A psychiatrist’s telemedicine experience [PODCAST]

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“I propose Zooming while driving be added to the DSM criteria for ADHD. I have gotten a new glimpse into the world of some of my patients. One patient even mentioned it’s hard for them to come to appointments, even with transportation, and we were able for the first time to talk at length about those psychological factors that prevent them from getting consistent follow up leading to lapses in effective treatment.

Is this the first step toward more consistent care? Better outcomes?

Some in my center therapists hate it as much as I do, but some really love it. Is this just not going to be everyone’s color?

There is room for yellows, blues, greens, reds, and all our mixtures. My experience is not representative of the entire tele field. Maybe there is even a place for it in my practice going forward, and our ability to bill for these encounters should continue. (Can you hear me, CMS!)

But this cannot be my full-time practice. I hope there is a place for all of us. I hope when I retire, “the money and screens” haven’t ultimately won over the best care for all patients. The optimist in me is hopeful, but the fast-talking irreverent realist in me says we will have to fight for our places.”

Allie Thomas-Fannin is a psychiatrist.

She shares her story and discusses her KevinMD article, “A psychiatrist crashes into telemedicine during the pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Allie Thomas-Fannin. She’s a psychiatrist, and she wrote the KevinMD article “A psychiatrist crashes into telemedicine during the pandemic.” Allie, welcome to the show.

Allie Thomas-Fannin: Thank you for having me, Kevin.

Kevin Pho: So we’ll get into the article in a bit, but first off, can you share your story and your journey to where you are today?

Allie Thomas-Fannin: I am a psychiatrist. I am currently in Vincennes, Indiana, which is where I’ve been for the last four years. I work for Good Samaritan Hospital in the Samaritan Center, which is a community mental health center in southern Indiana. We have a capture area of about four counties, and then an even wider area of about 11 counties, so that’s 250,000 to 300,000 people, mostly in a rural population. The city I live in is about 20,000 people.

I’m originally from Kentucky, from about two hours south of where I am now. I did my undergraduate at Haverford College, and I was actually a political science major. Then I decided that I wanted to go to med school, so I got a second degree from Austin Peay State, which is where I met my husband. We’ve been together for 13 years now, almost 14. We’ve got three kids, too, and he came with me to med school, so we have kind of been doing this whole journey together. I think it’s nice to have a partner who’s kind of outside of the whole medicine game.

I did my med school at the University of Louisville. I did residency in general adult, or general psychiatry, at Duke University. Then I left Duke and North Carolina to come back to a little bit around my home area. At that point, they were starting a residency program here in southern Indiana for psychiatry residents, with a goal to train physicians in rural practice. So we have a family medicine residency, we have an internal medicine residency that’s already started, and my psychiatry residency, which is now in its second year. We have a class of PGY-2s and a new class of PGY-1s, and I’m the program director for that program, with everything that goes into being an ACGME program and training people in psychiatry. But we’re doing it in a rural population, which presents its own unique opportunities, I feel like, for training. So that’s kind of how I got here.

I have three kids, four dogs, two guinea pigs, a cat, and a garden with squash that are taking over everything. What I love about where I am now is that I live on 11 acres, kind of outside of a smaller city, and I don’t have a lot of the hassles that I found in bigger cities, like traffic. I no longer have tolerance for traffic. I think it’s kind of a small-town feel, so I really love where I am right now.

Kevin Pho: All right. Now I want to talk about your KevinMD article, “A psychiatrist crashes into telemedicine during the pandemic.” So for those who haven’t read your article, can you walk my audience through it, and perhaps share how the pandemic has affected you in your practice?

Allie Thomas-Fannin: Oh, yes. I work in community mental health, and we had very little telemedicine involvement, mostly because of a lot of the restrictions that had been imposed on telemedicine before the pandemic. We couldn’t prescribe a stimulant to a kid in a rural area unless we saw them face to face, and that presented its own challenges prior to the pandemic. I had never done a lot of telepsychiatry in the past. I’ve enjoyed living in a rural area, and there’s not a lot of psychiatrists around, so I’ve always been a little bit different compared to, I think, my fellows. I wrote in the article about going through an exercise where I discovered just how different I was from a lot of folks, but that didn’t mean that I couldn’t have something to contribute to the field.

