Early use of telepsychotherapy in resident continuity clinics—our experience and a review of literature
Telepsychiatry refers to the provision of psychiatric care via video-based conferencing. It is widely adopted given its potential to extend care to underserved areas and those with limited access to mental health services. Research demonstrates a high rate of satisfaction with telepsychiatry both among patients and providers but also admits the need for consistency in accessing competency with the use of technology to ensure quality of care (1-7). Telepsychiatry is not inferior to the traditional approach in terms of reliability and allows for significant time and cost savings (8-12). Studies also show that telepsychiatry can be successfully applied in psychotherapy (13).
The field of psychiatry is rapidly evolving, but training in telepsychiatry is not currently a requirement in most US residency programs, and where available it is usually introduced in the final year of training (14,15). The difficulty in establishing early exposure to telepsychiatry may be linked to a lack of an ability to measure a training physician’s skills in performing distance therapy (1). We evaluated the feasibility of early training in telepsychiatry in resident continuity clinics and focused on the delivery of telepsychotherapy. To our knowledge, no studies of a similar design have been conducted to-date.
All patients receiving supportive or psychodynamic therapy with access to a smartphone or an Internet-connected computing device of two psychiatry residents in their post-graduate year (PGY)-2 and PGY-3 were asked to participate in telepsychotherapy. Four patients (three with major depressive disorder and anxiety disorder and one with schizoaffective disorder) volunteered and underwent telepsychotherapy using a secure cloud-based video communications service. The volunteer patients cited their distance from the clinic as the primary reason for favoring telepsychotherapy. The residents and patients were instructed on the technical aspects of the software.
The study protocol was by the Health Insurance Portability and Accountability Act (HIPAA) regulations. The patients received five or more standard in-person psychotherapy sessions before engaging in telepsychotherapy. Throughout the therapy, patients could choose between in-person or remote sessions at each encounter. They each received fourteen remote non-consecutive sessions of psychodynamic or supportive psychotherapy.
Study participants were instructed to use their devices (laptops, iPads, smartphones) in their home while residents used secure computers at the clinic. The interviews were not synchronously supervised. Cases were individually discussed with preceptors during long-term supervision sessions following the protocol used with in-person psychotherapy cases. The residents later evaluated their experience in the form of an unstructured narrative. The Institutional Review Board determined that these evaluations were not considered research on human subjects and, therefore, required no formal approval.
The patients remained psychiatrically stable and did not require hospitalization. All involved residents completed the evaluation. The unstructured narrative ensured that resident feedback was not limited to preconceived parameters.
The quality of video and sound allowed for adequate patient-provider communication. Minor technical difficulties such as poor connection or a short loss of connection were sometimes experienced but did not affect patient care. No concerns about patient confidentiality or general privacy were voiced by the residents, patients, or training supervisors.
Even though patient satisfaction with the use of telepsychiatry was not a targeted outcome in this study, there was overall positive feedback from all the study participants. This was consistent with the high level of satisfaction reported by the resident physicians. The discussion of cases with supervisors after the session is the standard practice of the continuity clinic and a lack of experience or supervision during the sessions was not cited as a barrier to successful provision of telepsychotherapy. Exposure to the technological aspects of telepsychotherapy and the new communication style associated with it was regarded as a benefit.
As perceived by the supervising attendings, the quality of psychiatric care was no different from that provided in regular office settings, and there was no compromise in the ability of the residents to empathize and relate to the patients. It was reported that non-verbal cue interpretation did not differ from in-person scenarios. The residents appreciated the flexibility associated with telepsychiatry, which allowed for a stable schedule and continuous care. Thus, patients scheduled for office visits often requested telepsychotherapy under circumstances of illness, last-minute commitment changes, or lack of transportation. Compared to the standard visit, remote sessions also seemed to better align with patient schedules. This reduced the number of no-shows and maintained continuity of care, thereby increasing overall satisfaction with the therapeutic alliance and the quality of services provided. As the study progressed, the residents observed an increase in the frequency of telepsychotherapy being chosen by patients.
The residents indicated that this early exposure to telepsychiatry was an exciting and positive experience that benefited their training and strengthened their interest in this type of psychiatric care. They also expressed a desire to continue using telepsychiatry in their residency and formal practice.
