Child telepsychiatry

[Merovinge]

I was recently looking at a moonlighting position for Child/adolescent psychiatry moonlighting and was curious if anyone had experience in this?

Details:
- 20 min med f/u, 45 min intake, complicated f/u can be extended to 30 minutes
- contained in a clinic with full staff but no CAP - pt is checked in, vitaled, and then a "liason" who is not medically trained stays in the room with the patient/family
- The actual video conferencing is all done by a laptop they send me, just need a place with stable high speed internet (not a problem for me)

I did not receive telepsychiatry training in residency and just curious how people have found these jobs previously, any specific pitfalls or things to clarify/ensure?

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[PistolPete]

Too short f/u and intakes in my opinion. This could work for adults but not for kids, in my opinion.

 

[milesed]

It's fine if you are already able to be pretty quick with in-person visits. I see kids in similar set up and have 15 min return and 30 minute new patient eval times. My only issue is with the hardware getting about a 1 second delay. If anything is off with the system it can just cut off. Make sure they have a fully tested system and someone in IT to call who can quickly get onto problems for you.

Also, make sure you train the staff who do vitals. I always specify to have shoes, coats off, BP cuffs must be appropriate sizes, etc.

 

[TexasPhysician]

I'd prefer longer times as well. The resolution is not as great as I would like, so I would compensate by spending more time with patients.

 

[hamstergang]

AACAP has practice parameters on telepsych that may be worth checking out.

 

[Merovinge]

Too short f/u and intakes in my opinion. This could work for adults but not for kids, in my opinion.

I technically get 30 min apts in fellowship but we have to do our own vitals/get our own patients (often with a line for the one BP cuff for the whole office) which leads to 25 min at best. I think 20 minutes would be doable if the patients are somewhat less ill on the whole, which I am led to believe that they will be.

I'd prefer longer times as well. The resolution is not as great as I would like, so I would compensate by spending more time with patients.

That's a great point, I would definitely like to try before I buy with the equipment, although I am not sure that would be feasible.

AACAP has practice parameters on telepsych that may be worth checking out.

Awesome, will check this out, feel silly not thinking of this first.

 

[DD214_DOC]

I have trouble seeing this working well

 

[nancysinatra]

Make sure they have a fully tested system and someone in IT to call who can quickly get onto problems for you.

This is just my experience, but the places that are most reliant on telemedicine are in rural areas, and good IT can be hard to find. It's a vicious cycle. At my current telemedicine job, they have this horrible IT guy, who sometimes doesn't even come to work, and when he is at work, he doesn't do anything. But they can't fire him because there's no one else for 50 miles who would probably know a thing about IT. Same thing hiring front desk staff who will book appointments, and that's not even a technical job.

 

[nancysinatra]

I'd prefer longer times as well. The resolution is not as great as I would like, so I would compensate by spending more time with patients.

Are you doing telemedicine too? I am working for a clinic that currently has a pretty horrible video system, and the last thing I want to do when the video is cutting out or there's an audio lag is spend MORE time with patients. I think patients probably feel the same way.

 

[nancysinatra]

I was recently looking at a moonlighting position for Child/adolescent psychiatry moonlighting and was curious if anyone had experience in this?

Details:
- 20 min med f/u, 45 min intake, complicated f/u can be extended to 30 minutes
- contained in a clinic with full staff but no CAP - pt is checked in, vitaled, and then a "liason" who is not medically trained stays in the room with the patient/family
- The actual video conferencing is all done by a laptop they send me, just need a place with stable high speed internet (not a problem for me)

I did not receive telepsychiatry training in residency and just curious how people have found these jobs previously, any specific pitfalls or things to clarify/ensure?

That's more time than I get for most of my telepsychiatry intakes. I don't see kids though. It might be different. But I find that telemedicine actually facilitates the 20 minute med check appointment pretty well. No one wants to be in front of a screen for much longer than that. I'm not saying it's good psychiatry, but I personally find it easier to quickly wrap up a telemedicine meeting than an in-person meeting.

I don't think anyone is getting much telepsychiatry training in residency. The people who run residency programs by and large don't have much experience with it. I actually like doing telemedicine because it gives me an opportunity to devise new solutions to problems that not many people have thought about before.

But telemedicine has problems. I find that the worst cases are where patients are on the extremes of age and cognitive status.A few times my clinic has made me see dementia patients by telemedicine, and every time, it is a disaster. You can't do a MOCA, you can't do any kind of neurological exam even if you think you should, and often the patients can't hear.

I wonder if kids might have some parallel issues? Will they cooperate, for one thing? (Or, maybe kids will be the perfect telepsychiatry patients...) If parents and teachers have to fill out forms and bring them in, how will you read them? I am guessing that if there's no CAP at this place, that they haven't fully tested the process yet, and there will be kinks to work out.

