Robert Boland, MD

 has switched to virtual meetings. In the last two weeks, I have used my computer, phone, and tablet to meet with groups large and small. These online encounters have ranged from one-on-one supervisory meetings that would usually happen in my office to groups of 100 or more that would normally have required an auditorium. We are also conducting our residency didactics this way, using various formats including traditional lectures, interactive workshops, and process groups.

, and I tend to be an early adopter of high-tech gadgets and software. That said, I was reluctant to give up in-person meetings, arguing that there is no substitute for sharing physical space with other people. I have always suggested that we cannot overestimate the value of having a person’s full attention, along with the nonverbal cues and food.

, all of that seems quaint. And I am happy to report that, for us, the transition to virtual meetings has been relatively painless. Despite the occasional experience of watching a person talk while they are unaware that no one can hear them, for the most part, the technology has been without glitches.

I do wonder about the future. Once this crisis is past, I expect that many of us will more easily dismiss holdouts like myself, having forced ourselves to brave this new world. I suppose that the faculty at my institution will be more likely to question the need to meet at my office or our conference space. I expect that the many national organizations whose business meetings I attend will reassess the need to fly me to their cities, both from a practical and budgetary standpoint. And, we may see the many large conferences that we so enjoy during the year as unnecessary and even hazardous, a luxury from a bygone era.

And what of patient care? Many of us are now managing outpatients via phone and telecommunication. Similarly, our consultation-liaison service is doing more curbside and phone interventions to minimize unnecessary exposure. If these patients continue to do well-and I wholeheartedly hope that they do-won’t insurance companies suggest that we move to less frequent in-person appointments and more frequent (and less expensive) virtual check-ins? And won’t other services question the need for traditional consultations?

Like most of us, I don’t have time to worry about this right now. I am too preoccupied with the health and safety of my patients, trainees, and faculty. However, I am hoping that at some more stable point we can reflect on this change. I am hardly the first to suggest that, long after we all receive the coronavirus vaccine, this pandemic may forever change us as a society. Many of the changes would have occurred anyhow, but this may greatly hasten them. Perhaps we should use this opportunity to learn as much as we can from this experience so that, once we are 

, we can intelligently discuss what changes make sense, and in which cases the old ways were the better ways.

is Vice-Chair for Education at Brigham and Women’s Hospital and Associate Professor at Harvard Medical School. He is also a member of the 

Articles

Many physicians thought we could not overestimate the value of having a patient’s full, in-person attention,  nonverbal cues and all. In the current crisis, all of that seems quaint.

Reflections on the New Normal

Physicians have been slowly adopting telepsychiatry as a way to provide remote consultation to emergency rooms and general hospital units. Virtual consultation is an emerging field; however, the 

to date suggests that telepsychiatry consultations have positive outcomes on patient care,

 and can be more efficient than face-to-face consults,

 especially when in-person consultation is not readily available.

Up until now, the focus on telepsychiatry has been as a solution for systems that lack robust psychiatry resources. As such, telepsychiatry consultation was not considered necessary or relevant for many urban and academic centers. However, the COVID-19 pandemic has upended this bias. We are currently dealing with a situation in which health care providers are at significant risk, both for becoming infected with and transmitting the novel coronavirus, without distancing and isolation protocols.

 It is becoming clear that a key to decreasing the spread of the disease includes limiting all but essential contact with patients.

With this in mind, various medical centers are at different stages in transitioning a portion of psychiatric consultation to telepsychiatry. These transitions range from a contemplation phase to programs that have already successfully made the transition.  Although there has been some informal communication, most programs have been going this alone as they decide crucial questions of when in-person consultation is necessary.

To help facilitate this process, we use the experience of two programs-one in a private and not for profit institution and the other in a Veterans Affairs hospital-to help planning, implementing, and transitioning to telepsychiatry consultations in the emergency department and general hospital floors. As such, this piece attempts to answer some of the most common questions that other medical centers are putting to us.

Telepsychiatry, also sometimes referred to as

 of technologies that can enable us to perform a patient consultation without being physically present with that patient.

 The technique can involve the use of familiar devices, such as telephones, to the use of virtual visits using, for example, computer tablets on an IV pole (more affectionately called 

) to allow for direct communication with patients.

2. When is it appropriate to forego in-person visits and use a technological option instead?

Psychiatry is somewhat at an advantage when compared with other disciplines in this regard, in that psychiatric consultations will often forego or limit the physical examination of a patient. In many cases, we can obtain needed information to make a preliminary diagnosis and prepare recommendations without touching the patient.

In a patient who is alert, logical, and coherent, a conversation can often give us the critical information. In cases where the patient is not able to cooperate with a phone interview, observing them by video may provide us with sufficient information-for example, help us determine whether the patient's incoherence is due to delirium or psychosis.