The use of telemedicine in psychiatry is widely introduced in modern practice due to its effectiveness, potential to address the disparities in access to care, reduce costs and supply comfort to patients (1-5,8-12). Other medical specialties have also addressed the need to educate residents in the use of telemedicine in various clinical settings (16-22). The experience of these studies has been equivocal, with no negative impact reported by the physicians in training, but some reservations expressed by the supervisors and attending physicians. The use of telepsychiatry in pediatric emergency rooms resulted in an overall positive impact in regards to call burden for the residents, hinting at the importance of early incorporation of telehealth training (23).
The patients in our study were volunteers, and therefore, interested in and comfortable with the use of technology. This familiarity resulted in the observed effect of continuous patient compliance and interaction with the resident. The patients also received at least 5 in-person sessions thereby developing baseline rapport, which then translated to the teletherapy session. Our supervisors did not express any discomfort
Despite publications on telepsychiatry competencies, life-long learning, and continuing medical education credits, residents receive little or no formal exposure to telepsychiatry during their training (14,15,24-26). In a survey of 183 psychiatry training programs, the response rate was only 25% (n=46) of which 21 programs reported resident involvement in telepsychiatry in some fashion while only 12 programs offered a formalized curriculum (27). A formalized training regimen has not yet been standardized. Hilty et al. have designed a framework for training and education in telepsychiatry (25). In their study, the focus is on the competencies of the electronic practice of psychiatry in general, but psychotherapy is not explicitly addressed. Several other studies on telepsychiatry also do not directly address the delivery of therapy using telemedicine (14,28-31).
There are a few reports on the utilization of telepsychotherapy specifically for resident education (32,33). DeGaetano et al. reported that 40% of the resident interactions involved some psychotherapy using telemedicine. The researchers report that residents were more comfortable with medical management and patient evaluations compared to therapy. However, the study admits that the residents had less experience with therapy in general. Mahoney et al. reported positive feedback from residents and educators in the use of technology in psychotherapy training.
The goal of our study was to assess the feasibility of conducting telepsychotherapy early in residency training and use technology to make our residents more comfortable with therapy in general. Our residents showed that the opportunity to conduct remote psychotherapy increased their interest in the evolving practice of telepsychiatry and therapy. Also, the experience of performing telepsychotherapy in the context of a training program increased resident readiness to use the modality and the software. In line with previously published data, our resident and supervisor feedback confirmed the conclusions by Glover et al. that there is a gap between exposure to telemedicine and the interest endorsed by resident physicians (34).
Although there are some reports of how telepsychiatry is implemented in resident training, there is no uniform consensus, and therefore, the use of telepsychotherapy in resident continuity clinics has not been explicitly explored. According to the recent review by Kocsis et al. (13), telepsychotherapy may be useful for a wide range of patients and may offer an innovative way of forming therapeutic relationships. It allows for an intimate dialogue, unique observations (i.e., patient’s home environment), and maybe preferred by patients with anxiety, PTSD, and paranoia (35).
The impact of telepsychiatry in the doctor-patient relationship is currently under debate (8). The resident psychiatrists involved in our study reported increased strength of the therapeutic alliance, which could be explained by reduction in patient stress level and perception of improved control over their lives due to the flexibility attributed to the use of technology. This flexibility in turn translated into more consistent follow-up, improved continuity of care, and a stable schedule for both patients and providers.
The lack of experience did not seem to pose a barrier to the successful implementation of telepsychotherapy at the resident clinic; therefore, early introduction of telepsychotherapy in training is feasible. Residents and medical students have uniformly responded favorably to the use of this technology in practice, and the educational experience has been reported to be rewarding when coupled with appropriate supervision (36,37).
