Daniel W. Knoedler, MD

[[{"type":"media","view_mode":"media_crop","fid":"25037","attributes":{"alt":"telepsychiatry","class":"media-image media-image-right","id":"media_crop_6832179568061","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2230","media_crop_rotate":"0","media_crop_scale_h":"251","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Telepsychiatry is a team sport. To run an effective practice, you need skilled people on-site with the patients. The on-site staff needs to be able to do more than just get the patient into the correct room and call the psychiatrist. The on-site staff needs to be able to assess the things that you, as the telepsychiatrist, would not be able to assess: Does the patient smell of alcohol? Did he or she interact with the staff at the front desk, or with the other patients in the waiting room, in such a way that you should be made aware? Is there a family member in the waiting room who should be included in the appointment? Does the patient have a medication list that needs to be deciphered? Does the patient’s behavior suggest that there might be a safety concern, either for himself or for the staff? Are there physical signs that you might notice in person that might not be evident on video, such as rash or exophthalmos? The level of training and expertise of the on-site staff needs to be clearly understood by the treating physician.

We need to be aware, also, of the increased stress that the staff who are actually with the patients feel: in telepsychiatry, the psychiatrist is not on-site to help if some difficult event occurs. It may be the psychiatric nurses and aides who tackle the patient when a crisis occurs, but the team still sees the psychiatrist as the one who ultimately needs to make critical treatment decisions.

Telepsychiatry is good for psychiatrists. It offers the possibility of working from home, and of working somewhere warm in the winter and somewhere that’s not too hot in the summer. It gives psychiatrists an opportunity to rejuvenate their careers in an interesting fashion, and to become proficient with a new set of skills using new technology. It may be that telepsychiatry will increase the shrinking pool of available psychiatrists, since some psychiatrists may choose to practice longer if telepsychiatry allows them to accommodate their own physical limitations as they age. Telepsychiatry may also allow younger psychiatrists to work more hours if the option of working from home creates greater flexibility for child care or a more satisfying ability to interact with family during the day.

All else being equal, I believe that having a psychiatrist on-site, in person, in the room, is better for most patients than having a telepsychiatry session with a psychiatrist. (Of course, for some patients it will not make a difference; other patients may feel that telepsychiatry is less threatening than a live interview.) Telepsychiatry is enjoying a boom, but that is primarily, in my opinion, because there is a shortage of psychiatrists. If there were a surplus, I believe the demand for telepsychiatry would be much smaller.

A relevant question is whether telepsychiatry for a rural clinic is better than the grand tradition of the traveling, itinerant psychiatrist who spends a day or two at a time, in person, in small clinics, traveling from small town to small town on a regular schedule. The answer, at least for most patients, is that telepsychiatry is better for the psychiatrist, but not necessarily better for the patient. One exception might be in very sparsely populated rural areas, where a patient might have to travel long distances even to get to a rural clinic. In that situation, a telepsychiatrist might be able to see a patient in a very small town-a town too small to support even an occasional full day of psychiatric time-perhaps by videoconferencing into the patient’s home.

Telepsychiatry is costly. In addition to the videoconferencing equipment, a telepsychiatrist needs two offices: one for the psychiatrist, and one for the patient. A telepsychiatrist also needs someone to be on-site and available to the patient at all times. If you have one technician or nurse at the patient end of the interaction, and that person calls in sick, goes on vacation, or even just goes to lunch, your practice will grind to a halt. You need a backup staff on the patient end.

You also need ongoing IT support-a little if you are lucky, but a lot if you are not! To minimize the risk of canceling patients because of a technology issue, your IT support needs to be readily available. Having a nurse with extensive mental health experience available at the patient end of the interaction is highly desirable and addresses many of the concerns raised by having the psychiatrist off-site.

Prescriptions can be handled by using an electronic prescribing service, such as Allscripts. Controlled substances that require a written prescription involve more effort, including a combination of calling prescriptions into a pharmacy and mailing written prescriptions.

Implications for the doctor-patient relationship

Should telepsychiatrists videoconference into a patient’s home, allowing the patient to be seen without even leaving his home? Can we use telepsychiatry to re-create the home visit that was such a tradition of doctors in the past? Perhaps there are patients who would benefit, but it seems as if telepsychiatry into a patient’s home might be a very different kind of interaction than what we are used to. Going to the doctor’s office, negotiating the reception desk and the waiting room, and sitting in a professional office must surely have significant meaning in the therapeutic relationship. Seeing a patient in his home via videoconferencing also involves the complicated issues of the home environment: privacy, technical equipment, the patient’s feelings about the psychiatrist being “present” in his home, and the expanded potential for disruptions.

