A psychiatrist crashes into telemedicine during the pandemic


As far as psychiatrists go, I admit I’m odd, even in a field known for its quirks. I’m fast-talking, irreverent, and most patients tell me I’m not what they expected, but they come back.

I’m not for everyone, and that’s OK. I love my field but didn’t always feel the field loved me.

At a conference workshop, as a PGY-III, in a room of 40 other psychiatrists, mostly attendings, the leader pulled out a “PACE palette” exercise. It seemed incongruous — a room full of people in a field known for exploring the multiple dimensions that make us human were putting themselves into neat boxes. We were instructed to go down each row ranking each set of words 1-4 that described us from most to least.

Before long, all my 1s were neatly lined up in a column to the far-right, and all the words that described me the least were in the far-left column.

Only two other kindred spirits had the same primary color as me — RED. The far-left column, the YELLOWS, filled half the room. So many, they split into two groups for part two. I really was different, no question now.

An attending in residency once asked if I could “be more like [another resident totally different than me in all ways].” I dejectedly wondered, “Is it really necessary for me to change my entire personality to be a psychiatrist?” The second part of the exercise with my fellow REDs, both attendings, would forever clarify for me the answer was a resounding no. I did not have to become someone else to be a psychiatrist.

Five years later …

All barriers on telepsychiatry are suddenly lifted, my entire community mental health center finds itself crashing into telepsychiatry in the middle of the coronavirus pandemic. I was optimistic and delved in, absorbed practice habits from others, attended an online webinar, and partnered with a nearby community mental health center on a continuous quality improvement project. I knew how to use the tech and made videos for our staff. I was excited at the experiment. I had heard of its wonders, convenience, and efficiency! I could not wait to try it.

I hated it.

Hated. It.

I was exhausted. I could feel my optimism fading with every technical glitch. I missed my staff, office, and patients face to face. I did not like the bleeding of my work into home space. Even in the office, I sat with my door closed, seeing patient after patient on the screen! It was still terrible!

As for the patients, some of them hated it.

I felt less “connected,” even as my no-show rate plummeted.

Silence, I found, is not therapeutic on the phone or screen. I physically felt tenser. My phone kept pinging as my Zoom kept going.

Why is this so much harder? Are my mirror neurons not firing, right? Am I helping anyone?

“Take a big deep breath!” My nurse texts me.

But, telepsychiatry is the future? I had initially pushed aside my concerns about the widespread adoption of telepsychiatry, a possible digital version of what’s already happened to medicine as the “money and screens” keep winning over the care of the patient.

Now the existential crisis. What about the future? What do we lose if we don’t live in the same communities as our patients?

Without direct relationships with the community groups, therapists, or knowledge of all the intricacies that make up a patient’s environment? Is this just a RED thing? A “me” thing?

This is the reason I enthusiastically signed on to start a residency program in rural America. More doctors next door. I see patients everywhere! I’m not anonymous or a “blank slate,” many are- that’s OK, that’s their color.

I have always derived greater clinical benefit from not being the blank slate. A common love of metal music, role-playing games, or passing at parent-teacher night was the break needed for a better therapeutic relationship. Just the right paint mix, not too much but not too little. Does the screen make the blank slate easier? Is that why I hate this?

Tell me about your mother? Mine was an optimist, and through the “Can you hear me now?” … some of the positives shine through.

Many patients appreciate the option! They like seeing my world, my cat, my messy home office, and my paintings. They can still see me when the Medicaid cab does not show up. I have met pets, children, parents, and significant others. I have learned to pay even more attention to subtleties in voice and tone. I have discovered patients who really need their meds bubble packed.

I propose Zooming while driving be added to the DSM criteria for ADHD. I have gotten a new glimpse into the world of some of my patients. One patient even mentioned it’s hard for them to come to appointments, even with transportation, and we were able for the first time to talk at length about those psychological factors that prevent them from getting consistent follow up leading to lapses in effective treatment.

Is this the first step toward more consistent care? Better outcomes?

Some in my center therapists hate it as much as I do, but some really love it. Is this just not going to be everyone’s color?

There is room for yellows, blues, greens, reds, and all our mixtures. My experience is not representative of the entire tele field. Maybe there is even a place for it in my practice going forward, and our ability to bill for these encounters should continue. (Can you hear me, CMS!)

But this cannot be my full-time practice. I hope there is a place for all of us. I hope when I retire, “the money and screens” haven’t ultimately won over the best care for all patients. The optimist in me is hopeful, but the fast-talking irreverent realist in me says we will have to fight for our places.

Allie Thomas-Fannin is a psychiatrist.

Image credit: Shutterstock.com


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