I’m a very outgoing person. I’m good face to face, and I always felt comfortable with that. Then we moved into telepsychiatry, and since I’m always open to new things, it’s part of my personality structure, I was like, “All right, we’re going to do this. It’s going to be great, and it’s going to work.” And I hated it, and I felt alone in hating it at first. A lot of folks who had done telepsych, my colleagues, were like, “Oh, it’s wonderful. You’ll love it. It’s great. It’s so convenient. You don’t have a commute,” which is always appealing to me. But I found that I was having a lot of difficulty engaging in telepsych as I was in an in-person practice, and I wondered if I was the only one that felt this way. I now know I am not.

I’m a huge advocate of increasing access to care, so if telepsych increases access to care, I am all for it. I’m not sure it’s my full-time gig, but it could definitely be my part-time gig, because I’m still doing it. In fact, you’re looking at my office from home, where I do my telepsych, and it’s just as messy as my office at work. Patients like to point that out sometimes on Zoom.

I found that I might have been facing some challenges that were more unique to crashing into this, but also to being in a rural area. A lot of my patients live in places where there’s no high-speed internet access. They don’t have high-speed internet; it’s not available. They couldn’t buy it if they wanted it. The Verizon tower is too far away, so their phones don’t work as well, their cell service. So I was running into a massive amount of technical problems. The infrastructure just wasn’t there for a lot of telework, and I found trying to make sure that I was taking care of people at the level that I’m used to, while doing it in this new medium, to be challenging. That was the inspiration for writing what I wrote.

As I’ve been doing it, we’re now in month five, I think; I’ve lost count. We’ve been sending out surveys to our staff, because I’m part of a community mental health center, so I’m with therapists. Some of the therapists are like, “This is great. I want to keep doing it.” Others are like, “This is not working for me very well. About half my patients can’t even connect,” because of the population that we’re taking care of, and some are waiting until we go back to full office to actually see people. Some therapies, like EMDR, are difficult to deliver over this medium, not impossible, but very challenging.

So I found that we’re facing some challenges that maybe other places are facing, and facing some challenges that might be more unique to our rural context. Somebody was in the middle of a cornfield talking with me, or doing their appointment, because that was where their cell service was the best, and I was like, “Oh, wow, there’s a Verizon tower over there.” OK. So I’ve done appointments in the most unusual places.

I’ve sometimes found that what has also been challenging in the realm of psychiatry is that a lot of my patients have prepared for their appointment, right, by driving to the clinic, sitting in the waiting room, and filling out the questions that I have. I have questions that I give people on yellow sheets, because I find it less distracting, which is helpful for that, to prepare for what they’re going to say to me. Sometimes on the appointments, it takes them a little bit to adjust to the fact that they’re having a psych appointment right now, right? So it’s, “Oh, I’m in my psychiatry appointment,” and my kids are yelling and my dogs are barking, and it’s chaos, right? That gives me a little bit of insight into the world, but it also makes it somewhat more difficult for some of them to engage.

What I’ve found is they’ve gotten more used to it over time. Some of them are like, “All right, I can’t do my appointment today, because there’s too much going on in my house.” And I’m like, “OK, well, we’ll reschedule you, right?” Or we’ll schedule you for the office, because we’re trying to do more in office, and I’m wearing my headband that has the buttons on it for the mask to save my ears. So as we go forward, I feel like we’re facing some challenges that maybe other places don’t have to face as much.

Kevin Pho: I think what you said about some physicians being comfortable with telemedicine and some not is really my experience as well, especially in primary care. Now, over the past few months that you’ve been doing telepsychiatry, are there any tips that you can share with other clinicians who still may not be comfortable with the virtual format?

Allie Thomas-Fannin: I’ve gotten more comfortable with it. I feel like some things are harder to do on tele, and some things might be a little bit easier. I had some patients engage more on tele. Some of my therapists who do marriage counseling said they have to look at each other’s faces now. They don’t have to in an office setting, really, but they do when they’re looking at the Zoom. So they’re noticing that marriage counseling might actually be a little bit better in some of these formats. So I think there are pluses and minuses.

To folks who are having some trouble taking the lead, I think it’s important to meet people where they are as much as possible. To my patient who said, “I’m absolutely not doing this,” I said, “OK, you can come into the clinic and wear a mask.” So I think some flexibility is helpful, and kind of assessing which patients it might be appropriate for and which patients it might not be.

