I think this blog makes it pretty clear that I’m enthusiastic about telepsychiatry. I’ve tried to keep my enthusiasm for it low key with my patients, primarily because I want to accommodate their needs, and not have them feel pressured about whether to use telepsychiatry or not as I work out the best way to do it.
I guess I’ve been drinking my own Kool-Aid, because I’ve now gone from passively offering to do telepsychiatry to pretty much insisting that some of my patients be able to use it.
Snow has been at record levels in Baltimore this season, and that’s been a pain for everyone living here. Recently, we had a record snowfall, and the city was pretty much paralyzed for several days.
Unfortunately for me and four of my patients, this total shutdown of everything came at a really bad time. I have a small practice, but I pride myself on doing everything I can to keep people out of the hospital, so I have a patient or two in my practice who are on the verge of being too sick to care for as an outpatient.
What happened was that the city was shut down and I was taking care of four people who were either on waiting lists for specialty beds or needed hospitalization., The possibilities for admission were murky because of a lack of hospital beds or the patient’s decision to decline to go to a particular hospital because of a bad experience there in the past.
It boiled down to four patients, all of whom probably needed to be in the hospital, and me trying to do what I could until beds opened up in a city where most people couldn’t drive anywhere and the public transportation system was barely working at all.
Two of these patients had Skype, two didn’t. I realize that a sample of four doesn’t prove anything, but the differences between what I could do via Skype and what I could do by telephone were so stark I just couldn’t believe it.
The two patients with Skype were, if anything, more ill than the two patients without.
I felt confident dealing with some pretty aggressive med changes with the patients with Skype. I could see and talk to the patients and the people who were staying with them. Although I couldn’t assess muscle tone over Skype, it wasn’t that hard for me to see that I had given too much neuroleptic to one of them, simply from his facial expression. I was also very confident that I had not made the other patient with Skype delirious, because I could do almost all of a mini-mental state exam without being there, and I could see the patient as well as talk to her.
By contrast, dealing with the two patients without Skype by telephone was much more challenging, and I managed them much more conservatively because I didn’t feel that I was getting the kind of information that I needed to do bold things safely. One of them ending up in an ER, and got admitted and discharged two days later. I think I might have prevented this admission if I could have had a better handle on what was going on.
Basically, for the patients with Skype, I treated them almost as aggressively as I would have in a hospital. For the patients without Skype, I didn’t feel I could do as much and feel that they were safe.
These four cases really made an impression on me. Both of the patients without Skype are in circumstances where getting set up for telepsychiatry involves little more than making the effort to get a Skype account. The expense of a webcam is not likely to represent a significant financial outlay for either of them.
With these latter two patients, I’ve crossed the line from being passive about telepsychiatry to being much more active. I told both of their families that I really thought they should be ready to do things by telepsychiatry next time. I certainly can’t force anyone to use it, but I didn’t have any problem writing that my medical advice was that they should, that their care with me would be worse without it, and that they were making a mistake if they chose to ignore my advice.
Tagged blizzard, emergencies, ER, snow, telephone