Residency Programs that Incorporate Telepsych
Started by psyspy
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They all were last year. I imagine they're all adapting it into the curriculum permanently to some degree.
If you're a med student, this should be the last on your list of priorities in choosing a program. Telepsych is not that hard and is not going anywhere. You can even moonlight via telepsych so whether or not your program does it isn't all that relevant.
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Pretty much everyone had to start doing telepsych during the pandemic and most places are going to keep it. It's not hard, but there are nuances and unique challenges compared to in person (including recognizing when Tele is insufficient and you need the patient to come in).
Moonlighting permission and opportunities do vary a lot from program to program based on state licensing rules and local need. Ask the residents about it when you interview.
From a training perspective, I would ask the programs if the telepsych they have is mostly/all to a fixed distant location with specialized cameras (zoom, high resolution).
In my opinion, you can argue that access and Covid safe are pros, but everything else is a con. Most patients/programs don’t have great resolution, sit at the perfect distance, have great internet access, additional cameras to monitor extremities, etc. You miss a LOT with telepsych that you catch in person. I require all patients to be in person now for new evaluations, especially kids.
Tics, fidgety behaviors, AIMS, hyperactivity, play therapy, attention, etc are all more difficult to identify via tele or missed. Say someone keeps averting their eyes and I ask what they are looking at. They can say nothing or shrug it off, but I can’t ask them to pick up their 30+ inch screen and turn it around to see what they are looking at. It could be a phone, distractibility, internally stimulated, or numerous things. Internet will lag or become pixilated at times. Maybe just bad camera placement.
There are many peers that love doing 100% tele now, and they argue that the care is just as good to reinforce what they do. It isn’t, and from a training perspective, attempting to learn in poor conditions is a terrible idea.
Given extra time, set location, zoom function from an elevated position, perfect seating, high resolution camera, and fantastic internet on both ends, I can see this being a worthwhile learning experience. Otherwise, I would avoid programs that have a tele focus.
I agree with you about the challenges of tele (particularly with kids, and new assessments), but are there really residencies that have a Tele 'focus'? To me the relevant question is are you taught the limits of tele and can you get the patient in in person (including have the ability to INSIST they come in person) when needed.
In my resident clinic as a pgy4 I do an about even mix of tele and in person, and I work under an attending who will back me 100% if I tell a patient we need to see them in person. It works and I have learned the benefits and downsides of both types of care. I think that's the ideal setup, and certainly a program that ONLY taught outpatient tele would be highly concerning... I hope that doesn't exist.
I’m glad someone else is saying this. I absolutely 100% agree. Tele has significant limitations compared to in person and anyone who tries to argue that they’re equivalent is really just not being honest with themselves for their own convenience. Especially in child, I honestly think it shouldn’t be standard of care at this point that there are child psychiatrists who are still doing 100% telemedicine without the ability or option to do in person unless they have some personal risk reason for this or they are truly doing tele to places that have no realistic access to child psychiatry.
Is it better than nothing or better than no care back in 2020? For sure. Is it better than in person care? Absolutely not. I see all my intakes in person and probably 95% of my followups in person right now. If I don’t think someone is good for tele or tele experience wasnt good (refused to let me see them, terrible connection, etc), I tell them and they have to come in person the next visit. Get minimal pushback on this. Most patients actually want to be seen in person at this point. I totally get that there are patients (especially stable patients) who want to followup via telepsych but I also know there are still psychiatrists out there who aren’t seeing anyone in person at all, even when the patients want to followup in person.
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As a patient, I'd definitely never go back to in person. Just eliminating the travel time has been amazing. I'm not sure where the strong animosity towards it comes from above. Just because something is easier...doesn't make it worse. I'm neutral on the provider side, there are pros and cons. For residency...please don't make it a focus. Any program today will offer it sufficiently. It seems like you moved on to moonlighting, which is a much more relevant focus for selecting between similar residencies.
I think telemedicine offers lower-quality encounters: lag, missing body language, missing subtle facial expressions, being unable to do any type of hands-on exam (cogwheel rigidity? test reflexes? vital signs? etc.), the patient often calling from a less-secure environment (including at home within earshot of family, while driving, etc.). The highest quality information comes from an in-person evaluation.
That said, I think offering at least a hybrid model is a no-brainer for most patients. You can have the person come in to the office when you need to, but otherwise offer tele-visits if they prefer. It is so much easier as a patient to block of 20 minutes for a doctor's appointment in the middle of the workday than it is to take most of an afternoon off to drive across town for an in-person visit. In general, the added convenience for encounters held by telehealth (with your approval) outweighs the real but typically not essential improved quality of information.
With that said, once you are familiar with in-person evaluations the switch to telepsych does not take a lot of training. You can pick it up in a few days' worth of encounters. I wouldn't stress about having it be an emphasis during training.
That said, I think offering at least a hybrid model is a no-brainer for most patients. You can have the person come in to the office when you need to, but otherwise offer tele-visits if they prefer. It is so much easier as a patient to block of 20 minutes for a doctor's appointment in the middle of the workday than it is to take most of an afternoon off to drive across town for an in-person visit. In general, the added convenience for encounters held by telehealth (with your approval) outweighs the real but typically not essential improved quality of information.