I recently decided to retire from my full-time telepsychiatry position with the VA and return to my previous full-time job as the Health and Human Services psychiatrist for Sheboygan County, Wisconsin. I will be on-site for at least half the year at Sheboygan County, and doing telepsychiatry for Sheboygan County from someplace warm for the rest of the year.

There are, undoubtedly, psychiatrists who will thrive doing telepsychiatry from home full-time; my experience has taught me that I am not one of them. Full-time telepsychiatry is a diet that is a bit too rich for me; tiramisu is delicious, but not tiramisu for breakfast, lunch, and dinner! I am looking forward to working with my colleagues at Health Human Services again, live!

Dr Knoedler reports no conflicts concerning the subject matter of this article.

Articles

To run an effective telepsychiatry practice, a solid partnership between skilled personal on-site with patients and the psychiatrist on the other end of the call is a must. 

Telepsychiatry Is a Team Sport

In the small, rural Veterans Administration clinic, where I worked part-time for 9 years, a nurse could use an otoscope to peer into the ear of a patient, and an ear, nose, and throat specialist could see remotely into the same patient’s eardrum from a 70-mile distance. A nurse could focus a camera on a skin lesion, and a dermatologist could examine the lesion clearly from a second location and interact with the patient in real time. Similarly, in my 

, I am well-equipped to perform an initial evaluation of a patient, prescribe medication, and arrange to see the patient for follow-up while I sit in the basement of my home in Sheboygan, Wisconsin, many miles away from the patient. Telehealth is here, and it’s here to stay.

As a practicing, full-time telepsychiatrist, a brief description of my setup from home may be of interest.


I am using VA-supplied equipment that consists of a laptop computer running two monitors. The laptop stays closed, and I have a monitor directly in front of me that displays the patient (and a small frame on the edge that shows me, as the patient sees me) and a monitor to my left that displays the electronic medical record. I also use instant messaging (IM) software, which allows me to communicate via text messages with the staff at the “Far End” (that is, the end where the patient is sitting; by contrast, I am at the “Near End.”) The monitors are standard equipment available at any computer store-a quick Internet search shows them to be available for less than $200 each.

The computer uses Windows 7, and an Intel® i5 - 2520M CPU @ 2.50 GHZ chip, with 4 MB of RAM. For those of you who are technologically savvy, you will recognize that this is a pretty standard, mid-priced laptop. The laptop sits in a computer dock that allows it to run both monitors, and a small Logitech® HD C920 Pro Webcam camera sits on top of the central monitor. The laptop is wired via an ethernet cord to my router; I upgraded to a $200 router when I started practicing telehealth, but that probably was not necessary-the router supplied by my cable company likely would have worked fine.

I chose to use an ethernet connection instead of my home wireless network because of advice I received that the speed and quality of the video would be higher. My home Internet service is the standard cable connection available through my local provider, with no special upgrades. The equipment is running Cisco® Jabber video software for video conferencing, which Cisco lists as being HIPAA-compliant. [The preceding is not intended as an endorsement.]

The quality of the video on my system is only fair, largely because of restrictions on bandwidth for a user accessing the VA computer network. There are times when there is some distortion of the picture, especially if someone moves quickly. However, this is not a critical issue. As my telepsychiatry colleague and friend, Jeff Zigun, MD, points out, the video is a nice extra touch, but the ability to communicate by voice is the critical issue. For unknown reasons, the video during my first telepsychiatry session was not working, and I had to conduct the interview by voice communication alone. It’s not ideal, but it worked.

Unless you are pretty technologically savvy, you will need ongoing IT support. In my situation, the VA has excellent support, but it took well over 10 hours of consultation to make things work correctly and to work through all the issues of how I would communicate with staff and deal with patients. I have also required ongoing support to address problems that occurred while I was seeing patients, which means you need to have quick access to IT help and contingency plans in place if the problem cannot be quickly resolved. The problems have ranged from loss of video, (but intact audio), to a complete loss of the connection. (In fairness, I have been told that my system had far more problems than the average telehealth setup.)


My patients seek treatment through the Veterans Health Administration Outpatient Clinic in Green Bay, Wisconsin. There, a trained technician lets me know via IM or telephone that my patient has arrived. She then greets the patient, brings the patient to the examination room, explains that I will be seeing them through an encrypted video system, and that the session is private and will not be taped. The technician then calls my video link, introduces me, and leaves the patient alone in the room.

The actual session is no different from an in-person evaluation, although I usually spend a minute or two making sure the patient is comfortable with the format. At the end of the appointment, I let the technician know we are done. She then comes to get the patient, makes the follow-up appointment, and takes care of any other business. We have an RN on site who can weigh the patient, take blood pressure, or handle other medical issues as needed.

