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It would have been easy for me to tell you I “like people” or am “extroverted,” and that social distancing and shifting my work and social life to a computer would be a challenge. But I think it would have been harder to predict just how much of a difference a screen could make.
I’m an outpatient psychiatrist. I function in the nuances of conversation and spend more time observing and listening than I do talking. Phone visits lack a lot of key data because I can’t see a patient and most of the art is in what we see. I assumed adding video would fix that and be enough. Turns out, it wasn’t.
When I get a patient from the waiting room we talk about silly things like the weather, the book they are reading, or sometimes the waiting room chairs. It may seem casual and pointless, but I do that to try to make them feel at ease. This part of the visit is important because I’m about to ask them about their feelings and things that they have never told anyone before. If they are comfortable, they might be more likely to tell me their truths.
In telepsychiatry, we don’t get to do that. I click a button and a patient joins me in a Zoom room. No chit-chat, no weather, no nothing. Sometimes I can make a joke about the awkwardness of the internet, but there is much less time to break the ice.
When we’re in my office, I give them a little bit of an overview of confidentiality and what to expect. I allow them to tell me their story with little interruption. I know no one they are talking about will walk in on them. I have created a kind of safe space to protect them and their story, so they can freely open up to me.
In telepsychiatry, I have no idea where they are talking to me from. Sometimes it’s in their car, or their bedroom, or you can overhear other people. They might be at home, but for some people home is not a safe place, or it’s causing their stress, and that’s why they need to talk to me. I have no control over the safety of their space this way. Even in my space a dog can walk in, or the internet can go down. It just doesn’t have the same predictability as being in my office and without that, patients might disclose less and be more guarded.
It is not uncommon for patients to cry while storytelling. If that happens in my office, I can hand them a box of tissues, or point to one. That’s a gesture I learned in medical school that is small but can often make a difference in showing compassion and empathy. I can’t hand anyone tissues through a screen. Even if I try to tell them that, it feels forced.
By the end of the session, I still get the same information, but I feel more exhausted and distracted. I find myself having a headache from staring at the screen. And then I do it all over again in the next hour or thirty-minute session. It sometimes makes me want to throw my computer out the window and absolutely makes it challenging to want to socialize by screen at the end of the day. It is no wonder I have taken to books and podcasts to relax instead of screens where possible.
Despite my own fatigue, it’s important to emphasize that I’m someone who completely understands the purpose and need for telehealth and is 100% on board with expanding and advocating for its use in psychiatry. It’s more than overdue and the barriers to using it widely are unnecessary. It’s shocking to me that it has taken a pandemic to open people’s eyes to this and I hope it keeps decreasing the barriers that have existed for so long. After this pandemic, It really can revolutionize access in a field that will be sorely needed without enough practitioners to cover the need.
But, even if telepsychiatry is needed, and even if it is liked by many users, that does not mean it is for everyone. Turns out, despite my love of working in comfy pants, it is not for me. Personally, I can’t wait until I can talk about those stupid waiting room chairs with a patient in person again. I promise I won’t take those conversations for granted.
Jessi Gold, MD MS
Assistant Professor of Psychiatry, Washington University in St. Louis
Dr. Jessi Gold is a guest writer for InCrowd. You can read more about her on her website: drjessigold.com.
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