Pros and Cons of Telepsych?

[Psychic Meep]

Hey all, I'll be graduating in 2023 and have been surveying the jobs on offer. I'm considering telepsych however this may require me to see pts outside of my state. Anything to watch out for or keep in mind? Will the future of the Ryan Haight act make my life difficult if I'm seeing patients in a far away state? Is telepsych even (admittedly subjectively) worth it in your opinion? Thoughts appreciated!

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[J ROD]

I think it a great way to get access to a specialist. I personally see patients in smaller ED's that otherwise would not have access to a psychiatrist and have to be transferred to a bigger center. I imagine seeing folks in another state could get tricky and I think you have to be physically in that state every 3 months or something similar. That would be a deal breaker for me. I like the mix of seeing folks but in person and tele. I think the pay I have seen has been fair. Also, great if you want to work from home. I am sure there are others with much more experience that can offer more.

 

[nexus73]

if /when Ryan Haight returns the telepsych companies are going to have a difficult time. No benzos or stimulants is doable but limiting. Can’t even give a short course of Klonopin, or the patient with panic their four tablets of 1 mg xanax they fill every 4 months. And obviously cerebral is the poster child of unethical practice. But will be interesting to see how many telepsych companies stay viable.

 

[calvnandhobbs68]

Yeah its going to be interesting to see how many of these telepsych only companies are gonna stay viable just in general.

COVID was a huge boom for telemedicine companies that were typically struggling/losing money before 2020. I think that boosted their visibility and acceptability but I also think many people are going to have a pretty hard time being completely telemedicine without any ability to see patients in person (even taking Ryan Haight out of the picture), going forward. In circumstances where patients absolutely couldn’t see a specialist, might be acceptable to them. Most patients like the ability to at least have the option to see someone in person and at this point if you’re only tele you’re also competing with the armies of tele only NPs too. Much harder to build rapport only virtual. Also much harder to get referrals in general, most of which will come from PCPs, therapists, etc…if you look at the tele companies they tend to rely heavily on advertising and google SEO to be the first thing that pops up when you search for “psychiatry Virginia” or whatever terms you use.

Also depends on your specialty. Once restrictions come back into place, child psych is going to be basically impossible to do telemedicine only because you’re kind of useless as a child psychiatrist if you can’t prescribe stimulants….that’s like 50% of my C+A patients.

 

[TexasPhysician]

More cons than pros

Cons: field of vision negatively impacts diagnosis accuracy (really need 2 cameras with zooming to see facial expressions and body movements), limited on meds (Ryan Haight), hard to build rapport, hard to market, lower demand, harder to get vitals, can’t identify hygiene issues, connection issues, patients can struggle to complete paperwork, can’t find my online waiting room despite doing it multiple times before, and I’ve had patients see the video time and request partial refunds because they didn’t need the full amount of allotted time.

Pros: can’t identify hygiene issues (smells), less disease transmission, less $ on pants/socks/shoes (unless hybrid), ease of access for patients, fewer excuses for missed appointments, and maybe less commute (unless hybrid practice to accommodate Ryan Haight)

 

[forchinet121]

Unless you’re starting your own practice, I don’t think there are many cons, I mean if you are working for a company and they’re paying you 330k for 40 hours a week it seems like a pretty good gig with no headaches

 

[Psychic Meep]

Great advice. Thank you. I'd be adult only and leaning towards outpatient but we'll see. It might even be worth thinking about it just because so many of my in office patients catch covid. Luckily I haven't been exposed but I feel like its only a matter of time. Extending Ryan Haight seems like it has bipartisan support even from the administration and new variants keep popping up.

