July 17, 2016

I Shrunk the Shrink and They Liked It

When I first began planning a personal/professional yearlong sabbatical in Melbourne, Australia I never expected that my experience with web-based telepsychiatry would profoundly change the way I treat children and their families.

I’d been practicing behavioral developmental pediatrics and family therapy in a suburban California office east of San Francisco for over thirty-three years. Then professional ennui and frustration with the American psychiatric industrial complex (insurance companies, the influence of big Pharma, etc.) led me to want to live and work in a different environment for a year. I wound up in Melbourne because I needed an English speaking country, the Australian doctors were welcoming and I could actually obtain an Aussie medical license (but it wasn’t easy).


Anyway, all the planning took about three years. In the months before I was to leave California I began to take steps to have my practice covered by a local child psychiatrist. But as the time grew nearer for my departure, I increasingly heard from the families I was treating that they were uneasy, worried and sad that they might have to work with another doctor. I began to seriously consider whether or not I could manage the families that I already knew from 7800 miles away.


I was lucky. Technology was rapidly changing during the time I was considering the plans for my sabbatical. I already had a few experiences managing college students via web-based videoconferencing. I knew video meetings were far superior to a session via the telephone. All the health insurance companies I had contracts with were actively recruiting doctors to participate in their telepsychiatry programs. So I knew that insurance was supporting the practice. My malpractice company had no problem with my being in Melbourne. Their only concern was whether the patients were all located in California (they were) where any legal action might occur.


E-prescribing was the last piece of the puzzle to fall into place. Electronic submission of prescriptions, including controlled substances – amphetamine type medications like Concerta or Adderall are an important part of any child-based practice in the United States – was being highly promoted in the months before I left. I joined one of the programs. I found I could be anywhere (even Antarctica) and as long as I had wifi, I could prescribe to local pharmacies in California instantly.


So I told my patient-families that I was prepared to continue to see them via the web if they were interested in my managing their treatment that way. The local child psychiatrist would remain available for emergencies. Local calls and faxes were all electronically sent via email to my laptop. Copayments could be made via PayPal or credit card. Insurance reimbursements were already all being sent electronically to my business bank account.


Not a single family declined the offer to continue. I wound up managing about seventy families, couples, and individuals over the year. About five families left the practice – but I believe they left for other reasons besides the fact that their view of me had shrunk to the size of a laptop or iPad screen. I was impressed with the effectiveness of the video encounters. I would give the video experience a 0.9 overall to the 1.0 of a face-to-face. In contrast earlier audio limited telephone calls rated as only 0.6 in my mind.


There are many academic studies to support the video to face-to-face equivalency of encounters in psychiatry and psychotherapy. Video has its advantages especially in providing services to remote or underserved areas. But I was surprised to find in this affluent, sophisticated suburban practice that many of the persons I saw preferred the video screen to the office visit. The children talked to me more on screen than they did when we were present together in my office. I speculate that they may have felt more overwhelmed with me in person and that they are in general quite comfortable with screens.


But I was even more surprised by the number of adults who said they preferred to meet me via video than in person. Besides the convenience, some said they simply felt more relaxed and comfortable in the video than live setting. I had many intense and challenging sessions with patients during the year so it cannot simply be that the experience was easier. Traditional analysts will go to town on the “transference” issues in teletherapy. But I’m a pragmatist and must then say that the telepsychiatry experience worked for these people during the year.


There were challenges.   A 45-50 minute session without a single audiovisual glitch was a minority but it was also rare that any session was so compromised by technical problems to be made useless (I’m talking about a few hundred sessions). A family’s ability to be organized and prepared for the video session was generally consistent with their overall organizational skills. I asked parents to set up their screen in a private part of the house and keep the kids away initially. Frequently many families would set up the screen in the kitchen or family room. Then I’d have to tell the parents to send the kids to their rooms or play outside for a while.


I had people meeting me in the front seats of their cars. One college student met me in the stair well of his dorm. And one man who had confessed an illicit affair to me would only meet me in a motel where he could be certain he had total privacy. He wound up telling the manager his sixty-minute assignation was with his doctor not his mistress.


But overall the telepsychiatry experience was so positive that I intend to maintain at least one day a week of this web-based practice when I return to California. I will still spend most of my hours in my office. But I will offer the screen to those patients who would find it difficult to get to my office -- and for those who actually prefer to see me on a laptop than in person. I will still see all my patients at least occasionally in person. You do miss their foot tapping or how much weight they’ve put on when you can only see them from the waist up. But you don’t miss much.

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