Carolyn Turvey, Ph.D., a professor of psychiatry at the University of Iowa and vice chair of the American Telemedicine Association’s Telemental Health particular interest group made the following statement:

“By insisting that patients come to our offices, we’re excluding potentially millions of patients who need care,”

Despite being an advocate of telepsychiatry, I still prefer seeing people in the office. The reason is not scientific, and I like it better. If that is my experience, that is also the experience of many patients.  Part of training as a doctor is understanding that not everyone gets ideal care. No matter how lofty you were in medical school, and how good your intentions, there is a necessity to adapt to current circumstances and provide the best possible care with the resources available.

I can recall an experience at Project Renewal, a haven for homeless men, (Depression being a common cause of homelessness) seeing patients on my laptop in a broom cupboard like an office.  Patients were often too depressed to get out of bed, even for breakfast in the winter months. One patient said to me ‘I know I am depressed when I can’t get out of bed to buy a packet of cigarettes on check day.’

I took to calling patients in their rooms when they missed appointments and if they didn’t pick up the phone sending security to knock on their door and ask them to come to their appointment. Sometimes they came, and sometimes they would ask to be left alone. But generally I didn’t detect any bad will, and the haven security guards assured me that I was doing the right thing. This wasn’t exactly what I have been taught in my psychodynamic training. Possibly disrespectful, definitely a boundary crossing under normal circumstances.

A psychodynamic psychotherapy model was not possible in a shelter setting, and if I had insisted on adhering to what I had been taught during my residency and psychodynamic training, at least half of my patients would not have been treated. Some needed the knock on the door, and the gentle escort in their current regressed state.

There were a few success stories. I bumped into one patient two blocks from my home in midtown. He was on his way to work and told me not to be alarmed but he had looked me up and was now my neighbor. He said, “You were right, there is nothing wrong with my intelligence. It is my mood that was holding me back, the Paxil helps”. He said he was doing well and had looked me up to say thank you, but had never contacted me in the end.

I am not advocating for psychiatrists to make their own rules, but adaptations to ensure an increase in reach and an understanding that some care and even a sub-optimal modality of care is better than no attention. A prescription for Paxil and a monthly visit, although not as ideal as biweekly titration and weekly psychotherapy can still be effective.

Likewise, although I prefer seeing patients in the office, I still believe telepsychiatry should be utilized, as it increases patient reach and is also highly effective.