 

[DD214_DOC]

The per session times are ok. You can always get what you can at the initial session and continue getting information at subsequent sessions. I made good use of the unspecified diagnoses very early on for this reason.

Good luck getting your hyperactive ADHD kids to sit in one place for the camera. What if a kid has a tantrum on your office floor and refuses to leave? (happened to me today in fact) Is that chaperone trained to handle such things? How will you fit the parent(s) into the sessions?

 

[TexasPhysician]

Are you doing telemedicine too? I am working for a clinic that currently has a pretty horrible video system, and the last thing I want to do when the video is cutting out or there's an audio lag is spend MORE time with patients. I think patients probably feel the same way.

Yes, I am, but only with my own patients as requested.

 

[F0nzie]

My concerns with this setup are that less time may lead to reduced quality of your work, more medical errors, poor patient/family satisfaction, and physician burnout.

I would start by negotiating the salary. Once the salary has been negotiated the next step is to ask for 1 hour intakes and 30 minute follow ups for EVERYONE. This is a 100% fair and legit move.

I also encourage you to research the telepsych laws for the state you are serving to make sure you do not fall below the standard of care. For example, some states require a face-to-face evaluation to establish a relationship with at least one-face-to face follow up during the year. Never assume your employer is following the rules because everything falls on you.

 

[Merovinge]

That's more time than I get for most of my telepsychiatry intakes. I don't see kids though. It might be different. But I find that telemedicine actually facilitates the 20 minute med check appointment pretty well. No one wants to be in front of a screen for much longer than that. I'm not saying it's good psychiatry, but I personally find it easier to quickly wrap up a telemedicine meeting than an in-person meeting.

I don't think anyone is getting much telepsychiatry training in residency. The people who run residency programs by and large don't have much experience with it. I actually like doing telemedicine because it gives me an opportunity to devise new solutions to problems that not many people have thought about before.

But telemedicine has problems. I find that the worst cases are where patients are on the extremes of age and cognitive status.A few times my clinic has made me see dementia patients by telemedicine, and every time, it is a disaster. You can't do a MOCA, you can't do any kind of neurological exam even if you think you should, and often the patients can't hear.

I wonder if kids might have some parallel issues? Will they cooperate, for one thing? (Or, maybe kids will be the perfect telepsychiatry patients...) If parents and teachers have to fill out forms and bring them in, how will you read them? I am guessing that if there's no CAP at this place, that they haven't fully tested the process yet, and there will be kinks to work out.

For higher acuity patients (ASD w/ aggression, DMDD) I already have difficulty getting them to cooperate in an office being present, but I can see advantages with telepsych in that I can focus on the behavior and parent without having to constantly worry about my personal safety. Great point about the forms, I imagine possibilities of the liason reading them aloud to me or scan them ahead of time. This position already had a CAP attending but they are moving on to focus on their own practice.

The per session times are ok. You can always get what you can at the initial session and continue getting information at subsequent sessions. I made good use of the unspecified diagnoses very early on for this reason.

Good luck getting your hyperactive ADHD kids to sit in one place for the camera. What if a kid has a tantrum on your office floor and refuses to leave? (happened to me today in fact) Is that chaperone trained to handle such things? How will you fit the parent(s) into the sessions?

Kids tantruming I think would be easier actually, I have had awful experiences with being trapped in my office and with this possibility avoided it would be much easier to maintain my own composure and instruct staff/parents. I presently see 95% of my outpatients with parents present for all of f/u's and expect this would also continue via telepsych, although it would also be easy to ask the parent to wait in the waiting room for part of the apt as needed.

My concerns with this setup are that less time may lead to reduced quality of your work, more medical errors, poor patient/family satisfaction, and physician burnout.

I would start by negotiating the salary. Once the salary has been negotiated the next step is to ask for 1 hour intakes and 30 minute follow ups for EVERYONE. This is a 100% fair and legit move.

I also encourage you to research the telepsych laws for the state you are serving to make sure you do not fall below the standard of care. For example, some states require a face-to-face evaluation to establish a relationship with at least one-face-to face follow up during the year. Never assume your employer is following the rules because everything falls on you.

I don't disagree with you, however I as mentioned, I already get less time than that as a fellow and I think its a worthwhile experience to figure out what one can/cannot expect oneself to be able to reasonably do with increasingly common 20 minute apts. I would absolutely love a 60/30 minute practice as an attending if I do any outpatient work, but this is a 10h/week moonlighting job. Great point about the state legistlation, I know it's been in flux here a lot lately and will contact my local state CAP chapter.

 

[milesed]

Hyperactive, tantruming kids is really not that common after the first visit and they have been treated. . I don't care if they move around the room some as long as they don't disrupt the equipment. Their behavior is pretty helpful for me to see.