Adventures in telepsychiatry

It seems to me that the information conveyed on a video and audio link between a patient and me has to be more than the information conveyed on a telephone call. All the information comings through on a telephone call is present on a videocall like Skype provides, and I can’t think of any way that having video of someone while I’m talking with them would somehow diminish whatever information is coming through the audio channel.

So, a video call is probably almost always preferable to a telephone call for psychiatry. I can think of a few exceptions, such as when it isn’t appropriate for one of the parties on the call to show themselves or their environment. For example, I’ve certainly answered a telephone call after just getting out of the shower but that wouldn’t be the right time for a videocall!

So, I think it is hard to argue that whatever standard of care exists for conducting psychiatric care via a telephone is being compromised by a videocall. In fact, I could easily see an argument someday, not so far in the future, when a doctor is being questioned along the lines of “did you think of a videocall to the patient rather than a telephone call?,”  just like the question that comes up now sometimes, “did you think that maybe you should have seen the patient rather than trying to handle this over the phone?”

The interesting comparison here is thus not between a telephone call and a video call, but between a videocall and a face-to-face visit.

All the information that comes through in a face-to-face visit comes through my senses, so going through them one-by-one:

Hearing

Voice quality on most telephone and videocalls is pretty good these days. As long as the microphone is of reasonable quality, close to the speaker’s mouth, and the line isn’t too noisy, I can’t see that there would be much difference in how much auditory information gets through when the visit goes through a videocall versus what I hear when I’m face to face with them.

Smelling

Well, nothing like this comes through the Internet, so face-to face-wins  here. Most of what I do as a psychiatrist doesn’t involve scent, but I can think of three examples:

• Smelling marijuana or alcohol on someone
• Noticing an excessive amount of perfume on someone, and
• Noticing that someone is not being attentive to personal hygiene

Tasting

Can’t taste through the Internet, but I can’t think of any time that I can remember getting any important information that way when I was face to face with someone, except once when a patient brought me one freshly made chocolate chip cookie when she came for an appointment.

Touching

Tactile information doesn’t come easily via the Internet. (I understand though that tactile feedback is extremely important  in situations like robotic surgery.) For psychiatry, there are a few times that touch is essential.

• I can’t get a blood pressure or a pulse on a videocall.
• I can’t push on someone’s ankle to see if he or she has pitting edema.
• I can’t do a point-to-point movement evaluation. (But I can think of a sort of comical equivalent.)

Although touch can sometimes be important, there isn’t much psychiatrically important information that comes that way through in a face-to-face interview.

Seeing

This is where almost all the the potentially clinically important differences between telepsychiatry and face-to-face psychiatry arise. I need to write about this in more detail later, but two things are obvious right away.

First, the visual information I get in a face-to-face interaction is much more detailed. When I first started doing Skype, I was delighted that video quality was good enough to see someone’s eye color or the shape of the earrings someone was wearing. I will bet though that this kind of degradation of visual information isn’t going to be very important in a short time–just look at any decent HDTV these days and you can see the pores on someone’s face. It’s pretty easy to predict that technology will close this gap relatively soon.

Second, if I’m face to face with someone I can glance over towards  her hand as  she reaches for a cup of water and see if she has a tremor without calling this bit of information gathering to her attention. Technology to remotely control a camera already exists and I don’t think it would be that hard for webcams to have a remotely controlled sensor. I’m not sure this will catch on.  I can imagine a scene like a bad science fiction move with the little robot eyeball looking around.

In summary, it looks to me like there’s really not much difference between face-to-face and telepsychiatry in terms of sensory input most of the time.

I’ve not talked about here something really important—the psychological impact of face-to-face versus telepsychiatry—and I need to think about that some more.