for several patients whom I didn’t even know past a five-minute triage conversation. Some really hair-raising things happen when people are sick and nobody taking care of them has had enough time to really get up to speed on what is happening.

Telepsychiatry would be a really good way to handle these kinds of “overflow” situations. Of course, I’m not suggesting that people who are grossly disordered should be taken care of by telepsychiatry exclusively, but I can think of lots of situations where a few minutes of consultation (with either with a staff member or a patient) with someone doing telepsychiatry would be a superior way to handle the crazy busy times and serve the patients better and more safely.

I won’t try to explain the math, but queuing theory suggests that it would make more sense to have multiple consultants available by telepsychiatry to several ER’s (for example), than to try to have a consultant available in every ER because the multiple consultants have more capacity to handle the crazy busy times.

A friend sent me a link to an article in the New York times titled “Are doctors ready for virtual visits?”

The article talks about the results of a study done at the University of Texas Medical School looking at the impact of telemedicine on patients in intensive care units.

There were two really interesting findings in the study, the first relating to patient outcomes, and the other to doctor’s attitudes.

Although there wasn’t a significant difference in patient outcomes when super sick and just sick patients were grouped together, it turns out that the super sick patients actually did a little better when managed by telemedicine, while the less sick patients did no better, or maybe a little worse. That’s a interesting finding, particularly if you are one of the super sick patients.

The real finding of the study though was that many of the doctors and nurses in the ICU really didn’t like the idea of telemedicine.

On the surface, the rationale the people who were opposed to telemedicine gave was the they were worried it would jeopardize the “doctor-patient” or “nurse-patient” relationship.

I wonder if that’s really the whole story. Invoking the “doctor-patient relationship” is one of those motherhood and apple pie kinds of arguments. The motherhood and apple pie argument for anything goes like this:

Premise: Motherhood and apple pie are a good thing
Premise: X is a not a good thing for motherhood and apple pie
Premise: Things that are not good for motherhood and apple pie are not good things

Conclusion: X is not a good thing

The problem with the telemedicine argument used by the participants of the study is that there isn’t any evidence that telemedicine hurts the quality of the doctor-patient or nurse-patient relationship. In fact, the article also points out that the patients and their relatives really like the idea of an extra pair of eyes on the patient.

The default argument in medicine against anything that health professionals don’t want to do is that it “hurts the doctor-patient relationship.” It’s true that some things do hurt the doctor-relationship, and that’s a bad thing. The problem is not to acknowledge that it’s incumbent on someone who makes the argument to prove it.

It’s no wonder that bloggers like David Collin say things like:

Does this seem as annoyingly familiar to you as it does to me? In my more than three decades around the health field it seems to me that again and again new ideas and tools for extending health resources have been greeted with less than open-armed acceptance. Medicine is said to be a “conservative¡ profession,” and perhaps that’s warranted to some degree because, after all, lives are at stake. But I’ve become more cynical about the motivations for this conservatism as years have  passed. During the years I’ve worked in public health my observation is that the medical profession has steadily become more ensconced in what has to be called a medical/industrial complex. All too often what the profession appears to be conserving is its own interests — authority, control, money –  and its justification is frequently cloaked in claims physicians are only concerned about the doctor-patient relationship.

Be that as it may, forces for change from outside the medical establishment continue to mount. The Health 2.0, participatory medicine, and patient-generated content movements are attracting a constituency among people who want an alternative to the passivity and powerlessness that have characterized personal health care for the past century. For its part, telemedicine might be said to be underway already in the flocking of people to the internet for health information, in the flourishing patient sharing sites around specific diseases, and in the rapid uptake of monitoring devices and health-oriented tools for smartphones.

Actually, I think he’s got a point.

Who’s being served by being against telemedicine? I don’t think it’s the patient. Time for medicine to get a little more 2.0….

In my last post, I talked about the informed consent form for my practice, and mentioned that part of the consent form says that emergency care might be more difficult via telepsychiatry.

I wrote that section because I doubted that there was any case law on emergency petitions and telepsychiatry.

In Maryland, certain mental health professionals (physicians, psychologists, licensed professional counselors, clinical nurse specialists in psychiatric and mental health nursing, and psychiatric nurse practitioners) can seek an emergency petition to have a person evaluated for a psychiatric admission, potentially against that person’s will, by filling out a form asking a police officer to pick up the person and bring that person to the nearest emergency room for a psychiatric evaluation.

There are some laws (Maryland Code, Health-General Article 10-620 et seq.) governing this procedure, but, to my knowledge, much of what judges go on in cases where someone feels the law wasn’t followed properly is based on case law.

The Maryland Code says that the mental health profession who seeks an emergency petition has to have examined the patient. I’ve been told by various forensic psychiatrists that I have to have examined the patient in the last week (or perhaps two weeks, depending on whom I spoken with) for me to be able to seek an emergency petition. I’ve also been told that a phone call doesn’t count as an examination, so if I haven’t seen the patient in a month, say, then I can’t really fill out an emergency petition because I haven’t examined the patient recently, even if I speak to him or her on the phone.

If my understanding is true, then telepsychiatry is an interesting case. Have I “examined” the patient sufficiently for an emergency petition, or not?

I don’t really want to be the person who finds out the answer to this question, but I’ve decided that I’ll do what I’ve always been taught is the “Golden rule of forensic medicine:” Always be a doctor first, don’t try to be a lawyer. I think I’ll just do what I would normally do if I were face-to-face with the patient. Hope someone else gets to find out if this is the right decision….