In some cases, in-person interviews may be the only option. This can occur if the patient is too psychiatrically ill (paranoid or psychotic, for example) or disorganized to participate in a remote interview. If the patient is diagnosed with COVID-19, or is currently on precaution and considered at-risk, you must use appropriate personal protective equipment (PPE).

At the time of writing, many hospitals are experiencing shortages of this equipment. In our opinion, the risk of exposing oneself and others to the virus outweighs any benefit of performing an interview while unprotected. If appropriate PPE is not available, our advice is to do one's best by discussing the case with colleagues who have examined the patient and collecting as much information as possible. "Batched care" is also recommended; request that the primary team ask critical interview questions or obtain crucial mental status information during a routine entrance into the patient's room.

3. What if the patient is not in control-agitated or aggressive?

It is never good practice to enter an uncontrolled situation. If the patient poses a potential danger, the priority is safe containment and control of the patient. In these cases, a discussion with the primary clinician may be the most critical intervention to help the consulting team with managing the patient's behavior. A more comprehensive consultation may have to wait, but we can complete much of the consultation with a thorough review of the medical record.

4. What about HIPAA and protecting patient confidentiality?

To encourage telehealth use, the Office for Civil Rights (OCR) at the Department of Health and Human Services, the agency responsible for enforcing parts of HIPAA, issued a statement saying that it will not impose penalties for HIPAA noncompliance by health care providers who use 

That said, we should all attempt to use technologies that respect patient confidentiality. Before the pandemic, popular telecommunication applications developed secure services that met the HIPAA compliance general standards. These platforms include: Skype for Business, Updox, Vsee, Zoom for healthcare, Doxy.me, and Google G Suite Hangouts. This list is not complete, and we do not endorse or recommend any particular product. (A comparison of products is likely irrelevant, as many hospital systems already use a specific technology.) Overall, each platform is relatively easy to use and more than adequate for this purpose.

Billing is always a tricky issue and varies between regions and insurance companies. However, it is helpful to know that on March 6, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which allows physicians to bill Medicare fee for service for care delivered by telehealth for the duration of this pandemic.

 The devil is always in the details, but we have begun billing for these consultations using the CPT modifiers GT for Video Virtual consultations and GPH for a telephone consultation.

6. What if the other services see this as a shirking of our responsibility?

We should stress that the motivation for this is safety: the safety of the patients and the health care workers. We should remain committed to our duties to help patients with psychiatric illnesses, as well as assisting other teams in managing these patients. In our experience, switching to virtual consultations does not mean that we spend less time and effort on patients.

If anything, we often are spending more time talking with colleagues to understand the situation, gathering information from the chart and collateral sources, and arranging for the technology to be in place and operating correctly. Thus, this is not a way to avoid responsibility but rather the opportunity to give the care we have sworn to give in a responsible manner.

7. If I concentrate on limiting in person-consultations now, am I risking creating a "new normal"-in which my colleagues may no longer consider psychiatry services an essential part of the treatment-long after the pandemic is over?

Maybe, but we doubt it. Amid the many adjustments we are making (professionally and personally), it is difficult to say how much may stick when the pandemic ends. It is most important to remember, however, that we should continue to be an essential part of the treatment team, regardless of the mode of the consultation. Remember, the other part of C-L is the liaison role. It is crucial, as always, to foster a good relationship with our consulting colleagues.

Our experience so far has been that our colleagues are welcoming and appreciative of these efforts. They do not wish to add unnecessary risk to the patient interactions any more than we do. We have found that when we are careful to make ourselves available quickly, even if only by phone, our colleagues on the front lines appreciate our contribution to the care of their patients. This appreciation is particularly sincere when we approach this with a collaborative spirit and check-in as needed to follow the progress of our patients.

That is not to say there is not the occasional conflict, in which thoughtful people may disagree as to whether we should see a patient in person. These are stressful times that are testing us all to the limits of our skills and professionalism. As psychiatrists, particularly those involved in consultation work, we are (hopefully) particularly keen on the impact of this environment on our interactions. In our case, such conflicts have been rare. However, we have worked with our consultation teams to use our skills at communication and rapport-building to negotiate these deftly.

An example of a simplified protocol to help when planning to transition to telepsychiatry consultations can be found in the 

 is Chief of the Division of Medical Psychiatry, Director, Consultation-Liaison Psychiatry Fellowship, and Associate Vice Chair of Clinical Consultation Services at Brigham and Women’s Hospital. 

 is Chief of Psychiatry Consult-Liaison Service at the Malcom Randall VA Medical Center and Professor of Psychiatry and Neurology at the University of Florida College of Medicine. 

is Vice-Chair for Education in the Department of Psychiatry at Brigham and Women’s Hospital and Associate Professor at Harvard Medical School. He also is a member of the Psychiatric Times Editorial Board.

