Hybrid Relationships With Your Patients: In Person and Online

Psychiatrists are increasingly being asked to see their patients in a hybrid manner—both in person and online—and to use a variety of communication technologies to interact with patients and their families. These new technologies potentially stretch the boundaries of the traditional doctor-patient relationship beyond those that are historically comfortable for some physicians.

What then should be the response to patients who would like to be able to contact their psychiatrist electronically? Perhaps they wish to have 24/7 communication on secure email or through an electronic record–mediated messaging system? Maybe they want to be seen at home using telephony or videoconferencing? Could you join them as a partner to monitor their eating and lifestyle on a shared app? Do they want to be able to text messages, or even send video attachments of recordings they have made of themselves for opinions or responses? Are they asking to connect via social media such as LinkedIn or Facebook? Can they monitor themselves via various apps and download the data to your computer? Do they want to accompany you on a trip through a multiuser games environment such as “Second Life” where they can relive some past traumatic experiences in a virtual world?

The use of telepsychiatry and multiple other health technologies is rapidly becoming the norm in psychiatric practice. Since many of our younger patients are “digital natives” and have never lived without the presence of the Internet in their lives, the use of technology is a normal expectation. At the same time, older patients are becoming more technologically sophisticated and increasingly keen to access care in the home. What then are the significant clinical points to bear in mind when adapting to these patient needs?

Patients are comfortable and eager to use technologies to receive their health care, as evidenced by the high rate of patient satisfaction found in telepsychiatry studies. Hybrid psychiatrist-patient relationships across multiple technology platforms are becoming a standard part of practice that patients are frequently requesting. These help to foster communication and rapport within the therapeutic relationship, although boundaries around interactions are critical to establish (for example, when to use what technology). There is a growing and robust literature base showing that both assessment and treatment can be done with equal effectiveness online compared with in-person treatment, with some patient groups preferring online treatment and having possibly better clinical outcomes (for example, children, patients with PTSD).

There are no absolute clinical contraindications to the use of telepsychiatry and health technologies, and a number of excellent guidelines and resources are available from the American Telemedicine Association. These include guidelines for both adult and child telepsychiatry. Another good and heavily utilized resource is a telepsychiatry toolbox of about 30 short videos on APA’s website.

Psychiatrists need to be mindful of the impact of these new processes on the doctor-patient relationship and in particular as it is leveraged in team-based care, which inevitably will add to the complexity of relationships and interactions. Learning how to manage new components that hybrid relationships bring to doctor-patient relationships will be challenging. For example, psychiatrists need to ensure that appropriate professional boundaries—ethical, physical, technical, and time-related—are maintained. Establishing expectations for patients around and respect for boundaries is an important piece of this management.

The success of the doctor-patient relationship of the future will be based on the ability of this dyad to form a trusting and safe relationship over multiple technologies to create a healing environment. Technology can enhance this relationship by providing more frequent and convenient interactions along with improved access to care, possibly anytime, anywhere.

Without a doubt, the number of possible approaches to technology-enabled psychiatric care will increase rapidly, incorporating more mobile care and virtual consultations and monitoring that will be multidirectional. Virtual reality and increased algorithmic screening of patients, use of facial and voice recognition technologies, as well as the combination of multiple data sources and predictive assessments, will be part of psychiatric practice. This will be facilitated by the capacity to do big data analytics in real time, drawing from massive datasets of both genomic and phenomic data sources so as to customize treatments to an individual level, creating truly patient-centric care. Whoever dreamed that psychiatric practice could ever become routine? ■

APA’s telepsychiatry toolkit can be accessed here.