I see kids, because I’ve been the only doc around for a long time. We just hired a new child guy, and I’m so happy, but it’s hard to find a child psychiatrist. I’m a general psychiatrist, so I’ve got some child training, despite not being an expert in child, and I have people I can consult with. Kids are very difficult to do over Zoom, because they’re not as engaged with the screen, and there are too many things going on in their environment. So the mom is following them around, like, “See how bad he is,” and I’m like, “All right, I get it. I’m getting vertigo.”

But I feel like meeting the patient where they are and problem-solving those as they come can be very helpful, and testing and finding a platform that you’re comfortable with. We use Zoom because it was just easier for my patients to understand. There were some other models out there, and they didn’t work. They would work well on iPhones, but not on other things. FaceTime is apparently very nice. I don’t have an iPhone, so I can’t use FaceTime. So we had to get a platform that was comfortable for everyone. If one integrates into your EMR, that’s better. Our EMR doesn’t integrate with anything, but we’re switching to Epic in a few months, which I’m told integrates much better with video visits.

And it’s kind of seeing which patients it’s appropriate for and which patients, too. I’m an advocate for people being able to practice the way that is the most comfortable for them, and figuring out what works for them. It might be a slow transition. I’ve got some people who started with phone calls with me, and now, three months later, they’re like, “I figured out the Zoom, because my grandchild helped me,” right? That can be helpful, too. But getting the right tech support is very helpful.

Kevin Pho: We’re talking to Allie Thomas-Fannin. She’s a psychiatrist, and she wrote the KevinMD article “A psychiatrist crashes into telemedicine during the pandemic.” Allie, whenever the pandemic ends, do you see telepsychiatry continuing past that?

Allie Thomas-Fannin: I think we’ve opened the box, and we’re not going to close it again. I think a lot of the restrictions on telemedicine before were not very evidence-based as far as their helpfulness or fears of harm. I also work in addictions. I’m sitting for the addiction medicine boards, hopefully in October, if I can ever get a testing center. I do Suboxone, I do buprenorphine, I do Vivitrol, and our community mental health center uses lots of long-acting injectables. So there are some things that people have to come in for, like drug tests. But I don’t think we’re going back, and I hope we don’t go back to the old way of so many restrictions that it basically shut us down from ever doing it. Our center just stopped doing tele when they increased so many restrictions that it wasn’t practical anymore.

So I think any way that we can increase psychiatric care is better. We still don’t have parity for psychiatric care, and I think that’s going to be a big issue going forward, getting parity with telepsych. But if it increases people’s access, I’m OK with it, and figuring out the best way to do it and prepping patients for how to prepare for an appointment on Zoom. And I think when we have more experience under our belts, we’ll figure out things that work and things that don’t.

Some of the concerns that I had going forward were doctor shopping: It was too much, too easy, especially for controlled substances. I need to know what people are taking, and if they’re getting them in states that don’t have PDMPs, or whatever your prescription monitoring services are, that can be difficult for my field, because I don’t know what people are on, and so I can’t help them. And then also racing to the bottom, having poorly trained providers doing things on Zoom because they’re legal in one state and not in another, and that can be challenging, too. But I think the box is open, and we’re not going to close it back.

Kevin Pho: Sure. And my final question, Allie: Do you have a take-home message that you want to share with the KevinMD audience?

Allie Thomas-Fannin: I think the take-home from my whole experience, and from the fact that I’m a program director for a rural residency, where most rural areas have trouble recruiting because they don’t train, or they don’t tend to train docs, and I feel like it’s every patient having the ability to see a physician in the format that they need, at the time that they need, including face to face. I have some patients who hate this, and they can’t engage very well with the screen, so I don’t want them to be forced into tele, if it’s not their cup of tea, because their insurer no longer pays for other things like face to face. So that is also the Pandora’s box that I’m worried about opening.

But I want people to be able to have a doctor next door, to share in the culture, to know that the farmers market closed, and so, you know, “My income for that day isn’t going.” And I’m like, “Yeah, I’m really disappointed about the farmers market, too.” Being able to engage people in those communities where they live, because community resources are so important for my field, and being able to have what you need in your environment, is important. If I’m a physician sitting thousands of miles away, I might not be able to engage with that as well.

So I feel like people should still have the option of the doctor next door, while also being able to increase access to other services that maybe this population doesn’t have access to, like addictions, or child pediatric specialists, who are very difficult to recruit to rural areas. So having that access, but still maintaining an ability to have a doctor next door.

Kevin Pho: Allie, thank you so much for sharing your insight and time, and thank you for being on the show.

Allie Thomas-Fannin: Thank you for having me.

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