Tele-Psychiatry for Kids?

At the risk of sounding like an old fart, I am not prepared to accept the changing nature of psychiatry, yet again! For many years, I have appreciated the advancement in technology leading to Tele-Psychiatry, where people who cannot leave their homes, or who live far away, can connect remotely to a psychiatrist, allowing for access which would otherwise be impossible.  For adult patients, I am excited by expansion of our services. Now, let’s move into Child Psychiatry. Can a Child Psychiatrist do an assessment through a computer screen? It seems to me that evaluating children, working with families, mandates a three-dimensional exposure which would be severely limited by Tele-Psychiatry. As so much interaction is non-verbal, and as so much of an assessment includes “playing” with the child, I do not see how remote communication can simulate this encounter. Two-way communication devices are wonderful advances in medical settings where doctors do not need to touch their patients, but as a Child Psychiatrist, the “touching,” or more specifically, the shared use of space is critical to understanding how a child navigates their world. Some kids come and sit quietly, whereas other kids have a hard time staying still. Sometimes my words help kids focus, whereas other times, a child needs to be active in my office. These nuances will be lost with a remote access device. Once again, I am left thinking that change can be good, but then again, not always. I understand the dilemma between improving access and quality assessments. I also understand that as a field Psychiatry, particularly, Child Psychiatry, has to hold on to the key tenets of the profession. For me, this includes being in the physical presence of a family is an important component to the understanding of powerful relationships and their sequelae. I am not sure I would be willing to compromise on that issue. Technology should aid us in our goals, not detract us from them. Tele-Psychiatry for kids seems to move my field in the wrong direction.

The Embedded Psychiatrist

Oh, no. Psychiatry is heading towards another turn and once again, I am deeply concerned. As I understand the future of psychiatry, according to my highly respected colleagues, is that psychiatrists are now going to be ”embedded” in primary care offices where they may or may not see the patient, but they will consult on the diagnosis and psychopharmacological intervention for patients that are seen by nurse practitioners and primary care physicians. Now, understand, that I work in primary care, and I am a strong advocate that primary care physicians should have psychiatrists to consult with on their cases, but this does not mean that the psychiatrist should not have the ability and skill set associated with deep listening to patients and understanding the nuances of a good evaluation. My concern is that the psychiatrists of tomorrow will help primary care physicians prescribe psychotropics, without developing the tools of listening to patients and having continuity with patients. Psychiatrists will mostly be trained to consult, without having direct patient care responsibilities. Once again, this will change the field, both in terms of how it is practice, and in terms of who is attracted to this kind of work. In essence, the doctor/patient relationship, the most valued aspect of the treatment, will disappear from the field of psychiatry. I have previously posted about the development of a psychiatrist, strictly as a psychopharmacologist, has minimized the doctor/patient relationship, but this new development, where the psychiatrist is strictly a consultant, takes my issue into a deeper concern. I wonder if history taking and relationship building will be a lost art in medicine. I certainly hope not.

 

See also…http://shirahvollmermd.wordpress.com/2010/11/08/patient-centered-medical-home/

Shock in Child Psychiatry

   Stacy, a child psychologist of a mutual patient, says “I have never seen a child psychiatrist be so thorough. The mom tells me you are going to do a school visit. I think that’s great.” Although I am flattered by the compliment, I am also dismayed that a thorough assessment is no longer the standard of care in child psychiatry. School visits, as with meeting both parents, as with playing on the floor, as with talking with current and past treating clinicians, used to be the standard of care for child psychiatric assessment. These steps were the basic building blocks of understanding what was going on with the child. Now, it seems, that child psychiatrists are trained to look at symptoms which are amenable to psychopharmacological intervention. This means that the context, such as the school setting, or the family environment, is less important to understanding the nature of the presenting problem.

      James, our mutual patient, six-years old, is by all reports suffering from “terrible anxiety.” This might trigger the need for a medication such as Prozac, yet, upon further history taking, it seems that his parents are under a lot of stress, and as such, it might make more sense to help the parents be less anxious and that might calm down James. Further, James is having trouble at school, especially on the playground. I am going to do a school visit to see how James navigates his social milieu. Maybe if James could find a way to have friends at school then maybe he will not need medication to calm him down. Friends tend to relieve a lot of anxiety, both for kids and adults. On the other hand, maybe James needs medication to calm down so that he can make friends. This is a judgment call, but a judgment that will be better made after a school visit.

   Understanding, explaining and treating children is the job of a child psychiatrist. Understanding comes from deep history taking and sharply honed assessment skills. Seeing a child in multiple environments is key to thinking about a child in a comprehensive manner. The consultation room narrows the field, as children can behave so differently with one authority figure, as opposed to the challenge of peer relationships. These are basic concepts, yet lost in the present day of rushed assessments and low-thresholds for medicating kids. Consequently, psychologists like Stacy are appreciative of my 1980s, pre-Prozac, training. Again, it is nice to be appreciated for my assessment skills; it is sad that those skills, at least among child psychiatrists,  seem to be going the way of the typewriter.