The digital revolution has transformed society and forever altered the practice of psychiatry. Technology permeates our daily lives and poses new social and professional challenges (Table 1).1 The speed, range, and permanence of digital communication magnify both its efficiency and the effects of breeches in professionalism. Few standards exist regarding the use of technology in medicine, and those that do exist can become quickly outdated as technology advances and patient expectations and standard-of-care practices continue to change.
In psychiatry, professional challenges are heightened by the importance of the psychiatrist-patient relationship. Because of its intimacy, the sensitivity of clinical content, and stigma about mental illness, the psychiatrist-patient relationship must be one of safety and trust. However, psychiatric patients deserve the same access to medical information and up-to-date clinical care practices that all medical patients merit and that technology may enhance. How can psychiatrists integrate technology professionally into clinical practice?
This article addresses key concerns that can arise with the use of technology. It then looks at promising technological opportunities that can be integrated into psychiatric practice while respecting professional boundaries. Finally, recommendations for use of technology in psychiatric practice are discussed.
Clinical care and liability
While technology offers opportunities for improving care, its use in clinical practice has potential pitfalls. Electronic communication largely lacks nonverbal cues such as affect and is easily misinterpreted. Visual and other diagnostic data are lacking. In the rapid back and forth of an electronic exchange, the physician may miss important information; a patient may be having a problem for which he or she needs to be seen.2 For example, a patient with bipolar disorder who takes lithium e-mails her psychiatrist because she is not feeling well—she attributes her symptoms to exercising in hot weather. Unless the psychiatrist recognizes the possibility of dehydration and resulting lithium toxicity and insists that the patient be evaluated in person, the patient may suffer harm, such as a fall and fracture due to ataxia, thus exposing the psychiatrist to liability.
If someone who is not a current patient contacts a psychiatrist seeking medical advice, the psychiatrist must avoid inadvertently establishing a physician-patient relationship by providing advice with the patient’s implied consent.3 Patients have the right to know the source of medical information; anyone who provides medical information online should identify himself or herself and provide appropriate credentials.
Psychiatrists who post information online using a pseudonym should never assume anonymity. One example is the case of a Boston pediatrician, a defendant in malpractice litigation who was blogging under the pseudonym “The Flea” about a case. When his identity was revealed by the plaintiff’s attorney, the case was quickly settled.4
Finally, the psychiatrist who provides medical advice to patients online may be providing care across state lines if the patient is not physically within the psychiatrist’s state; such situations occur when an adult patient has moved but wishes to continue treatment or when an adolescent has graduated high school and attends college away from home. If the care largely takes place electronically, the psychiatrist should ascertain the other state’s medical board requirements.5
Doctor-patient relationship and boundaries
Traditionally, psychiatry has insisted on the maintenance of a therapeutic frame for effective treatment. All psychiatric treatment—particularly psychotherapy—requires clear boundaries for patients to feel safe. By restricting treatment to time-limited, face-to-face encounters, patients receive the important message that the relationship is professional. When working through a patient’s deeply personal thoughts and feelings, revealed verbally and nonverbally (eg, through affect and gesture), face-to-face sessions are key to successful treatment. Technology does not allow these types of physician-patient encounters and it can blur the boundary between personal and professional.
Because of easy access to the Internet, patients and psychiatrists can obtain personal information about each other. Communication can occur 24/7, and while the participants are invisible to each other, they may be communicating in their nightclothes. The disclosure of intimate feelings and thoughts in such a context invites boundary erosion, and the communication may become an unhealthy vehicle for meeting emotional needs of both psychiatrist and patient. Conversely, the impersonality of text on a screen may increase opportunities for countertransference. Psychiatrists need to remember that it is their job, not the patient’s, to maintain the therapeutic frame. Avoid “friending” patients and other electronic interactions that blur professional boundaries.6
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