Our study suggests that tele psychotherapy can be effectively used by residents in the continuity clinic starting as early as the second year of training. Supervisors in our program did not identify any patient-care related challenges. We attributed this level of comfort to an understanding of technology, and the lack of access to mental health in our community needing the use of telepsychotherapy. Our findings call for the modification of the existing residency curriculum to prepare the new generation of psychiatrists for the growing demand for mental health services. A survey of the extent of telepsychiatry in the American residency programs demonstrated interest in designing a formalized and standardized telepsychiatry curriculum (38), and we illustrate a trend in that direction (27,39). As shown in our study, use of telepsychotherapy in continuity clinics has the potential to create a more longitudinal educational experience and increase opportunities for residents to be active participants in therapy sessions. More extensive studies are needed to explore the nuances of the resident experience further and devise the framework for a telepsychotherapy curriculum.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
- Hilty DM, Maheu MM, Drude KP, et al. The Need to Implement and Evaluate Telehealth Competency Frameworks to Ensure Quality Care across Behavioral Health Professions. Acad Psychiatry 2018;42:818-24. [Crossref] [PubMed]
- Bashshur RL, Shannon GW, Bashshur N, et al. The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemed J E Health 2016;22:87-113. [Crossref] [PubMed]
- Santa Ana EJ, Stallings DL, Rounsaville BJ, et al. Development of an in-home telehealth program for outpatient veterans with substance use disorders. Psychol Serv 2013;10:304-14. [Crossref] [PubMed]
- Stain HJ, Payne K, Thienel R, et al. The feasibility of videoconferencing for neuropsychological assessments of rural youth experiencing early psychosis. J Telemed Telecare 2011;17:328-31. [Crossref] [PubMed]
- Fortney JC, Pyne JM, Kimbrell TA, et al. Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry 2015;72:58-67. [Crossref] [PubMed]
- Saurman E, Kirby SE, Lyle D. No longer ‘flying blind’: how access has changed emergency mental health care in rural and remote emergency departments, a qualitative study. BMC Health Serv Res 2015;15:156. [Crossref] [PubMed]
- Wynn R, Bergvik S, Pettersen G, et al. Clinicians’ experiences with videoconferencing in psychiatry. Stud Health Technol Inform 2012;180:1218-20. [PubMed]
- Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry 2016;6:269-82. [Crossref] [PubMed]
- Hilty D, Yellowlees PM, Parrish MB, et al. Telepsychiatry: Effective, evidence-based, and at a tipping point in health care delivery? Psychiatr Clin North Am 2015;38:559-92. [Crossref] [PubMed]
- Mitchell JE, Crosby RD, Wonderlich SA, et al. A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus in person. Behav Res Ther 2008;46:581-92. [Crossref] [PubMed]
- Pyne JM, Fortney JC, Mouden S, et al. Cost-effectiveness of on-site versus off-site collaborative care for depression in rural FQHCs. Psychiatr Serv 2015;66:491-9. [Crossref] [PubMed]
- Lokkerbol J, Adema D, Cuijpers P, et al. Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a health economic modeling study. Am J Geriatr Psychiatry 2014;22:253-62. [Crossref] [PubMed]
- Kocsis BJ, Yellowlees P. Telepsychotherapy and the Therapeutic Relationship: Principles, Advantages, and Case Examples. Telemed J E Health 2018;24:329-34. [Crossref] [PubMed]
- Saeed SA, Johnson TL, Bagga M, Glass O. Training residents in the use of telepsychiatry: review of the literature and a proposed elective. Psychiatr Q 2017;88:271-283. [Crossref] [PubMed]
- Teshima J, Hodgins M, Boydell KM, et al. Resident evaluation of a required telepsychiatry clinical experience. Acad Psychiatry 2016;40:348-52. [Crossref] [PubMed]
- Jackson CD. Commentary on "Resident Perceptions of Competency and Comfort Before and After Telemedicine-ICU Implementation". South Med J 2018;111:348. [Crossref] [PubMed]
- Govindarajan R, Anderson ER, Hesselbrock RR, et al. Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations. Neurology 2017;89:951-9. [Crossref] [PubMed]
