I guess what I’ve been thinking about is the term “prudent.”

I’m sure that most psychiatrists in my area aren’t using video Skype with their patients, so I guess “ordinary” doesn’t apply anyway, but I’m beginning to wonder whether it is prudent to avoid the use of telemedicine these days.

As I’ve mentioned before, the usual criticism of telemedicine is that it may not be as good as face-to-face in some circumstances. I completely agree that that criticism is true. However, often the proper comparison is not between video telemedicine and face-to-face visits, but between telephone call medicine and video telemedicine.

I would be surprised if there was any valid argument that video Skyping someone would be worse than calling them on the telephone. After all, you get the same information as you would get on a telephone call, but with a video call you also get to see the patient as well as talk to him or her.

I’m aware of plenty of situations where I’m sure that the local “standard of care” would dictate that I really need to see the patient, not just talk with him or her on the phone. I’m aware of at least one physician who got into trouble for basically just refilling patient prescriptions over the phone for years and never seeing the patient face-to-face to make sure that there was some oversight over whether the patient really needed to be taking the prescription in the first place. I’m pretty sure, but not certain, that I can’t just manage a patient indefinitely but talking to him or her on the phone for a few minutes and never really seeing them in the office.

A doctor can’t do everything over the telephone; that’s pretty clear. I’m sure that I can’t do everything with Skype either; that’s pretty clear, too.

But I wonder. There’s a lot of things that I do that I feel pretty comfortable doing on Skype that I don’t feel as comfortable doing on the telephone.

We’re back to the same problem of comparison that I started out this blog entry with. It seems to me that there are some cases where a prudent psychiatrist would do something after having a Skype video conversation but not after a telephone call.

It seems to me that “prudent” is going to include at least the possibility of telemedicine for many psychiatrists fairly soon. Whether or not they want to do it, at some point it’s going to be unavoidable because I believe enough people will adopt it that there will be the same kind of network effect that happened with fax machines. Having the only fax machine in the world is useless, but at a certain point you pretty much have to have one because everyone else does.

I’m not sure that having a fax machine is the standard of care in my community, but I can’t think of anyone who doesn’t have one, and I would sure would hate to try to explain why I didn’t do anything if something went wrong because labs couldn’t send me faxes and everything went through the mail.

I wrote that section because I doubted that there was any case law on emergency petitions and telepsychiatry.

In Maryland, certain mental health professionals (physicians, psychologists, licensed professional counselors, clinical nurse specialists in psychiatric and mental health nursing, and psychiatric nurse practitioners) can seek an emergency petition to have a person evaluated for a psychiatric admission, potentially against that person’s will, by filling out a form asking a police officer to pick up the person and bring that person to the nearest emergency room for a psychiatric evaluation.

There are some laws (Maryland Code, Health-General Article 10-620 et seq.) governing this procedure, but, to my knowledge, much of what judges go on in cases where someone feels the law wasn’t followed properly is based on case law.

The Maryland Code says that the mental health profession who seeks an emergency petition has to have examined the patient. I’ve been told by various forensic psychiatrists that I have to have examined the patient in the last week (or perhaps two weeks, depending on whom I spoken with) for me to be able to seek an emergency petition. I’ve also been told that a phone call doesn’t count as an examination, so if I haven’t seen the patient in a month, say, then I can’t really fill out an emergency petition because I haven’t examined the patient recently, even if I speak to him or her on the phone.

If my understanding is true, then telepsychiatry is an interesting case. Have I “examined” the patient sufficiently for an emergency petition, or not?

I don’t really want to be the person who finds out the answer to this question, but I’ve decided that I’ll do what I’ve always been taught is the “Golden rule of forensic medicine:” Always be a doctor first, don’t try to be a lawyer. I think I’ll just do what I would normally do if I were face-to-face with the patient. Hope someone else gets to find out if this is the right decision….

I tried to write it in fairly plain English, unlike my HIPAA form , which is so complicated that I don’t really understand half of what it says.

Although I agonized over this informed consent form for a while, I realized that much of it was fairly straightforward. Many of the risks were technical, the benefit was mostly convenience, and the alternative to telepsychiatry was to do what I’ve been doing.

However, I did put in some language covering specific situations, because I’ve thought about certain potential problems:

• I can’t necessarily get the same information that I would get if the patient and I were face-to-face.
• Emergency care might be harder via telepsychiatry.
• Either the patient or I can call it quits if either of us doesn’t think it is working well.
• Neither of us can make recordings of the session.
• Both of us have to know if there is a potential for anyone else to hear our conversation.

I’m sure that I’ll modify this form as time goes on, but at least it’s a start.

Up until now, one of the key issues for me was that I sometimes need to see someone for an emergency visit, and, because my office and my residence are within walking distance of each other, I’ve seen patients, at various times, on every day of the week.

Last week something happened that made me realize that I don’t  need access to an office seven days a week. I needed to have a session with someone and just did telepsychiatry from my home office rather than my practice office.

I think it may be a little in the future, but I can see a time when I might be able to handle more and more of my emergencies by Skype rather than having to go into my office.

This is a little tricky because some emergencies are clearly better handled face-to-face rather than via Skype, but my experience last week made me realize that as telepsychiatry develops, a different business plan might make more sense for my practice. Right now, my office is sitting empty most of the time, and I can see how a group of psychiatrists doing telepsychiatry could easily get together, rent some space for face-to face-visits with  individual patients, and do more and more of their work out of their home rather than their practice office. The default could be telepsychiatry, with office visits no longer being the norm.