 

[G Sheb]

pros:
- ease of access and convenience for both psychiatrist and patient, which is absolutely huge and saves a ton of time for your and patients. one should also never underestimate the amount of effort patients have to go through to attend appointments and the anxiety associated with sitting in a waiting room and going through the registration process. I've had many patients with poor compliance in person suddenly attend every appointment, especially sicker ones with SMI.
- safety, especially in the ER setting. You aren't really worried about sprinting with the first sign of violence from the interview room. That allows to be more relaxed and conduct the interview with more confidence and better skill.
- location flexibility obviously. You CAN live in Nice while seeing patients in Iowa.

cons:
- the interpersonal connection is degraded. that is also a big one. That is a huge part of treatment. Makes it more difficult to establish rapport and takes away one of the most important parts of psychiatry.
- may be harder to get a sense of hygiene, body language and overall presence.

Overall, it's a tricky one. Telepsych is here to stay but it cannot supplement in person, imo. Although the way the world is going convenience does trump everything, but at a cost.

 

[michaelrack]

face to face without masks>telepsych>face to face with masks

 

[calvnandhobbs68]

face to face without masks>telepsych>face to face with masks

Absolutely not true. I’ve heard this argument before and it’s bizarre. If you can’t get a decent sense of someone’s affect with a mask on, I don’t know what to tell you. This has literally been inpatient psych for the last 2 years (and still is the vast majority of places).

I’ve seen down to 5yo in masks and it’s leaps and bounds better than telepsych. What exactly is so superior to seeing someone’s face over video than having the bottom half of their face covered but in person?

 

[comp1]

I think everything is headed towards telepsych. It's so hard to recruit anyone anywhere for an in person position.

 

[jbomba]

I like the hybrid model. Rent an office a day a week. See news and whomever else needs to be seen in person in your one day a week. Do they rest via tele. Best of both worlds with very minimal overhead.

 

[allantois]

I almost feel like they should make a permanent carve out for kids as many live in areas with no child psych. My state actually doesn’t allow opioids to be prescribed over telemedicine, but does allow psych drugs. I imagine that can be another possibility. Prior to COVID only radiologists could only really do telework and honestly looking at people outside of medicine I feel like we have limited ourselves for no apparent reason other than that we don’t like change. I will say that we will have huge issues with access to care if people are forced back into offices. Heck, my own PCP works mostly from home now

 

[mistafab]

the con of telepsych is that it is mind-numbingly boring.

 

[smalltownpsych]

the con of telepsych is that it is mind-numbingly boring.

I hated doing video sessions. It made every session a little less productive and a little more boring. Since many sessions in person can already be boring or unproductive, taking away just a bit from each one quickly takes it into mind-numbing place. A great session becomes a good session, a good session becomes a meh session, a meh session becomes a dreaded session, and a dreaded session or patient (there is always at least one of those in my week) becomes…I don’t even have a word for it. I find myself staring at the screen wondering if it would be ethical to pretend to drop the connection or will they notice if I was to surf the internet while they are droning on about something inane and irrelevant. In person with a patient like that was bad enough.

I’m just glad I only did it for a few days a week for a couple of months while I was getting my business up and running. Just to top it off, I was getting paid 30 bucks an hour (they were misleading). What is funny is I just hired a front office support person for 25 an hour. I guess I value staff support almost as much as they valued a psychologist.

 

[Dr.MONO]

There are certain limitations with Telepsych. I am eager to see what will happen when pandemic waivers are cancelled.

 

[Alemo]

I don’t know how anyone can (and does) say with a straight face that telepsychiatry is better than the real thing. Convenience and access are important, but at what cost?

We are already trying to discern someone’s state through their spoken description of their mind/behavior which is obviously limited. The patient needs to be dialed in by which I mean focused and ready to talk. The same goes for us. It just doesn’t happen when you’re on Zoom.

I know that’s kinda vague but I think it’s pretty important. I just wonder how to study this. Most studies I’ve looked at so far seem to show “non-inferiority” of telepsychiatry. If you’re like me, you love getting something new when you expected one thing and hearing the explanation “it’s just as good!!”

 

[comp1]

Access is THE thing. It's more than just important. If people can't access a service, the quality does not matter. That said, with providers vastly preferring telehealth, the problem is going to switch to people having access to face to face.

