Suddenly Becoming a “Virtual Doctor”: Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Study Participants and Sampling Strategy
Analysis
Results
Characteristic | N | % |
---|---|---|
State | ||
New York | 8 | 40 |
California | 6 | 30 |
Washington State | 3 | 15 |
New Jersey | 2 | 10 |
Louisiana | 1 | 5 |
Primary practice setting | ||
Private practice | 11 | 55 |
Private practice plus other setting | 3 | 15 |
Hospital outpatient clinic | 2 | 10 |
Othera | 4 | 20 |
Years in practice | ||
<10 | 6 | 30 |
10–20 | 3 | 15 |
≥21 | 11 | 55 |
Previous experience with telemedicineb | ||
None | 11 | 55 |
1%–4% | 2 | 10 |
5%–10% | 7 | 35 |
Minimal Use of Telemedicine Before COVID-19
Extensive Use of Telemedicine in March 2020
Telemedicine modality (%) | ||||
---|---|---|---|---|
Participant | Primary practice setting | Phone | Video | Video platform |
1 | Private | 0 | 100 | thera-LINK |
2 | Private | 25 | 75 | Zoom |
3 | Private | 5 | 95 | Doxy.me, FaceTime |
4 | Private | 25 | 75 | Doxy.me, Skype, FaceTime |
5 | Private | 30 | 70 | Zoom, FaceTime, WhatsApp |
6 | Private | 100 | 0 | NA |
7 | Private | 10 | 90 | Doxy.me |
8 | Private | 1 | 99 | Doxy.me, Zoom, FaceTime |
9 | Private | 2 | 98 | Zoom, Doxy.me |
10 | Private | 5 | 95 | Clocktree, Google Meet |
11 | Private | 33 | 67 | FaceTime, Zoom |
12 | Community mental health agency and private | 90 | 10 | Zoom |
13 | Hospital outpatient clinics and private | 35 | 65 | Zoom and FaceTime (hospital clinics), Skype (private practice) |
14 | Community mental health center and private | 100 | 0 | NA |
15 | Federally qualified health center | 5 | 95 | Doxy.me |
16 | Hospital outpatient clinics | 10 | 90 | Zoom |
17 | Hospital outpatient clinics | 100 | 0 | NA |
18 | Nonprofit agency contracted with Medicaid | 98 | 2 | Zoom |
19 | Nonprofit clinic | 100 | 0 | NA |
20 | Community mental health center | 95 | 5 | Zoom |
Impacts of Telemedicine on Psychiatrist-Patient Interactions
Characteristic | Illustrative quote |
---|---|
Positive impact | |
Helpful to see patient’s home environment | “One advantage is that I get to see people in their environment, [which] gives me a little bit of extra information, and . . . often they are in the middle of work, so now I see them in a more informal environment.” “If their home is disheveled, I can see that, so that’s useful. Sometimes I do have patients whose apartments are a mess. With those patients, I . . . do one video session just to see what their homes look like, to get that information, the reality of the situation and how bad it really is.” |
Some patients are more relaxed at home or over the phone and can be more forthcoming | “They’re more relaxed, and so they tell you a lot more about things you would not otherwise hear about, just because it’s like you’re a friend on the phone.” “I definitely had one patient with social anxiety who told me that was explicitly why he wanted to do a phone session, and [he] was much more forthcoming than he’s been before.” |
Improved access for certain underserved patients who could not be seen in person before the pandemic because of logistical challenges | “I’ve been able to reach some people . . . who may be wouldn’t have come, because they weren’t that motivated or they had forgotten about the appointment. But because I did call them at home and they weren’t otherwise busy, even though they wouldn’t have planned to come into the clinic, I reached them, and they were willing to speak with me.” “It’s allowed us to engage with the patients that previously were having problems engaging because of either logistics or time.” |
Negative impact | |
Less information to support diagnosis and treatment and inability to use all senses | “It makes my job a little bit harder because especially for newer clients when I’m trying to do an assessment, I’m losing a lot of information [by not observing] them directly and their mannerisms, especially if patients may have psychosis.” “It definitely affects the efficacy of the assessments. Especially for intakes, I don’t even know who this patient is, and sometimes, especially when I want to choose a medication, . . I am trying to figure out if they have obesity, [which] is more difficult now. And I really like interacting with people—the facial expression is very important to me—I’m missing this part with telemedicine.” “There’s an austerity that . . . creates a distance. Sometimes it’s harder to tell if someone tearing up . . ., [which is a] big red flag that says, ‘Go. Follow that. What’s going on now?’ That’s a really important visual cue. Sometimes, you just can’t see quite as well, or just the connection isn’t as good. Some of the nuance around more subtle emotion is lost.” “There’s a lot of information you can’t get [via video]. Also, it must be in person for forensic evaluation; if someone’s in jail, I have to go see them [there]. None of the jails that I work with at this point have video capacity. If you’re trying to assess if someone’s malingering or lying, you’ve got to [meet them] in person.” “I want to see the patient in the waiting room, how they’re interacting with other human beings. I want to hear their voice through the door, if they’re arguing with the nurse. I want to watch them, the nature of their gait when they walk into the room. I want to see how much effort it takes them to sit down or get out of a chair. I want to smell them . . . if they’re malodorous or not. I want to see if [someone] has gone through a lot of effort of putting cologne on. I want to use all my senses in this experience.” |
Less privacy in the home setting | “Right now, patients have to go hide in the bathroom, and they might be talking about their family members who they’re having conflicts with, and they have to whisper. When they’re in my office, they don’t have to worry about [this].” “There’s a few people for whom their home and the people they live with doesn’t feel as comfortable or private of a place to talk as the clinic.” “I have patients who are sitting in the closet when they’re doing a Zoom call with me, or people who go out on a walk, not because they prefer the telephone, but because it’s the only way they cannot be overheard.” |
Challenges with hearing patients clearly by phone or video | “Some people have a problem speaking clearly, and this is probably a characteristic of their illness or just their communication style. But that can be very difficult over the phone. I sometimes have to ask people, ‘Can you speak clearly?’ or, ‘Can you just try to speak a little bit louder?’” |
