“The doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.¹“

A couple of days ago, I was doing a Skype session with someone and the video cut out suddenly, so we had to reconnect halfway through the session. As the connection was failing, we could each tell the other was talking and could see some disconnected video, but couldn’t really hear what the other was saying.

One thing I noticed about having the communication cut out on Skype was that, unlike the analogous problem with having the cellphone cut out halfway through a conversation, both of us knew right away that the other was probably not getting any good information, and we both stopped communicating anything important as soon as it was evident that Skype was cutting out on us.

This is the first session I had any trouble with Skype, and I realized that maybe Skype has one more advantage that I hadn’t thought of. I’m sure everyone who uses a cell phone has had the experience of delivering a monologue to someone else after the cell dropped, and realizing that he or she wasn’t talking to anyone at all! On a cell, we rely on little verbal cues like “uh-huh” and “OK,” but most people tend to take turns talking and a lot of times when a cell drops you don’t really know how much got through before the other person couldn’t hear you anymore. With Skype, even if people are fairly quiescent, there’s enough moment to moment activity like head movement and eye-blinks to know just about when the other person and you are probably disconnecting. I like that.

When I was walking home that evening, I had a flash of the quote that I started this blog entry with, and thought for a couple of minutes about whether Freud would have used Skype. I’m not a psychoanalyst, and certainly don’t have the “blank slate” approach of the television or movie psychiatrist, but I think that Freud certainly had a lot of good ideas (along with some big losers.)

Anyway, I read somewhere once that the reason Freud used a couch was because he didn’t like being stared at all day by patients. The Skype interruption made me think of the blank screen (here, a blank monitor screen) metaphor and I just can’t help wondering if Freud would have shared his video image with the patient or what it would be like for the patient to share video while the psychiatrist doesn’t.

Of course, there’s really no way to know, but  the title of this post is an interesting thought-experiment question. Would Freud have refused to share his Skype video?

“AFAT” is an acronym I coined myself and it stands for “Atom Fool Around Time.”

The idea behind this acronym comes from a book by Nicholas Negroponte written in 1995, called “Being Digital.” Negroponte’s book was, and still is, completely on the mark with regard to understanding how the Internet has changed and will change our world going forward.

Negroponte starts with a simple distinction. Most of what is important to us in the world is either something that weighs something (“atoms”), or something that weighs nothing, like information (“bits.”)

Houses, people, chairs, and nose rings are atoms; Music, books, almost all money and the map in your GPS are all bits. Now, to be sure, something like a printed book weighs *something*, but the essence of a book isn’t the paper it is printed on, but the information that it contains. I would argue that my copy of The Lost Symbol on my Kindle is just a much a real copy as the one on sale this week at Walmart. Take your favorite music CD and break it in half. It still weighs the same, but the music is gone–the information that makes the music play weighs nothing.

Weightless bits fly through the Internet to me at close to the speed of light and cost essentially nothing to transport; Atoms come to me by cars, trucks, airplanes, ships and trains and cost real money to move from one place to another.

This is a long winded introduction to what I think telepsychiatry’s greatest advantage is over face-to-face communication. When a patient and I see each other we are usually exchanging information, not atoms. If the most important thing is information, then does it really make sense for the patient to fool around with hauling his or her atoms to come see me for every visit? I don’t think so.

I’ve already made it clear that atoms can be important, even vitally so, but is equally important to notice that seeing people face-to-face rather than via a videocall has big transaction cost which seems to be unnoticed by many people: To have a face-to-face visit, the doctor or patient or both have to drag their atoms into proximity to each other. This has a cost, just like it costs Amazon thousands of times more money to send me a physical book than to send some bits to my Kindle. The transaction cost of a face to face visit is not just gas, parking fees, office overhead and the risk of a car accident. There is also a psychological cost. At times the streets outside my office are jammed with cars and patients come in late and stressed. Sometime their car breaks down. Sometimes they are late to pick up their kids at school. Sometimes they miss something else because of their commute time.

I spoke to a colleague last week who told me clearly that he could see no reason for telepsychiatry and thought face to face was always better. He works in a location which is hard to drive to, expensive to park at, and staffed by so many poorly paid and surly employees that one of  my other patients refers to this place as having a “patient prevention plan.” My colleague can see the possible disadvantages of something new like telepsychiatry, but can’t see any of the costs that he and his patients incur by his belief that only face to face contacts could work to help his patients.

AFAT has a big cost, it’s just that most people don’t see it. Telepsychiatry eliminates a lot of AFAT. That’s why there”ll be more telepsychiatry in the future.