David Goldbloom is a psychiatrist and senior medical advisor at the Centre for Addiction and Mental Health. He is the author of We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care.
We are all telepsychiatrists now, connecting with patients through telephones and a variety of secure televideo links. A year ago, we were not.
The first published report of televideo psychiatry for people in underserved communities appeared in 1957. By 2017, only 7 per cent of Ontario psychiatrists used this medium to connect with patients. Then COVID-19 arrived. And while the unprecedented rapid development of multiple vaccines has been the most exhilarating scientific advance engendered by the pandemic, it has occurred against a backdrop of less dramatic but still significant changes in health care delivery. Televideo hesitancy has resolved faster than vaccine hesitancy.
Telepsychiatry reflects both old and new values and traditions in health care. It constitutes the revival of the house call, for example. Such visits were an essential component of the clinical routine of my pediatrician grandfather and father, and one I occasionally incorporated into my own practice as a psychiatrist. New technology once again affords us clinicians the opportunity to see where and how our patients live, to meet their families, friends and pets, in an environment where they often feel more at ease. And, as we both stumble through the challenges – as in “You’re on mute” or seeing only the tops of foreheads – there is a levelling of the playing field.
Also notable is the patient-centred aspect of telepsychiatry. It is often maximally convenient to our patients that their encounters with us do not demand extensive travel, time off work, child care and inevitable waiting. And it introduces novel contexts to our encounters. Parked cars, bathrooms and even open fields have become telepsychiatry studios for patients whose living or working arrangements preclude the privacy necessary for confidentiality.
Some of us are accustomed to providing such care to underserved northern communities, but that model was based largely on patients going to their local health clinic’s televideo studio, and was often hampered in winter months by poor driving conditions. Now these patients connect using their computers or phones in their own homes.
Telepsychiatry is not without its drawbacks. Patients without access to smartphones and computers can be left behind – people who are homeless, poor or live in settings without sufficient broadband access. There will always be a need for in-person services, and there will always be people who do not feel “connected” through the web. But for most of my fellow clinicians, the surprise has been how many patients do feel comfortable with this mode of interaction – perhaps even more so than we do, because it represents such a transformative change in how we provide care. What counts, ultimately, is what helps our patients.
The ramp-up to televideo care was sudden. At the outset of the pandemic, the Centre for Addiction and Mental Health went from providing 350 such sessions a month to 3,500. Drivers included both clinical need and the need of providers to be working and to be paid. This triggered unprecedented changes to government payments for virtual care that must continue.
The pandemic has been described not as an equalizer but as a revealer of inequities in our society when it comes to vulnerability to infection, vaccine distribution, access to care – and access to broadband internet and hardware. This has implications for the delivery of health care and essential education services, and also for promoting social proximity at a time of physical distancing. As we plan for things such as adequate PPE supply and local vaccine development in a future pandemic, ensuring that all Canadians have access to virtual lifelines of broadband is a national priority.
Will we return to the tradition of visits to offices and clinics? I suspect a hybrid model will evolve, with patient choice at the centre. However stressful the pandemic has been, it has triggered radical changes in care delivery, catalyzing the uptake of opportunities that have had a long enough gestation. I have no doubt they will endure.
The prepandemic status quo of access to psychiatric care was not acceptable. We need to leverage the lessons learned – and forced upon us.
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