Residents Dial Up Psychotherapy Experts

At the University of Kentucky’s residency training program in psychiatry, residents learn from experts dispensing wisdom thousands of miles away and work with patients who might not otherwise receive psychiatric care.

Debra Katz, M.D., is the residency training director for the general psychiatry and child and adolescent psychiatry programs in the department of psychiatry at the University of Kentucky College of Medicine. She moderated a two-year course in psychodynamic psychotherapy using teleconferencing equipment to bring nationally renowned experts in psychoanalysis to the Kentucky trainees. She talked about the course at the March meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Seattle.

The course was launched as a research project that sought to determine whether telemedicine is an effective method for teaching residents psychoanalytic theory, psychodynamic formulation, and psychodynamic psychotherapy skills. The American Psychoanalytic Foundation, Research Funds of the Cincinnati Psychoanalytic Institute, and the American Psychoanalytic Association funded the project.

When staff from the university’s large telemedicine department, Kentucky TeleCare, came to the department of psychiatry to demonstrate its teleconferencing system, Katz thought about her residents and the training possibilities such a system would provide.

“We have a medium-sized program, and like any other, we do not have experts on hand to expose the residents to every area of psychiatric training. New residency requirements stipulate that residents show competency in five types of psychotherapy, so accessing experts who can provide exposure is important,” she said.

Four professors collaborated with Katz to teach a two-year course in psychodynamic psychotherapy. The professors were Charles Brenner, M.D., of the New York Psychoanalytic Institute, and Fedor Hagenauer, M.D., Ed Kohn, M.D., and Marcia Kaplan, M.D., of the Cincinnati Psychoanalytic Institute, where Katz is a candidate in psychoanalytic training. Katz wrote a grant to fund the project in 1997 and began to moderate the course in 1998. David Goldberg, M.D., who is director of education at California Pacific Medical Center in San Francisco, designed the curriculum.

During the course, residents were seated around a conference table in a lecture hall. In the middle of the long table was a conference phone, or an augmented speakerphone with excellent sound capability. The image of the professor appeared on a television monitor next to the table, and the residents could see, hear, and interact with him or her. On the other end, in an office in the Cincinnati or New York psychoanalytic institutes, the professors could also see, hear, and interact with the residents.

As moderator, Katz had a number of important duties. “I made the group comfortable, made sure that the residents raised questions if they had puzzled looks on their faces, and made sure that the course was running smoothly.”

Shari Sistrunk, M.D., was one of the residents in the course. “The formal training helped. At the end of the two-year course, I felt much more comfortable making a psychodynamic formulation and coming up with specific treatment goals in my psychotherapy sessions,” she said.

Other residents benefited as well. Katz did some formal testing of the residents after the course ended. Looking at several subscales of the Psychiatry Resident In-Service Training Exam, she found that 73 percent of the residents’ scores had improved from the beginning of the course to a re-examination a year later.

Since the psychodynamic psychotherapy course was held, the residency program has conducted a course in child psychopharmacology taught by Tom Hunter, M.D., of the University of Miami and one in brief psychotherapy taught by Goldberg using POTS technology, which stands for “plain old telephone system.”

The POTS system used by the residency program is relatively inexpensive. The system is composed of a television; conference phone; a pan-tilt-zoom camera with remote control; and a ViaTV 8X8 “videocodec” unit, which converts visual information into a digital signal and sends that signal across a phone line to the other unit.

Rob Sprang, M.B.A., director of Kentucky TeleCare, said that unlike traditional videoconferencing systems, the POTS system is easy to use and can be set up anywhere that has a regular phone line; it does not require high-bandwidth communication lines.

The entire system, according to Sprang, costs no more than $3,000.

According to Sprang, psychiatrists from the university first used the POTS system in 1997 to conduct psychotherapy with patients with postpartum depression. After the initial success of that project, the University of Kentucky psychiatrists began performing home evaluations of children with suspected attention deficit/hyperactivity disorder and home-based psychotherapy for children who lived too far from Lexington to complete their therapy.

After the course in psychodynamic psychotherapy, Sistrunk, who is in a triple-board-certification program in pediatrics, adult psychiatry, and child psychiatry, decided to launch a pilot project using the POTS system. With the help of her pediatric supervisor and the support of the department of psychiatry at the University of Kentucky, Sistrunk began to conduct psychiatric consultations at the Northern Elementary School in Lexington in February 2000.

Students were referred to Sistrunk by their pediatricians, parents, or teachers because of some type of disruptive behavior. She first spoke with the parents to get the child’s history and then observed the child and the parents together.

“I was in a private office, controlling the camera so that I could either focus on the child’s face or else [zoom] out to see the child and the parents interacting with one another.”

Then Sistrunk interviewed the child alone. “Some of the children were skeptical toward the videoconference system at first, but many warmed up and enjoyed being the stars of their own TV shows,” she said.

If the child’s treatment involved medications, the child could be taken to his or her pediatrician, the University of Kentucky’s child psychiatry clinic, or the community mental health clinic in Lexington.

“The telepsychiatry consults drastically improved access to care for the children,” said Sistrunk, who said that the average time for a referral to a child psychiatrist is eight weeks. She reduced that time to two weeks with her consultations.

“Many of the mothers of these children were single parents with little or no money,” said Sistrunk, who found that a lack of finances was a significant barrier to getting these children to treatment.

“Telepsychiatry may not be the best thing for everyone, but in communities where the children wouldn’t otherwise get the help they need, it is very helpful,” she said.

Norman Alessi, M.D., chair of APA’s Telecommunications Subcommittee and director of the Psychiatric Informatics Program at the University of Michigan, agreed that telepsychiatry is not appropriate for everyone, but he first called attention to the word “telepsychiatry.”

Alessi said the word has no standardized meaning, and could apply to anything from e-mail or telephone correspondence between doctor and patient to a POTS system like Katz and Sistrunk use, to a traditional teleconferencing system with high-speed lines that deliver a near flawless image of the person on the other end.

Alessi, who evaluates patients using a traditional teleconferencing system, was careful not to generalize about the benefits or effects of telemedicine.

“We are at the beginning of an era in telepsychiatry, and we just do not know enough about what types of patients would benefit from psychotherapy, for example, with teleconferencing equipment.” Alessi said.

“Some people will not tolerate communicating via teleconferencing equipment because they can’t handle it cognitively or emotionally,” he said, adding, “I hope the federal government will sponsor more aggressive research to determine who will benefit from this type of therapy.” ▪