 

[Liquid8]

I don’t know how anyone can (and does) say with a straight face that telepsychiatry is better than the real thing. Convenience and access are important, but at what cost?

We are already trying to discern someone’s state through their spoken description of their mind/behavior which is obviously limited. The patient needs to be dialed in by which I mean focused and ready to talk. The same goes for us. It just doesn’t happen when you’re on Zoom.

I know that’s kinda vague but I think it’s pretty important. I just wonder how to study this. Most studies I’ve looked at so far seem to show “non-inferiority” of telepsychiatry. If you’re like me, you love getting something new when you expected one thing and hearing the explanation “it’s just as good!!”

While I can take notes while doing a telehealth session, the time savings here were negated by less inefficient processes in relation to sending out scripts, letters, documents for patients, settling accounts etc – all things that would normally simply be handed to patients at a face to face consultation.

One thing I don’t see mentioned much is the frame of therapy. The consulting room provides a private, safe and consistent space. There is a process - a ritual if you like. The patient has to organise themselves to attend, they check in at the reception counter, take a seat and wait to be called. During that time they may be collecting their thoughts, working out what needs to be addressed during the session

While a patient may be more convenient staying at home, often there are other distractions or elements that blur the boundaries. That preparation phase identified earlier is lost, often they aren’t ready to talk. There might be other people around, so they can’t speak openly and freely about their troubles. What I have found is that many of my patients still prefer to attend in person.

 

[michaelrack]

One thing I don’t see mentioned much is the frame of therapy. The consulting room provides a private, safe and consistent space. There is a process - a ritual if you like. The patient has to organise themselves to attend, they check in at the reception counter, take a seat and wait to be called. During that time they may be collecting their thoughts, working out what needs to be addressed during the session

If you do dance therapy by telehealth , you won't have to worry about picking up the patient when they fall

 

[calvnandhobbs68]

Pros: You don't have to leave your house, you can sit outside, you can wear shorts and flip flops, you could go somewhere else to work (vacation, second home, visit people, etc.), you can pet dog/monitor kids/birdwatch while working, you run less of a risk of being assaulted by your patients, less overhead, easier to conclude the visit when you decide its over. These are just a few.

In what all your vast experience doing telepsych visits med student?

What happened to you not posting on here anymore?

 

[michaelrack]

Is dance therapy a common treatment modality? I wouldn't mind doing some salsa dancing with patients

For psychiatrists who practice dance therapy: dealing with falls

This is a post for fellow psychiatrists who practice dance therapy. I’m guessing there aren’t any on here, but if I post this it will become indexed by search engines and other psychiatrists who employ dance therapy might find this and chime in. What do you do when a patient falls down during...

forums.studentdoctor.net

It was a reference to this thread. I didn't realize how old the thread was until I looked for it just now

 

[smalltownpsych]

For psychiatrists who practice dance therapy: dealing with falls

This is a post for fellow psychiatrists who practice dance therapy. I’m guessing there aren’t any on here, but if I post this it will become indexed by search engines and other psychiatrists who employ dance therapy might find this and chime in. What do you do when a patient falls down during...

forums.studentdoctor.net

It was a reference to this thread. I didn't realize how old the thread was until I looked for it just now

I completely remembered that thread. I was thinking, I hope that’s what he was referencing. One of my all time favorites. If I recall correctly, it was from another frequent poster creating a fake account. It was sort of wrong in a way, but funny enough and well done enough that I think everyone just let it go. 😁 Besides we all know of mental health professionals who advocate more kooky things than that so it was a great satire.

 

[nexus73]

For psychiatrists who practice dance therapy: dealing with falls

This is a post for fellow psychiatrists who practice dance therapy. I’m guessing there aren’t any on here, but if I post this it will become indexed by search engines and other psychiatrists who employ dance therapy might find this and chime in. What do you do when a patient falls down during...

forums.studentdoctor.net

It was a reference to this thread. I didn't realize how old the thread was until I looked for it just now

are we going to be posting here in 30 years telling our grandkids to "hold on a sec" as we conjure the perfect reply?

