Before saying anything about the document though, it’s worth pointing out that “Evidence-Based Medicine“  (EBM) is one of those straw man topics like  motherhood and apple pie.  Nobody is really against applying the scientific method to medicine. However, some EBM zealots have very little knowledge of clinical medicine, and that can be a big problem.

I’ve been a researcher and a clinician for a long time. Researchers usually plan studies on patient groups that are homogeneous as possible, so as to make their results more clear. Clinicians have to deal with patients, and real patients don’t always fit in a clear diagnostic category. Researchers look at ideal groups, clinicians deal with real patients. That’s the problem. This doesn’t mean that research doesn’t apply to patients, just that, as far as I can see, clinical practice will never be 100% scientifically based.

Some of the biggest proponents of EBM are insurance companies. From their standpoint, why should they ever pay for any services that aren’t EBM? It’s a great way to save money while hiding under the motherhood and apple pie rhetoric. The problem is that insurance companies are not credible interpreters of scientific research.

Here’s an example. I have a patient who does well on a slightly higher than usual dose of venlafaxine, 450 mg per day rather than the usual maximum dose of 300 mg/day. There’s at least some evidence that giving higher doses of this medication helps some people. However, every six months, the patient’s pharmacy benefits manager for this patient refuses to approve the patient’s prescription, stating that I’m giving her too much, and that there’s no evidence that she should be on this much medicine. I send the pharmacy benefits manager the same three articles I sent them six months before and they generously allow the patient to continue her medication. After about the third round of this, I talked to a supervisor at the pharmacy benefits manager and was told that their program was “strictly based on evidence-based medicine.” The fact is, the pharmacy benefits manager doesn’t give a damn about EBM, except as a way to deny people benefits.

Now, I’m not trying to say that EBM is a scam, because it isn’t. EBM is being used for some really good purposes like deciding on which prostate cancer treatments are better than others. Real EBM is great for medicine. Fake EBM in the hands of insurance companies is nothing but a scam.

Sorry for the rant. Anyway, the American Telemedicine document is well organized and I applaud the committee who wrote it on a job well done. Most key questions that any clinician would have about telepsychiatry are answered. I’ll summarize part of what I took from the document.

• Can patients be reliably assessed, diagnosed and treated by real-time audio-video sessions? Yes.
• Is it possible to do emergency evaluations via telepsychiatry? Maybe.
• Does it work for inpatients? Don’t know.
• How does it interact with the therapeutic relationship? Sometimes it hurts, but sometimes it helps.
• Are technical issues like video resolution important? Perhaps, but probably not at the current level of technology.
• Does it help the under served? Undoubtedly.
• Can you do individual therapy this way? Yes.
• What about group therapy or marital therapy? Probably.
• Does it work for the elderly or those in prison? Yes.
• Does it work for children and adolescents? Probably better for adolescents than young children.
• Does it help in reducing seclusion and restraint? Maybe.
• Does it meet the criteria for an exam for involuntary commitment? Don’t know.

Anyway, I highly recommend this report for anyone who is interested in the evidence that telepsychiatry works. Let hope those EBM folks at the insurance company show a little integrity and read it too.