As part of maintaining a safe environment for patient and staff, we have pre-established practices for various contingencies. We have protocols if the patient needs to be hospitalized, referred for immediate medical care, or other difficulties. I also have the contact information of clinic security staff and local law enforcement, if need be.

 that might not be otherwise available in their area. It allows them to be seen locally, rather than traveling to a distant location. For the practitioner, telepsychiatry and telehealth offer the ability to work from home, which means no commute. It also is very time efficient and allows more free time during the day. Best of all, telepsychiatry offers clinicians the option of working from any location where a good Internet connection can be found.

In my case, my primary goal in becoming a telepsychiatrist is my 

 (heck, I grew up in Duluth, Minnesota-I have my cold weather bona fides! I will say 

to escape the northern winters.  I anticipate practicing from Wisconsin during the summer, and somewhere with lots of good sailing and warm weather in the winter. I think it is likely I will practice longer before retiring because I have this option.

Medical licensing and malpractice need to be explored before starting a telepsychiatry practice. In general, the medical encounter is felt to occur where the patient is-that is, the medical encounter is in Wisconsin if the patient is in Green Bay, even if the physician is in, say (just as an example) Florida. However, the issue of physical proximity is evolving, and a practitioner should clarify this matter both with the state medical board where the patient will be located as well as the state medical board where the physician is.

This concern also needs to be clarified with your malpractice carrier, including the question of which set of state statutes would apply if you were to become subject to a malpractice lawsuit. As an example, Wisconsin has a state-run Patient Compensation Fund that essentially protects the personal assets of physicians from malpractice settlements; in some states, personal assets are at risk in malpractice settlements. As Warren Buffett loves to say, most surprises in the area of insurance are of the unpleasant variety!

The greatest barriers to adapting to this technology are in our ways of thinking about telepsychiatry and our resistance to embracing new patterns of practice. The benefits for both the patient and the caregiver can be substantial-and as a result, perhaps more patients can be helped.

Dr Knoedler left his “Comfort Zone” job as Medical Director of Sheboygan County Health and Human Services in Sheboygan, Wisconsin. He is now a full-time Telepsychiatrist for the VA Hospital in Green Bay, Wisconsin.  He reports he has no conflicts of interest regarding 

the subject matter of this article, with the exception of possible shares of mutual funds

Telehealth is here, and it’s here to stay. A telepsychiatrist gives a brief description of the setup from his home office. 

Telepsychiatry Basics: Setup, Sessions, and Pros and Cons

In spite of the minor mishaps of my first week, outlined below, it has become clear to me that 

, valuable, and timely addition to our psychiatric lives and that of our patients.


I begin my first week of my new job as a full-time telepsychiatrist, working for the Green Bay VA Hospital in Green Bay, Wisconsin.


The basement, my new office, is far colder than I ever imagined. I have donned a Polartec® jacket for warmth. My fingers are tingling. I’m thinking of putting on a knit cap. When I turn on the electric baseboard heater, which we have never used in our 17 years in the house, things start to warm up.

Then, I sense the strong smell of something burning. Then, the fire alarm system goes off-not just in the basement, but throughout the house-after I had dutifully linked all the fire alarms in the house to go off at once! I hear the footsteps of my obviously startled son and his girlfriend, home from Texas, on the floor above me as the alarm wakes them. Fortunately, there are no open flames.

Later, while seeing a patient, I realize that there is a stream of warm air coming from the side of the laptop on the right side of my desk. Slowly I start to slide my hands towards the warmth as I talk, hoping to warm up my freezing fingers. I suddenly realize that the patient can tell I’m doing something with my hands, but he can’t tell what I’m doing, because my hands are outside of his field of vision. An awkward moment of silence occurs. I slowly pull my hands back towards me. Grist for the mill.


I must not look into the mirror very often. In a small window in the corner of my monitor, as I talk with my patients, there is some old guy who seems abnormally animated staring at me. Wait! That’s me, looking back at me! What happened? The last time I looked at myself, I had a lot more hair and I looked at least 15 years younger! This is not pleasant. I also notice that I have a tendency to lean towards my patient when I talk-something I was unaware of until now.

When I lean in on my telepsychiatry system, my head suddenly looms large and fills the screen that the patient sees. It must look like Shrek coming out of the woods. I consider whether my patients might enjoy having 3D glasses so my head will appear to bulge out into the room towards them. It might work as a sort of a Rorschach test, to better assess their startle response.


I’m considering writing a movie script, a sort of sequel to “Home Alone,” about a psychiatrist whose parents accidentally leave him home alone. (Wait, that won’t work!)

