Aftermath

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Good morning, everybody.

I have another question from our studio audience today. (Please keep those cards and letters coming)

“What happens after a telepsychiatry consult? Do you get any kind of feedback about what happens to your patient?”

Excellent query.

As I have mentioned in previous posts, doing telepsychiatry is a lot like any other emergency room work. It can be tediously slow and boring. It can be horrendously busy. It can get stale when one sees the same thing over and over again. It can be tremendously exciting when a fresh new problem associated with a rare diagnosis presents itself. Another caveat of doing this work is that we often see a patient, are very invested in the story they tell, make recommendations for their care, and then never see or hear from them again.

So, what usually happens after I do a telepsychiatry consult? What is my ongoing connection to the patient? This can break out several ways.

First, if a recommendation is made to release the patient to outpatient followup, and the ED staff agree with this, then they may be sent home minutes to hours after the consult report is sent it. In that case, of course, no more contact is made. The patient is off to follow up in a local mental health clinic or with a private psychiatrist, and that is that.

If the feedback from the telepsychiatrist is to admit for safety, to restart medications, or to further observe to make a more definitive diagnosis, then it can go two ways. An inpatient bed may be found fairly quickly (something that is getting more and more rare in the state of South Carolina, where I practice) and the patient will be transferred to the other facility as soon as that is practical. There is  no real “active mental health treatment” in the ED per se, so this scenario is optimal if inpatient intervention is needed.

More common is the recommendation for inpatient admission followed by days (or sometimes weeks, unfortunately) of waiting for an appropriate bed to open up. In this case, treatment may be started, at the very least the medication portion of treatment, while the patient waits. If that happens, then within seventy two hours, when the commitment papers need to be recertified in order to hold the patient in the ED, a follow up consult may be sent, and the same telepsychiatrist (or one of his or her colleagues) will re-evaluate the patient. If sufficient progress in relief of symptoms has been made at that time, suggestions for release and follow up may be made. If not, then continued hold may be suggested to the attending in the ED.

The latter is one scenario that allows for me as a telepsychiatrist to actually see, paradoxically, progress in my patient. If an antipsychotic is started for a patient who is floridly delusional and agitated to the point of needing physical restraints and intramuscular medications to prevent harm to himself and others, forty-eight to seventy-two hours of treatment and observation can sometimes work miracles. Someone who was afraid of the camera and tried to hit me through it (yes, that has actually happened) may be able to much more calmly explain how they felt on admission after three days of treatment. That is the closest we telepsychiatrists usually get to seeing a positive outcome or even a “cure”, as much as one with true mental illness can ever be “cured”.

A spinoff of this is the patient who is seen, for whom a treatment plan is crafted, who is then discharged, but then “bounces back” with the same or similar problem that got them there in the first place. This happens quite often with folks who have substance abuse problems.

Alcoholism, for example, is a “cunning and powerful” disease, and the patient who reappears in the ED with a blood alcohol level of 450 a week after being seen for intoxication is far too common. Other patients who have chronic mood disorders, psychotic disorders, or even personality disorders may revisit the ED many times with superficial lacerations to forearms or wrists, repeated overdoses with sub-lethal amounts of pills or other problems that recur. This is good in the sense that the telepsychiatrist gets a much more accurate picture of the pathology involved over time. It is bad in the sense that the patient may be traumatized over and over by the admission and evaluation experience, and emergency resources are used where outpatient mental health services should be employed instead.

Finally, if the patient has presented with a one time, first episode, self-limited process, then a consult may be done, a disposition reached and the patient discharged, never to be seen or heard from again. I like to think when that happens that we have helped them move through and past a bad patch in the road and that they go forth and live their life well and happy. I am not so naive that I think this really happens in every case, but it’s a nice thought. This may also happen with those who are itinerant or transient patients. They may or may not be back the next time the direction of the wind shifts and the leaves begin to fall with the temperatures.

I hope this gives you a sense of what happens after telepsych consultation is completed.

In the style of Steve Jobs, I have one more thing for you before I move on with my day and let you do the same.

I received an email yesterday from the powers that be that told me our merry little band has received tentative approval to work from home. Up until now, to do my telepsychiatry duties I have had to physically go into an office in the local mental health center. Now granted, this has not been an extreme hardship, in that the office is exactly six  minutes from my apartment. However, working from home would mean that I have control over the thermostat, that I get to make my own coffee, that lunch is ten steps away, and that when a sixteen hour shift is over I can walk two rooms over and fall into bed if I wish.

It’s the little things people.

I’ll be sure to let you know how that scenario plays out. Could make for some interesting writing about autonomy versus isolation and other associated issues.

As always, thanks so much for taking a little time out of your own day to read my musings. I welcome your comments, feedback, and suggestions for things you’d like to read about here.

Have an excellent day (or evening, for those of you who insist on staying fourteen hours ahead of me. You know who you are.)

 

15 thoughts on “Aftermath

  1. Thanks for a peek behind the curtain, Doc. It’s compelling, and satisfies my curiosity about telepsychiatry–not so bad after all! I must admit, I imagined a bunch of levers, dials, wheels, and steam whistles, and you in a wizard hat. Good news on the office-in-home front, too, though cabin fever could, in fact, present a problem. Not to mention polishing off all the Oreos in one 16-hour shift. When you find yourself scratching for a topic, I’d like to have your thoughts on Nature v. Nurture. It’s been done once or twice by others, but your opinion means much. -Rob

  2. It IS the little things. For me, having to go into work sometimes is the only time I socialize with others besides the dogs. I think authors and those working from home need resilience to avoid isolation – which I, frankly, enjoy :). Thank you for your musings.

