I really didn’t notice much difference between staying at home and doing several hours worth of telepsychiatry versus doing face to face visits in my office. However, I was acutely aware of how important it is for me to get myself organized at home and how useful a dual monitor would be when I get around to buying one.

In my practice office, I’ve got the supplies I need at my fingertips, and have routines for the usual things like writing and printing prescriptions, making return appointments and taking payment.

I didn’t have any of these things really set up at home, and I really noticed what a difference it makes for me to have things better organized. This wasn’t really much of a surprise, but I did notice one thing that was much better at home: my efficiency at using my computer and doing telepsychiatry at the same time.

At work, I typically use a desktop computer to do Skype, and type on a laptop to take notes. This is a little silly, I know, but I’m usually using the laptop with my face to face patients, and so sticking with the laptop at work means doing what I’m already doing anyway.

A couple of years ago I bought a 30 inch computer monitor. With this much screen space, I can easily use Skype on one side of the screen and do notes on the other side. (The laptop I use at my practice was locked in the file cabinet at my practice when the blizzard came, and I didn’t have access to it the day I was doing so many Skype visits.)

Telepsychiatry intrinsically requires some multi-tasking if you are taking notes while you see the patient: you have to look at the patient most of the time, but you also have to look at where you are typing part of the time so you can correct your typing.

Having a big screen or two monitors really makes a difference when I need to do more than one thing on the computer at one time and be efficient about it. When I’m talking and typing, I really don’t have time to be moving the mouse all over the place and clicking icons to switch from one window to another.

I’ve been told that one of the best means that many people can use to increase their productivity on a computer is to go to dual monitors or a big screen.

I’m very certain that this is true, and I would suggest that people doing telepsychiatry really go for a dual monitor system.

I actually saw patients almost all of one of the days of the blizzard, did a lot of Skype video calls, and a lot of telephone calls, too.

I really noticed the age effect on telepsychiatry on that day. Basically, about half my patients that day were below about 30 years old, and the other half was over 30.

Pretty much all the 30 and under crowd had Skype set up on their computers and things went very well except for a couple of people who didn’t have Internet access because of the storm.

A couple of people over 30 Skyped in; most called in instead.

The age effect is really striking to me.

I’ve been pondering what to make of this. I know that I have to do my best to take care of all these people, but it is really clear to me that I’m doing a better job with the younger patients (because of Skype) than the older ones on days where people can’t get to their appointments.

In my last post, I mentioned that I’m becoming more insistent that patients who are frequently sick enough to go to the hospital get set up for Skype, but what about the rest?

Not so sure what the best thing to do for the over-30 crowd. Education in what Skype can do, or wait for them to come to it in their own time?

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.