 

[calvnandhobbs68]

I observed a few telepsych visits one time. Thought they were pretty neat.

Regardless of my qualifications, my points are valid.

Hilarious

 

[Alemo]

How does someone go into a specialty not rads or path and then decide “actually my first love *IS* sitting at a computer all day!”

 

[Liquid8]

How does someone go into a specialty not rads or path and then decide “actually my first love *IS* sitting at a computer all day!”

I remember going on a date with a physician who after 1 year switched in radiology - she was basically sick of dealing with people. When I think back I recall she was somewhat manipulative, so would either have been great or a disaster in a more patient facing role.

One of my good friends who is a pathologist had a similar attitude. During his general internship he had found dealing with other doctors quite infuriating, and I can't say that I disagree - over the years I've often felt that other medical staff are often the main source of much frustration. The irony is that in his role as an anatomical pathologist he has countless meetings with surgical teams, filled with asinine arguments about clearance margins.

Another radiologist friend unashamedly did it for the money, having also done a year of basic physician training - I remember him being fairly sick of the onerous on call requirements and pressure from the Emergency Department. He did land a high paying position, but after a few years in was involved in a pretty serious accident. After receiving absolutely nothing in the way of emotional support from management or colleagues who only wanted to know when he could return, he consequently became fairly disenchanted about the whole thing. At the time I remember thinking that our little hospital/clinic would often have events like farewell parties or lunches for staff who were leaving, or card/collections for sick colleagues, new mothers etc. Can't really put a price on that strong sense of community.

 

[CB5T]

Interesting variation in opinions.

My starting bias is actually liking people. I like interacting with patients. I chose group private practice so I could work with a wide range of employed people who can afford to see me with their insurance.

I'm exclusively telepsych. From an actual office. That functions more like video studio set. Very occasionally someone will want to come in. And it's a refreshing change. But they all mostly want to do telepsych. No one wants to come across town, find parking, rush to their appt, stressed out. Many are not even local to my part of our state.

Pro's:
1. Efficiency: Efficiency of in/out process. No wasted time ushering people about. More face to face time working on their issues. Efficiency of referencing chart, medication history. All with a semblance of eye contact. I would never type or look a chart while talking to a live person. Efficient time management. I can see my next client in the digital waiting room. That's my curtain call.

2. Multi-media integration: I can use video, graphics, charts, drawing on top of them with my ipad, integrate slides, etc. If you're dialed out like a potato head on facetime you're not grasping the advantages of digital multi-media integration.

3. Access: I'm seeing rural patients while living in a metro area. I like the diversity. They are so appreciative of being able to see a psychiatrist.

4. Geographic flexibility: Psychologically I like separating work from home. But I like the idea that if I needed to care for a sick relative back home or something, I could continue to work remotely while doing so, uninterrupted.

5. Safety (also lack of ripe smells): That manic intake is a lot less sketch. I don't have to breath people's cigarette-cat pee soaked cardigan that hasn't been washed since the Reagan administration.

____________________________________

Cons:

1. Loss of some element of connection: I don't get the extreme sense of this. I think our social intelligence evolved from reading faces to a large degree. But I can respect this purist point of view.

2. Loss of body language appreciation

3. Loss of physical presence for vibe detection and possibly loss of important medical information of physicality.

4. Medical-legal uncertainty: I personally don't think you can put this particular genie back in the bottle. But it certainly concerns me that my whole practice is telemedicine.

5. More transient, transactional sense of being replaceable with another shrink on the screen.

_______________________


All in all. This is the future of medicine. I think that's what makes us emotional about this. It's a new way of doing things that has rapidly and unexpectedly gained primacy.

I'm diving in headlong. Using technology and having a ball.

Don't knock it until you've tried embracing its potential instead of begrudging it.

 

[smalltownpsych]

Interesting variation in opinions.