  3. Greg,

    Both my sister & brother worked for many years from their homes. My brother began his satellite position actually at the time his wife was diagnosed with brain cancer. It was such a blessing. The convenience of being there, not only for her but also readily available for their 9-year-old son was just priceless. Also, as you state, the convenience of having your own kitchen (i.e.: coffee;), bathroom & bed, just steps away…well, they loved it. Another plus for my sister, not having to doll up with make-up! Both of them also loved being able to wear whatever was comfortable…shorts in the summer, sweatshirt & jeans in the winter. There are many positives. I sure hope it works out for you. Then you’ll also be just steps away from your needed work-outs at the gym!! Cool, huh? :)

    M

  4. If I were ill I’d probably get very paranoid about your last line!
    But there are others who live 14 hours ahead and thoroughly enjoy reading your blog. :-)

  5. Jury is stil out for me, but I’m thinking about it. The isolation and having my apartment also be my work office has its positives and negatives. I may decide to keep this space my personal space and keep using the office at the center, which after all is only five minutes away.

  6. Hey Doc, An afterthought about working from home. Can you do both? Might you have the option to go to the office or work from home? That, I think, would be ideal. A friend of mine who took advantage of an opportunity to work from home came to regret it because, in his words, “I didn’t feel like I was working.” What’s so bad about that, we might wonder. Lots of things maybe, depending on the individual. He was told he had to finish out the fiscal year at home, and compensated temporarily by actually leaving home 20 minutes before work time each morning, walking around the block (often snagging a coffee and doughnut on the way), and arriving at “the office” in time to begin his work day. Different strokes, I guess. I’m not worried. You’ll figure it out. There’s no place like home–maybe! -Rob

  7. Hi Doc,
    Yes we 17 hours ahead people know who we are…although not too happy about it being the early hours of Sunday morning and still being awake…

    But happy to see you working on your “work-life” balance (shameless plug of my post on this http://wp.me/p3BTRI-90), but seriously though, how long till your 6 minute commute looks attractive…

    And I’m very grateful for your comment “as much as one with true mental illness can ever be “cured”.”…too many people don’t recognise that mental health conditions are chronic illnesses that need long term management strategies…even garden variety anxiety/depression…not just floridly exotic illnesses. Personally don’t think there’ll be any cures while we don’t have any real clue about pathophysiology…despite DSM5 rearrangements….

    Anyway, very curious as to your definition of “non-true” mental illness….await your reply with 14 hour ahead curiosity…

  8. Jocelyn,

    I have to be very careful with my words, now that I have several of you fellow Word-People following my blog!

    See today’s post, which I shall wrote presently, about the working at home thing. I think I’ve made my decision, at least for now.

    I agree with you (and this will anger a lot of patient advocates out there, I realize) that there are few real “cures” for mental illness. I also subscribe to the theory that most all of the illnesses that I see are certainly treatable, manageable and controllable, but that we don’t know enough about them to eradicate them. I think that some of this knowledge will surely come in my working lifetime; at least I hope so. It will be much nicer to diagnose definitively and treat decisively.

    I see a lot of people who present with “mental health problems” that are at least partially under their own control. Some people manipulate. Some make repetitive decisions that are injurious to themselves or others. Some are certainly bright enough to see maladaptive patterns in their lives and simply choose not to change them. I know that by current convention that we categorize these folks as having mental illness. This is where I start to agree with critics of the DSM who say that we are starting to make almost all extremes of human behavior pathological, when in fact some fringe behaviors and symptoms may simply be normal variants of our ability to cope with life in various predictable, albeit odd or weird or dysfunctional ways.

    “True” mental illness to me, as a clinician, is mental disease that presents as symptomatology that hurts a patient, makes it hard for her to live her life, impairs her ability to make good decisions for herself, and holds her back from being the best human she can be. In this vein, illness such as schizophrenia can be devastating to the person who suffers from it. They have to do nothing to see the devastation that it can cause in their lives. They come to the emergency rooms out of control, fearful, and sometimes experiencing symptoms that make them a danger to themselves or others. To me, this is “true” illness in the same sense that developing a malignant brain tumor is a “true” illness. We don’t understand it fully yet, but that makes it no less real, no less devastating to the one who carries it as a burden through her life.

    I hope this makes sense. Thanks as always for reading and for making me think through what I am trying to say in these posts.

    Greg

  9. Do your patients react the same way when then have genuine contact with you (i.e., are in the same room) and while a telepsychiatry consult? Speaking to a webcam is not that real, isn’t it?
    What do you feel about that? Can it be a bit somehow deceiving?

  10. No, actually the lines we use and the quality of the high definition screens make you forget that you are even on a monitor at all. It is just like sitting with a patient in real time and space for the most part. Very realistic. The equipment is not like a regular webcam but much higher quality, and that makes all the difference in the world. I have even had people get up after the interview and spontaneously try to shake my hand through the monitor!

  11. This is stunning.
    And how are these patients selected? Just because, or you have specific criteria to fulfill? (I’m sorry if these questions are too intrusive; tell me to stop please, I’m terribly curious :) )

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