1. Reinhardt I, Gouzoulis-Mayfrank E, Zielasek J. Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence. 

2. Brenner R, Madhusoodanan S, Logiudice J, et al. A comparison study of the turnaround time for telepsychiatry versus face-to-face consultations in general hospital nonpsychiatric emergency rooms. 

3. Liu M, He P, Liu HG, et al. [Clinical characteristics of 30 medical workers infected with new coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020;43(3):209-214.

4. Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. March 2020.

5. HHS Press Office. OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. HHS.gov. March 17, 2020. 

https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html

6. US Department of Health and Human Services. Notification of Enforcement Discretion for telehealth. HHS.gov. March 17, 2020. 

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

7. Lowey NM. Text - H.R.6074 - 116th Congress (2019-2020): Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. March 6, 2020. 

https://www.congress.gov/bill/116th-congress/house-bill/6074/text

Psychiatry is being thrown, ready or not, into the world of telemedicine. Here you will find  lessons, tips, and answers to common questions from psychiatrists who have successfully taken the leap.

Developing the Capability for Virtual Consultation in the Age of COVID-19

has switched to virtual meetings. In the last two weeks, I have used my computer, phone, and tablet to meet with groups large and small. These online encounters have ranged from one-on-one supervisory meetings that would usually happen in my office to groups of 100 or more that would normally have required an auditorium. We are also conducting our residency didactics this way, using various formats including traditional lectures, interactive workshops, and process groups.

I enjoy technology, and I tend to be an early adopter of high-tech gadgets and software. That said, I have been reluctant to give up in-person meetings, arguing that there is no substitute for sharing physical space with other people. I have always suggested that we cannot overestimate the value of having a person’s full attention, along with the nonverbal cues and food.

In the current crisis, all of that seems quaint. And I am happy to report that, for us, the transition to virtual meetings has been relatively painless. Despite the occasional experience of watching a person talk while they are unaware that no one can hear them, for the most part, the technology has been without glitches.

Many of us are now managing outpatients via phone and telecommunication. Similarly, our consultation-liaison service is doing more curbside and phone interventions to minimize unnecessary exposure. If these patients continue to do well-and I wholeheartedly hope that they do-won’t insurance companies suggest that we move to less frequent in-person appointments and more frequent (and less expensive) virtual check-ins? And won’t other services question the need for traditional consultations?

Like most of us, I don’t have time to worry about this right now. I am too preoccupied with the health and safety of my patients, trainees, and faculty. However, I am hoping that at some more stable point we can reflect on this change. I am hardly the first to suggest that, long after we all receive the 

vaccine, this pandemic may forever change us as a society. Many of the changes would have occurred anyhow, but this may greatly hasten them. Perhaps we should use this opportunity to learn as much as we can from this experience so that, once we are past this, we can intelligently discuss what changes make sense, and in which cases the old ways were the better ways.

For more on the coronavirus 2019 (COVID-19) pandemic, 

visit our resource page for psychiatrists

Many of us are now managing outpatients via phone and telecommunication. While the transition has been relatively painless, one can't help but wonder what the future will bring.

COVID-19, Virtual Meetings, and Anticipating the Future’s New Normal

Few recent issues have affected us as a profession as much as Maintenance of Certification (MOC). Although the details are complicated, the basic rationale is simple: psychiatrists need to show that once their formal training is over, they are continuing to practice lifelong learning. The adage of the wise old doctor who improves with experience is not true: doctors’ skills tend to deteriorate after their formal training is over if they do not challenge themselves to keep up with the latest developments in their field.

 Prior to formal MOC, most states required some evidence that we were keeping up with our field; this was usually achieved through the accumulation of Continued Medical Education (CME) credits. However, we all know that this can range from very active participation in excellent courses to simply showing up, signing in, and heading out to the golf course.

Considerable evidence suggests that CME alone is ineffective at achieving its goal of keeping physicians up to date in their specialties.

 As a profession, we are a very motivated group, and we would like to think that the desire to learn and grow, to remain on the cutting edge of our field is motivation enough to remain lifelong learners in our field. Nevertheless, we are only human, and with the multiple demands on our time, voluntary educational efforts tend to make way for the more pressing exigencies life throws at us.

Why is MOC so important? The answer is simple: because our patients deserve this. When I see my primary care doctor to discuss my health issues, I assume that she is aware of the latest guidelines and standards as well as promising research. I routinely bring up studies I have read and am usually reassured that she’s read them as well and has an informed opinion as to the findings. This should not be an unusual occurrence; it is what I expect of my doctor. Surely, my patients should expect the same of me.