My starting bias is actually liking people. I like interacting with patients. I chose group private practice so I could work with a wide range of employed people who can afford to see me with their insurance.

I'm exclusively telepsych. From an actual office. That functions more like video studio set. Very occasionally someone will want to come in. And it's a refreshing change. But they all mostly want to do telepsych. No one wants to come across town, find parking, rush to their appt, stressed out. Many are not even local to my part of our state.

Pro's:
1. Efficiency: Efficiency of in/out process. No wasted time ushering people about. More face to face time working on their issues. Efficiency of referencing chart, medication history. All with a semblance of eye contact. I would never type or look a chart while talking to a live person. Efficient time management. I can see my next client in the digital waiting room. That's my curtain call.

2. Multi-media integration: I can use video, graphics, charts, drawing on top of them with my ipad, integrate slides, etc. If you're dialed out like a potato head on facetime you're not grasping the advantages of digital multi-media integration.

3. Access: I'm seeing rural patients while living in a metro area. I like the diversity. They are so appreciative of being able to see a psychiatrist.

4. Geographic flexibility: Psychologically I like separating work from home. But I like the idea that if I needed to care for a sick relative back home or something, I could continue to work remotely while doing so, uninterrupted.

5. Safety (also lack of ripe smells): That manic intake is a lot less sketch. I don't have to breath people's cigarette-cat pee soaked cardigan that hasn't been washed since the Reagan administration.

____________________________________

Cons:

1. Loss of some element of connection: I don't get the extreme sense of this. I think our social intelligence evolved from reading faces to a large degree. But I can respect this purist point of view.

2. Loss of body language appreciation

3. Loss of physical presence for vibe detection and possibly loss of important medical information of physicality.

4. Medical-legal uncertainty: I personally don't think you can put this particular genie back in the bottle. But it certainly concerns me that my whole practice is telemedicine.

5. More transient, transactional sense of being replaceable with another shrink on the screen.

_______________________


All in all. This is the future of medicine. I think that's what makes us emotional about this. It's a new way of doing things that has rapidly and unexpectedly gained primacy.

I'm diving in headlong. Using technology and having a ball.

Don't knock it until you've tried embracing its potential instead of begrudging it.

I like your well thought out response, but not so sure that this is the future of medicine and especially for mental health treatment. Almost all my new patients will first ask if I am taking new patients and then ask if I’m doing doing in-person. They are actively seeking that. I would worry that psychiatry on-screen is going to be placed in the med manager role more so than a key player in the treatment. That being said, I did a telemedicine appointment with a patient today who couldn’t make it to the office and I have one holdover from my couple of months doing telepsych parttime. I kind of wish of wish I wasn’t with that last patient because she needs more and in her community, but I’m kind of stuck now.

 

[CB5T]

I like your well thought out response, but not so sure that this is the future of medicine and especially for mental health treatment. Almost all my new patients will first ask if I am taking new patients and then ask if I’m doing doing in-person. They are actively seeking that. I would worry that psychiatry on-screen is going to be placed in the med manager role more so than a key player in the treatment. That being said, I did a telemedicine appointment with a patient today who couldn’t make it to the office and I have one holdover from my couple of months doing telepsych parttime. I kind of wish of wish I wasn’t with that last patient because she needs more and in her community, but I’m kind of stuck now.

Well yes. I work at an interdisciplinary clinic where the therapists are getting in person requests. I suppose then it also concerns me that they would prefer to see me by telemedicine given they would prefer to see their therapist in person.

That's also a great point about the appt being a reason to be out in the world in general.

So, not the future of therapy or perhaps not a one dimensional future of medicine.

But it's going to be here and growing. And given I started this job in the depths of a pandemic. It became what I had to do.

And now I've adapted to liking it.

 

[smalltownpsych]

Well yes. I work at an interdisciplinary clinic where the therapists are getting in person requests. I suppose then it also concerns me that they would prefer to see me by telemedicine given they would prefer to see their therapist in person.