It’s frighteningly quiet here when I’m not seeing a patient. I think up a ruse, and call the nurse I used to work with, ostensibly with a valid question. I think she sees through me. She’s probably thinking: “Here we go. He’s been home alone for less than a week, and he’s losing it.” I’m fearful that she might be correct.

I’ve always known that interacting with other staff was a big part of my job satisfaction, but that fact is being driven home with painful clarity. I start flipping through the job ads at the back of 

 Prison psychiatry is looking like a viable option for the first time ever. At least there would be someone to talk with!


I realize I forgot to shave yesterday morning, and didn’t notice until this morning. Is that it? Is that the beginning of the decline? Will they find me some day looking like Howard Hughes, unshaven, fingernails growing in long curves back into the pads of my fingers? How long will it take the technician on the other end of the system to recognize that I’ve gone over the edge?

There’s a shortage of psychiatrists, I tell myself: I can probably keep working even if I start wearing pajamas and carry a teddy bear to my basement office. I’ll get a short stool to prop the teddy bear up, just under the line of sight of the camera. He can keep me company. It will be good to not be alone.


I’m painfully reminded of the old adage: Be careful what you ask for-you might get it! Taking this telepsychiatry job, and leaving the warm comfort zone of my old job, has been like jumping off a cliff; heading off to college; hopping a freight car. It’s a big shake-up at a time when I could have coasted along for another 5 or 10 years and never even dusted off my office bookshelf. It’s the kind of thing I sometimes encourage my patients to do: get out of your comfort zone.

I can feel the stress this change causes, but I keep telling myself this is how we move forward.

Of course, as a psychiatrist, I know jumping off a cliff doesn’t always turn out well. Sometimes you land on a new ledge filled with new challenges. Sometimes you . . . don’t land on a new ledge filled with new challenges. I time the mail delivery perfectly to get a chance to chat with the letter carrier. “How’s the new job?” she asks. “Too early to tell,” I respond, deciding that honesty is the best policy. “Too early to tell.”


Despite the growing pains of my first week, I have come to discover that telepsychiatry serves to address the lack of access to psychiatric care that is such a problem for so many patients.

The limitations of the current technology do not affect the key elements of good psychiatric care, which in my opinion are the ability to

•form a strong therapeutic alliance
•successfully understand what the patient is thinking and feeling
•collaborate and develop an ongoing and flexible treatment plan

On the one hand, the technology can present a barrier; on the other, I have found that patients have been intrigued by the novelty, and that the technology should not and does not prevent an experienced clinician from being fully engaged.

Dr Knoedler left his “Comfort Zone” job as Medical Director of Sheboygan County Health and Human Services in Sheboygan, Wisconsin. He is now a full-time Telepsychiatrist for the VA Hospital in Green Bay, Wisconsin. 

The transition to telepsychiatry is great, but the benefits, many. In this humorous piece, it becomes clear to this clinician that telepsychiatry can be a viable, valuable, and timely addition to the psychiatric profession, despite minor mishaps in the first week. 

Telepsychiatry: First Week in the Trenches

. At the US Veterans Administration (VA) clinic in Cleveland, I treat veterans from the navy, the army, the air force, and the coast guard. I have been privileged to hear of the trials that our military men and women have endured, and the ongoing trauma that many of them feel in their dreams, as memories, and in response to their nervous systems that had been hyperactivated during combat but have never returned to baseline. Many of my VA patients avoid exposure to the news. They do not watch violent movies and prefer not to talk about what they have been through.

I see another group of veteran patients at the psychiatric clinic at Sheboygan County Health and Human Services in Sheboygan, Wisconsin. These veterans are Hmong. Many of them served as soldiers in General Vang Pao’s Secret Army, which was subsidized by the CIA. They mostly fought along the Ho Chi Minh trail and focused on disrupting supply lines, rescuing downed US airmen, and battling in ways that put them in great danger-often to save American lives.

These Hmong soldiers are not eligible for services at the VA clinic. They fought, bled red blood, and died alongside American soldiers-but they cannot receive medical care alongside American soldiers.

From US soldiers at the VA clinic, I hear amazing stories-being on a minesweeper in Tokyo Harbor, being rescued from a concentration camp in Europe, or boiling soup in a helmet on the Korean peninsula. They recount what it was like to be in Vietnam and to return home full of confusion about what it meant to be drafted into the cultural morass of a dispirited military. The families of my patients at the VA clinic have lived with the aftermath of the war, as their loved ones have tried to keep their lives moving forward, but the families of these soldiers were not 

The families of Hmong veterans that I see were 

 the refugee camps in Thailand. From these veterans, I hear of fighting in the jungle under incredibly stressful conditions, and seeing many of their fellow soldiers die. From their families, I hear of trying to live and raise crops and take care of their children while war was raging all around them. They talk of fleeing through the jungle with their children, holding their hands over the mouths of their children to prevent sound, and swimming through rivers to reach Thailand. One woman told me that her soul is still in Laos, with the souls of her children that died there. The souls of these Hmong veterans-combatants and families-run deep into the war.