With that said, once you are familiar with in-person evaluations the switch to telepsych does not take a lot of training. You can pick it up in a few days' worth of encounters. I wouldn't stress about having it be an emphasis during training.
My reaction may have been overly strong ha.
But I think there’s been this huge swing to the telemedicine direction in psychiatry without as much movement back. I believe a significant portion of this is driven by how convenient psychiatrists find it. For a relatively uncomplicated patient population who WANTS telemedicine visits, telemedicine works. However I do think it really shouldn’t be standard of care at this point to have no capability for in person visits but there are still a significant number of psychiatrists out there doing exclusively telepsych (even people who were doing in person visits prior to the pandemic) and now trying to argue this is comparable to in person visits (driven largely I suspect by how convenient it is to do telepsych in your pajamas from home).
I also think trying to argue that telepsych is equivalent to in person visits starts devaluing the service relative to other specialties. If what we do can be done 100% through a zoom call but no other speciality can, why are we getting paid so much again? (how regulators and joe public going to start seeing it). Insurance companies are going to start going, well if you can provide equivalent care over zoom from your house, your overhead is going to be so much lower, you don’t need to pay for an office or drive or pay office staff, we should start reimbursing 20% less for tele visits across the board. It also provides a huge in for companies like Done and Cerebral to argue they provide comparable care.
I've actually found that for too many patients, telepsych has been too convenient. They aren't really setting aside the time for my visits and instead just "attend" wherever they are and doing whatever they're doing. I'm CAP, and I don't always have both the child and the parent available at the visit.
For some patients, this has worked out great for everyone involved. For others, it's made me never want to do telepsych again.
For some patients, this has worked out great for everyone involved. For others, it's made me never want to do telepsych again.
I loved when doing telepsych that for some patients, you were an inconvenience and would do other stuff (like driving) while doing the "visit".
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And that's when you stop the visit and tell them to reschedule.
I think it's worth asking how telepsych is done and how well supported it is both technically and clinically, particularly from resident perceptive. For example, do they have a good platform, or is it constantly glitching out? Is it used for consults or just outpatient? Do their supervisors "get it" or are they still learning themselves? Has there been a decrease in "no shows" and subsequent increase in charting? How do they determine whose appropriate and what type of contingency plans are in place for patients who have some emergency?
I'd be skeptical of any program that says they give formal training or at the vanguard, since it's all relatively new and no one really knows how to teach it. But it could show you how well they support residents or how thoughtful they are making adjustments (as opposed to making haphazard changes in an attempt to keep visits up or meet ACGME requirements).
I'd be skeptical of any program that says they give formal training or at the vanguard, since it's all relatively new and no one really knows how to teach it. But it could show you how well they support residents or how thoughtful they are making adjustments (as opposed to making haphazard changes in an attempt to keep visits up or meet ACGME requirements).
These are all excellent points.
The decrease in no shows hit us hard. Suddenly you have to count on every patient showing up, and clinics that were built on a staffing model that assumed a normal amount of in person no shows are a lot more strained. Does our admin care about the impact on learning trying to cover all this volume? Nah.
On the other hand our actual platform/tech is adequate and we have appropriate facilities so win some lose some. And anyone we either want to see in person or need to insist on seeing in person we can.
The decrease in no shows hit us hard. Suddenly you have to count on every patient showing up, and clinics that were built on a staffing model that assumed a normal amount of in person no shows are a lot more strained. Does our admin care about the impact on learning trying to cover all this volume? Nah.
On the other hand our actual platform/tech is adequate and we have appropriate facilities so win some lose some. And anyone we either want to see in person or need to insist on seeing in person we can.
This is the annoying part. "I didn't want to take my child out of school for this" even though I can write a school excuse letter easily. Or when children or adolescents tell me that their parents are in a meeting or out of the home and cannot talk with me during the appointment for me to get their consent on what to do. I have 9 year olds who are doing the telemedicine visit all by themselves with no parent to be found and therefore, nothing about their plan can be changed until I follow up with them, which causes me an additional burden on my schedule to find that administrative time and remember to do that.
I definitely found that among some families tele visits really degraded the doctor/patient relationship with younger kids and in other cases had parents take things much less seriously. Some of these kids would have significant pathology and I would have the parent connect going through a McDonald's drive through. Suddenly our appointments became on the same significant as a hair cut or dog grooming. I don't hear this mentioned much with the televisit side of things but I found it a significant malus to child psychiatric practice (particularly the 3-11 age range).
I'm a psychologist in a clinic housed in the psychiatry department. we just got word that most insurances (including medicaid) in our state are ceasing coverage for evaluations via telehealth (though initial interview can be telehealth). Therapy is still covered by most but not all insurances; some are requiring a certain number of them to be in person. I agree it's not goign anywhere for therapy purposes anyway- but have experienced many of the downsides (how many times do i need to tell a client that they cannot have an appointment from a restuarant, driving the kids home from school, outside the state... etc). On the other hand, many of the generally functional but emotionally struggling adults are accessing care when they never would have otherwise (work schedules etc) so getting to them before they, ya know, get to the point of deeper dysfunction, so that's a real plus.