- Coletti C, Elliott DJ, Zubrow MT. Resident perceptions of a tele-intensive care unit implementation. Telemed J E Health 2010;16:894-7. [Crossref] [PubMed]
- Summe A, Foor L, Hoeck L, et al. Resident Perceptions of Competency and Comfort Before and After Telemedicine-ICU Implementation. South Med J 2018;111:344-7. [Crossref] [PubMed]
- Butterfield A. Telepsychiatric Evaluation and Consultation in Emergency Care Settings. Child Adolesc Psychiatr Clin N Am 2018;27:467-78. [Crossref] [PubMed]
- Marttos AC Jr, Fernandes Juca Moscardi M, Fiorelli RKA, et al. Use of Telemedicine in Surgical Education: A Seven-Year Experience. Am Surg 2018;84:1252-60. [PubMed]
- Papanagnou D, Stone D, Chandra S, et al. Integrating Telehealth Emergency Department Follow-up Visits into Residency Training. Cureus 2018;10:e2433. [PubMed]
- Reliford A, Adebanjo B. Use of Telepsychiatry in Pediatric Emergency Room to Decrease Length of Stay for Psychiatric Patients, Improve Resident On-Call Burden, and Reduce Factors Related to Physician Burnout. Telemed J E Health 2019;25:828-32. [Crossref] [PubMed]
- Crawford A, Sunderji N, López J, et al. Defining competencies for the practice of telepsychiatry through an assessment of resident learning needs. BMC Med Educ 2016;16:28. [Crossref] [PubMed]
- Hilty DM, Turvey C, Hwang T. Lifelong Learning for Clinical Practice: How to Leverage Technology for Telebehavioral Health Care and Digital Continuing Medical Education. Curr Psychiatry Rep 2018;20:15. [Crossref] [PubMed]
- Sunderji N, Crawford A, Jovanovic M. Telepsychiatry in graduate medical education: a narrative review. Acad Psychiatry 2015;39:55-62. [Crossref] [PubMed]
- Hoffman P, Kane JM. Telepsychiatry education and curriculum development in residency training. Acad Psychiatry 2015;39:108-9. [Crossref] [PubMed]
- Hilty DM, Rabinowitz T, Mccarron RM, et al. An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care. Psychosomatics 2018;59:227-50. [Crossref] [PubMed]
- Crawford A, Gratzer D, Jovanovic M, et al. Building eHealth and Telepsychiatry Capabilities: Three Educational Reports Across the Learning Continuum. Acad Psychiatry 2018;42:852-6. [Crossref] [PubMed]
- Ratzliff A, Sunderji N. Tele-Behavioral Health, Collaborative Care, and Integrated Care: Learning to Leverage Scarce Psychiatric Resources over Distance, Populations, and Time. Acad Psychiatry 2018;42:834-40. [Crossref] [PubMed]
- Hilty DM, Sunderji N, Suo S, et al. Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies. Int Rev Psychiatry 2018;30:292-309. [Crossref] [PubMed]
- DeGaetano N, Greene CJ, Dearaujo N, et al. A pilot program in telepsychiatry for residents: initial outcomes and program development. Acad Psychiatry 2015;39:114-8. [Crossref] [PubMed]
- Mahoney N, Walaszek A, Caudill R. Incorporating Technology into the Psychiatric Residency Curriculum. Acad Psychiatry 2018;42:847-51. [Crossref] [PubMed]
- Glover JA, Williams E, Hazlett LJ, et al. Connecting to the future: telepsychiatry in postgraduate medical education. Telemed J E Health 2013;19:474-9. [Crossref] [PubMed]
- Yellowlees P. Telepsychotherapy. In: Dewan MJ, Steenbarger BN, Greenberg RP. editors. The art and science of brief psychotherapies: a practitioner's guide. Arlington: APA Publishing, 2017:303-13.
- Dzara K, Sarver J, Bennett JI, et al. Resident and medical student viewpoints on their participation in a telepsychiatry rotation. Acad Psychiatry 2013;37:214-6. [Crossref] [PubMed]
- Szeftel R, Hakak R, Meyer S, et al. Training psychiatric residents and fellows in a telepsychiatry clinic: a supervision model. Acad Psychiatry 2008;32:393-9. [Crossref] [PubMed]
- de Groot J, Tiberius R, Sinai J, et al. Psychiatric residency: an analysis of training activities with recommendations. Acad Psychiatry 2000;24:139-46. [Crossref]
- Hilty DM, Crawford A, Teshima J, et al. A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications. Int Rev Psychiatry 2015;27:569-92. [Crossref] [PubMed]
Cite this article as: Famina S, Farooqui AA, Caudill RL. Early use of telepsychotherapy in resident continuity clinics—our experience and a review of literature. mHealth 2020;6:1.