Many of the Hmong patients practice shamanism. 

In traditional Hmong practices, one does not separate the physical well-being of a person from their spiritual health; the spiritual realm is highly influential, and dictates what happens in the physical world. According to these beliefs, everything possesses a spirit, both animate and inanimate objects. There is a delicate balance between these worlds.

I see most of my Hmong patients with a translator. It is slow work-questions and repeat questions are asked to try to understand how my Hmong patients see the world, what it means when I suggest a certain course of treatment, and their understanding of medications. They always dress nicely, often in beautifully embroidered clothing, in brilliant colors. They are very deferential. The women, in particular, rarely look at me, except sometimes out of the corner of their eyes. I have discovered that they won’t ask all their questions unless I directly ask them if they have questions; then, permission given, a flood of questions come forth.

My friend Tao Lee is a nurse practitioner at the VA clinic. I asked him what his Hmong parents thought about his becoming a practitioner of Western medicine. They weren’t happy, he said. They are both shamans, but (he quickly added) “retired.” You become a shaman when you are recognized by the community as having healing powers. I asked if Tao’s parents might come and talk to our medical staff; he declined. That would be difficult. They would not feel it was right.

I have learned that I should ask if my Hmong patients have also consulted a shaman to help with their depressive symptoms and with their 

. When I asked my translator to raise that question with a very reserved Hmong woman I was seeing who was racked with PTSD, I could tell she was hesitant to answer. My translator also hesitated, and laughed a little.

“She came to see you first,” he said, “because she would have had to bring a chicken to see the shaman.”

Practicing in the county community mental health clinic, I was free.

As one of my favorite sailing authors wrote (in a different context), “Good work, if you can get it.”

This psychiatrist has learned to ask if his Hmong patients have also consulted a shaman to help with their depressive symptoms and with their PTSD.

Cultural Psychiatry and the 'No-Chicken' Doctor

The day began on a high note. As I sat and talked with an elderly patient sitting in her wheelchair, quiet, not remembering much, she suddenly broke out in song:

The Old Gray Mare just ain’t what she used to be

The song “The Old Gray Mare” was about a horse named Lady Suffolk. She was reportedly the first horse to trot a mile in less than two and a half minutes. This was on July 4, 1843, when she was more than 10 years old.

Her eyes twinkled at me, and she laughed a little laugh, and smiled at me. I was slain. I could have proposed right then and there. My day brightened. “Thank you,” I thought.

Later, the nurses insisted I see a new patient: another elderly woman whose memory was fading. Her “gals” (the nurses, that is) thought she was depressed. They were worried, and hoped I could help ease her transition into whatever came next.

I found the tiny, slender woman in her bed, in her shared room, behind her privacy curtain. She was very slight, and dressed in a prim white shirt, a knit sweater unbuttoned, simple pants, and white compression stockings on her shoeless feet.

She looked at me as I approached-she was fully awake, just lying there peacefully.

I pulled out all of my best questions and tried to make contact and understand how she was feeling, to little avail. Her answers were short and noncommittal. Finally, I blurted out, “Is there anything at all that is bothering you?”

I waited. She didn’t offer anything more.

Finally, I asked, “What is bothering you?”

She paused a moment, then said, “My feet are sticking out over the edge of the bed.”
I looked. Her little white, TED-stockinged feet were sticking out over the edge of the bed.

She didn’t have the strength to pull them in.

I looked up at her face. As she gazed at me, it wasn’t clear whether she expected me to say anything else.

“Would you like me to put your feet into the bed?” I asked.

Gently, I lifted her little white crane’s feet and put them into the bed, and then pulled the little crocheted baby blue blanket that covered her legs over her feet.

“Thank you,” I thought as I walked back to the nursing station. Thank you.

The day began on a high note. As I sat and talked with an elderly patient sitting in her wheelchair, quiet, not remembering much, she suddenly broke out in song.

Author | Daniel W. Knoedler, MD

Articles

Telepsychiatry Is a Team Sport

Telepsychiatry Basics: Setup, Sessions, and Pros and Cons

Telepsychiatry: First Week in the Trenches

Cultural Psychiatry and the 'No-Chicken' Doctor

Nursing Home Rounds