That's also a great point about the appt being a reason to be out in the world in general.

So, not the future of therapy or perhaps not a one dimensional future of medicine.

But it's going to be here and growing. And given I started this job in the depths of a pandemic. It became what I had to do.

And now I've adapted to liking it.

I actually do like that it is here especially since I can bill for a phone call or video session now. Yesterday, I had to remind the Psych NP that she could bill a virtual visit the same as in person otherwise she would have been talking on the phone to patients who didn’t make their appointment about their side effects and overall treatment plan and adjusting dosages without getting paid. One was a 99213 and other was a 99214. Both were about ten minutes. I think this was appropriate.

This brings up a completely different issue, but it’s kind of tough working with a Psych NP because they seem to need quite a bit of guidance and much of what they need guidance with is outside my scope. Fortunately, she does seem pretty savvy about medications and dosages and also has a psychiatrist that I know and trust to consult with, but for the ancillary aspects of psychiatric practice it can be challenging. How to bill is one aspect, also legal and ethical issues is another, and another I ran into yesterday is taking ownership of a case. She loves it when the patient is one of mine too because I “have the case”. One patient yesterday that wasn’t mine and she thought it was, I found myself pointing out a number of things that needed to be considered and how to manage the case. I actually think it is better when a nurse practitioner tends to defer responsibility than the converse, but just something I ran into yesterday. I am obviously preaching to the choir on the aspect of NPs and independent practice, just find it interesting to think of a psychologist in the role of leadership.

 

[Merovinge]

Well yes. I work at an interdisciplinary clinic where the therapists are getting in person requests. I suppose then it also concerns me that they would prefer to see me by telemedicine given they would prefer to see their therapist in person.

That's also a great point about the appt being a reason to be out in the world in general.

So, not the future of therapy or perhaps not a one dimensional future of medicine.

But it's going to be here and growing. And given I started this job in the depths of a pandemic. It became what I had to do.

And now I've adapted to liking it.

Wondering if it relates to my work being in CAP but I have had the opposite experience where most patients were excited to resume in-person appointments. I have some colleagues whose patients prefer remote appointments but I gather this is related to them preferring the remote work and leading the patients towards this. At my last job, my receptionist basically said "you can come in-person or stay remote, Dr. Merovinge is in the clinic either way and this will not otherwise impact the care you receive". Outside of a few logistic challenge cases, around 2/3 to 3/4 wanted to come back in person.

 

[jbomba]

Wondering if it relates to my work being in CAP but I have had the opposite experience where most patients were excited to resume in-person appointments. I have some colleagues who prefer remote appointments but I gather this is related to them preferring the remote work and leading the patients towards this. At my last job, my receptionist basically said "you can come in-person or stay remote, Dr. Merovinge is in the clinic either way and this will not otherwise impact the care you receive". Outside of a few logistic challenge cases, around 2/3 to 3/4 wanted to come back in person.

It's odd how much different experiences can be. We've reopened clinic and are in person for visits or tele. 95% want tele still.

 

[Merovinge]

It's odd how much different experiences can be. We've reopened clinic and are in person for visits or tele. 95% want tele still.

I'm actually fascinated to know what drives these dramatic differences, absolutely worth studying even if it will be a complicated study to setup and get funding for.

 

[calvnandhobbs68]

Wondering if it relates to my work being in CAP but I have had the opposite experience where most patients were excited to resume in-person appointments. I have some colleagues whose patients prefer remote appointments but I gather this is related to them preferring the remote work and leading the patients towards this. At my last job, my receptionist basically said "you can come in-person or stay remote, Dr. Merovinge is in the clinic either way and this will not otherwise impact the care you receive". Outside of a few logistic challenge cases, around 2/3 to 3/4 wanted to come back in person.

I think part of it is definitely a child thing. For younger kids, telepsych is terrible. Even for some older kids, I got the "how can you really know what's going on if you've only seen my kid over facetime?" during 2020-early 2021 when there was no in-person....which is fair.