More distractions in the home setting | “Some people really struggle, and it seems that it’s hard for them to stay present or just focus on what we’re doing. Maybe they’re trying to multitask. Maybe they’re not really comfortable.” “You’re not quite as emotionally connected to a person when they’re on video, and it’s easier to get distracted.” “This is a doctor’s appointment. It’s kind of a big deal. It’s not you talking to your mom on the phone twice a day. You get this once every 3 months, and you need to pay attention. You can’t be putting the laundry in the dryer.” |
Inability to do a physical exam and take vitals | “I can’t do certain things like blood pressure . . , which I like to take when people are on medications that can affect blood pressure. That’s a concern, so I’ve just been having people monitor it on their own instead.” “Just checking vitals . . . that’s really challenging.” |
Difficulty to assess movement disorders induced by antipsychotic medications | “When I’m prescribing antipsychotics . . . I don’t yet have a modality for evaluating patients for symptoms of any movement disorder by video. I do have them perform a couple of maneuvers to see if I can elicit any symptoms or signs of extrapyramidal symptoms. But I haven’t yet come across a standardized proven version of being able to do that by video that would substitute for a live examination, because a few maneuvers . . . require me to physically examine the patient.” “I have a patient who is on Haldol, [and] it’s been hard to look for any [extrapyramidal symptoms].” |
Visits tend to be shorter and do not go into as much depth | “I started with phone appointments, and some of them . . . would shorten the session and stop early, but if they do FaceTime, they get more engaged with the process.” “The [video and phone] sessions tend to be shorter sometimes, and I feel in person, you might be able to get more information.” “So far, especially when they’re [on the] telephone, [it is more of] a check-in.” |
Difficulty to manage time in telemedicine visits | “They’ll talk on and on [on the phone]—it’s hard to stop them at the end of a session . . . but the video really does help. You can see them. They can see you.” “It is difficult to end sessions. In person, at the end of the hour, I lean forward in my chair, and I don’t have to say anything.” |
Positive Patient Response
Sustainability of the Telemedicine Model
Plans for Telemedicine After COVID-19
Lessons Learned
Strategy | Quote or specific application of strategy |
---|---|
Start each visit asking whether the patient is concerned about privacy and take steps to ensure that the patient is in a private place. If there is no privacy, reschedule the session. | “I always ask people if they’re comfortable with the level of privacy they have, and we try to problem solve if they say no. Maybe they say yes, but then they worry that somebody is listening or overhearing them.” |
Brainstorm with patients about their options for finding a private place for visits. Some patients have used their car, a closet, or a bathroom or have gone on a walk. Offer these options to patients. | “People have been creative. I’ve had a couple of patients go to their car outside their house . . . so that they could have some quiet and are able to concentrate on the visit.” “I would encourage practitioners to encourage their patients to be as creative as necessary to establish that safe space where they can have their psychiatry sessions. I’ve had patients who didn’t feel that they had enough privacy in their own homes, but they would either sit in the car in the driveway, or they would drive to a place where they felt that there was privacy, and they would sit in their car with their smartphone or their iPad, and we would do telepsychiatry.” |
Ask the patient for his or her location and a call-back number at the start of each session. This will be helpful if you are disconnected, or if there is an emergency. | “Patients need to tell me where they are. I think Medi-Cal is expecting us to document it, and if there’s an emergency situation, we do know their location, and we can send first responders.” “We’re actually entering the actual address of each patient at the time of the phone call or the video call.” |
Conduct video visits from the same spot in the home or office, rather than switching locations. This is reassuring for patients. | “[At home] I’m going to set up in exactly the same place every time.” |
Provide FAQs that explain how to change the background (i.e., options to not show your surroundings) on platforms like Zoom, because some patients are self-conscious about video and don’t want the clinician to see their home environment. | “I have suspected that a few patients don’t want to do a video session because they don’t want me to see their space.” |
Call each patient before the telemedicine visit to explain what to expect and why telemedicine is being used. | “It is very important to inform the patients in advance . . . because especially in psychiatry, [patients] don’t like short notices. Some patients get nervous when they are not familiar with the situation, but when they [know] what is going to happen, they feel much more comfortable and make themselves available.” “They also get a phone call ahead of time telling them not to come into the office and that I’ll reach out to them at their appointment time.” |
Identify patients “at risk” of having difficulty with video visits (e.g., older adults and adults with cognitive impairments), explore whether someone in their environment could aid them, and conduct test calls with this population. | “I had one patient [with whom] I did FaceTime, and her daughter showed her . . . If there was somebody who can help them work through it, it’s easier.” “We really took our time identifying the patients that are most at risk and explored how we can guide them over one, two, or three phone calls or see if somebody in their environment can assist them. We also have case managers that can visit [and help] patients.” |
Choose a platform that ensures that the patient will not see your personal phone number, or work out a process to block your personal phone number. | “The biggest issue that I contend with is that FaceTime for the most part requires the patient to see your cell phone. And I don’t use my personal cell phone for psychiatric patients I see.” “For telephone calls, I’ve been using my home phone and blocking its number.” |
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