That lifelong learning is important to professional development is inarguable, but the devil is in the details. How can one demonstrate that he or she is keeping up with latest developments in the field? The American Board of Psychiatry and Neurology (ABPN) has identified 4 components that must be demonstrated to remain board certified:

2. Lifelong learning (CME) and self-assessment

3. Assessment of knowledge, judgment, and skills

4. Improvement in medical practice, ie, performance in practice (PIP)

The first and third components are not new: professional standing is demonstrated by holding an active and unrestricted license to practice medicine, and cognitive expertise is demonstrated by passing an ABPN board examination; these have been longtime requirements for board certification. The second component is an elaboration of the previous expectation that physicians complete a minimum number of CME activities: diplomates are expected to complete an average of 30 specialty or subspecialty Category 1 CME credits and an average of 8 self-assessment CMEs per year, averaged over 3 years. The purpose of self-assessment is to alert psychiatrists to potential knowledge deficits in order to direct their study at a CME activity. The final component, improvement in medical practice or PIP, is a type of quality assurance in which physicians must demonstrate that they are assessing their own practice through either a Clinical Module, entailing a quality improvement exercise such as a chart review, or a Feedback Module in which the psychiatrist collects data from peers or patients.

There have been various criticisms of the process. From a broad perspective, there remains a great diversity and variance in defining what components should be used to constitute MOC programs.

 However, it is difficult to dispute the basic principles underlying this effort: a doctor’s education does not end with residency training and if we as a profession do not develop a credible system for monitoring continued competence in our specialty, other groups will do it for us. Many other specialties have ongoing systems in place, some for a long while, so, in a sense, psychiatry is simply playing catch up.

In response to criticisms, the ABPN has made several changes to the requirements in the past several years, including lessening the overall requirements and allowing for activities that one may already be performing as part of one’s professional role. For example, most individuals working in a hospital system are expected to participate in quality improvement efforts, and many of these could potentially count as PIP as well. The ABPN has approved a number of existing products and quality improvement programs (see 

Even with this greater flexibility in the requirements, this system creates some burdens, both in complying with these requirements and in record keeping. A number of organizations are attempting to help with this. For example, the ABPN is maintaining a Physician Folio site to help with record keeping, and the American Psychiatric Association (APA) lists resources that address the various aspects of MOC. A number of other subspecialty organizations have developed programs to meet some or all of the MOC requirements. For example, the Academy of Psychosomatic Medicine offers Self-Assessment credit as part of their annual meeting activities; a number of other organizations offer similar activities.

For those who feel that they are not keeping up with the requirement, what should they do? The most important thing is not to avoid this. The ABPN conducts random audits of activities, and before taking a recertification exam, you will be required to attest to your MOC activities. So it is best to keep up to date. If you have not done this already, the first thing you should do is register for the ABPN Physician Folio, which is an excellent way to keep track of your MOC activities and to be aware of what your outstanding requirements are.

Finally, if you are one of the many dissatisfied with the MOC process, I encourage you to become active at an organizational level, either at your state or national level. Although MOC is not likely to go away, there is certainly room for improvement, and my experience has been that the ABPN is open and interested in feedback as to how to make the system better. Ultimately, the purpose of this is to help us be well-informed psychiatrists for our patients, and the more the system helps us achieve that, the more we will see it as an important part of our professional development.

• Details of the ABPN’s MOC program: 

• ABPN existing products and quality improvement programs: 

https://www.abpn.com/maintain-certification/abpn-approved-products-list/

https://application.abpn.com/webclient/folios.aspx

https://www.psychiatry.org/psychiatrists/ education/certification-and-licensure

• The Academy of Psychosomatic Medicine: 

Dr. Boland is an Associate Professor at Harvard Medical School and the Vice Chair for Education at the Brigham and Women’s Hospital Department of Psychiatry in Boston. He is also the President of the Academy of Psychosomatic Medicine.

The author reports no conflicts of interest concerning the subject matter of this article.

I am grateful to Amanda Bishop and Patti Vondrak at the ABPN for reviewing the article. Their contribution was limited to reviewing the correctness of content related to the ABPN MOC requirements. I am not affiliated with the ABPN; the opinions stated in the article are my own as are any remaining errors.

 Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. 

 Nissen SE. Reforming the continuing medical education system. 

 Horsley T, Lockyer J, Cogo E, et al. National programmes for validating physician competence and fitness for practice: a scoping review. 

A brief update--and some practical advice--about MOC, whether you love it or hate it. 

Author | Robert Boland, MD

Articles

Reflections on the New Normal

Developing the Capability for Virtual Consultation in the Age of COVID-19

COVID-19, Virtual Meetings, and Anticipating the Future’s New Normal

Maintenance of Certification