Rent is a pretty significant part of my overhead, and cutting it by 50%, say, would really be something worth thinking about.

Psychiatrists (and mental health workers in general) have always had a somewhat different relationship to hospitals and other institutions than other professionals. A surgeon pretty much has to have some relationship with a hospital, and can’t really do surgery without some kind of team behind him or her. Mental health work is different. The institution doesn’t tend to do much for psychiatrists seeing outpatients (as opposed to inpatients) other than feed them patients and, ideally, do enough work for the psychiatrist to justify the overhead that the institution adds.

I’ve been in a lot of situations where the overhead from the institution (rules, regulations, meetings, visits from JHAHO, fees for administrative services, poor collection policies) far far exceeded the value they brought to the outpatient setting.

I’m not trying to say that institutions don’t provide some value on the inpatient side, because clearly they do, but one of the best things about a solo private practice with no employees other than myself is that my overhead is much less than I think it would be if I were attached to some institution.

Telepsychiatry might just bring that overhead down some more. I need to think about setting up my home office a little better than it is….

I still can’t see an easy way to get around this problem, but I did notice something this week that made a difference to how I’ve set up the webcam I use with Skype.

I was having a Skype conversation with the parent of a patient, and I noticed that the video I was getting from his side clearly was using some face-tracking software because whenever he moved his head, the camera would tilt, pan and zoom to keep his face in roughly the center of the picture.

When I installed my Logitech webcams,  I did what I suspect most other people do—I just ran the install CDROM , got to work, and never read any of the documentation.

What I didn’t notice when I installed the webcams were all the special bells and whistles that Logitech provides. I clicked on the Logitech icon in the System tray, looked under Camera Settings, found an item for Face Tracking and checked the box. Voila! Now the camera not only follows my face when I move around but it zooms in on it too.

Not a gigantic improvement, but I (and my next Skype patient) thought it made a noticeable positive contribution. The only problem with it is that the face tracking software gets a bit confused if I move my hands around in front of the camera—it looks to me like the face-tracking software isn’t that sophisticated just yet, but it certainly works well enough to be more of a help than a hinderance.

Another problem is that although I used Windows at my practice, I tend to use Ubuntu Linux on all my other computers and the Linux drivers don’t support the face-tracking yet. It’s hard for me to imagine that the face tracking is built into the camera’s firmware. I would suspect it is in the driver software that interfaces the camera to the operating system, but I’m not really sure. I hope someone in the Linux world is working on this problem….

I think that there is a psychological reaction to telepsychiatry that relates to how both the patient and the psychiatrist experience the encounter when it takes place over the Internet rather than in an office.

The first two psychological issues that come to my mind are:

• The patient and the psychiatrist each come with some attitude toward the technology, and
• The patient and the psychiatrist are in the same environment when they are face-to-face, but not when they are doing  telepsychiatry.

Regarding attitudes toward technology, I’ve certainly come to appreciate just how big the differences are between me and some of my patients. I work part time as a psychiatrist, and part time as an engineer. Not much about technology scares me, and I’m intrinsically friendly toward trying something new. Some of my patients share my attitudes, and some clearly do not. There is a clear age effect: I can’t think of one person under the age of 30 who has had trouble navigating my website or printing an Acrobat document. Among people who are age 50 and above though, I find that a substantial fraction don’t really understand hypertext links, what the scrollbar does, or how to use the back button on a browser.

It takes time for people to adjust to new things, and telepsychiatry isn’t any exception. If someone is phobic of technology, I see that as a problem worthy of treatment. I remember an therapeutic interchange I had with a 80 year old patient a few months ago. The patient lived alone in a rural area, and was just barely able to take care of herself. Her daughter, who lived a few miles away, was very worried for her mother’s safety and begged and begged her mother to carry a cell phone with her so that she could call for help if something happened to  her. The patient stubbornly refused to learn how to use her cell phone. I spent about 20 minutes with the patient one session working on this problem. It took 19 minutes to get the patient to overcome her resistance to trying something new and less than one minute to teach her how to push the speed dial key on her phone that would call 911 if she needed help. At the end of the session, the patient said, “I would have learned this a long time ago if I knew it was this easy.”

This isn’t to say that I can’t think of ways that the patient or the psychiatrist couldn’t get justifiably irritated by technical problems or a slow Internet connection. I also can’t see any reason why normal transference and countertransference issues couldn’t relate to the technology for telepsychiatry.

However, I believe the environment is probably more important for telepsychiatry than technophobia. In a face-to-face session, the patient and psychiatrist are in the same environment, while in telepsychiatry the patient and the psychiatrist are in different environments. When a patient comes to see me, we are both in my office together, and I try to keep the office quiet and to avoid interruptions. Because I have a fair amount of control over my office space, I can make sure that patients have a cup of tea or a glass of water if they want and that their session is not interrupted.  The patient has a few moments while waiting in the waiting room to settle down and think about what they want to say before they come through the door to my office.

The “teletransference” is highly dependent, not only on my environment (which I can control to some extent), but on the patient’s environment (which I can’t control at all.) I realize that I need to think about some straightforward things about my environment (such as what is in the background when I’m on Skype.)

A bigger issue though, is that I obviously need to think about how to help a telepsychiatry patient shape his or her environment to make the interaction better. Some obvious things come to mind:

• Privacy,
• Quiet,
• Comfort with the technology, and
• Freedom from interruptions.

I’ll write more about how to help the patient shape his or her environment in a later post.

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.