Sixth Sense



People often ask me if I can really connect with patients via telepsychiatry.

What they mean, I think, is this:

Are you able to really listen to and see and evaluate someone when you’re sitting hundreds of miles away from them in another room and only seeing them on a screen, albeit a large, high definition one? 

The answer of course is yes, but there are drawbacks. 

The use of my Spidey Sense is dramatically decreased when I’m in my Virtual Shrink superhero role as opposed to sitting with patients in the clinic consulting room as a Dr. Peter Parker wannabe. 

There is something to be said for face-to-face, real-time, in-the-same-room discourse. When you’re in the same room with a patient, you can smell last night’s alcohol binge as surely as if you were there with them for every shot at the bar. You can pick up on tiny physical fasciculations or tremors that might be missed on camera. You see the writhing, circular gyrations of the foot of one crossed leg that might not be picked up if the camera is focused in too tightly on the patient’s face. You can see a patient’s nervousness, twitchiness, and physical desire to move about when they are uncomfortable being in the same room with you. 

The thing that is hard to replicate on camera is that sixth sense that stands every good shrink in good stead. 

The feeling that someone is not really telling you the truth. The sense that the mild paranoia that a patient presented with is about to dramatically increase, and the decision to back off and not ask just one more question. The feelings of tension between therapist and patient that have been described as transference and countertransference in the psychodynamic literature. The feeling that you are about to be assaulted in some very real way. (Yes, I have been hit three times in my psychiatric career, and it’s never a fun thing to go through)

Telemedicine allows us to see patients hundreds of miles away in a timely fashion, providing needed evaluation and treatment services to those who might otherwise go without. it is a wonderful advance in modern technology, but it is not perfect. 

Until we can plug completely into someone’s world in a virtual sense, we may miss bits and pieces of their story that would help us provide the care they need. 

6 thoughts on “Sixth Sense

  1. Telemedicicine intensivists are saving lives in rural ICUs where no specialists are available.. It is pretty impressive to see them run a rapid response or code from on camera. I think any physician has to be super alert and perceptive doing these assessments . and we all might as well get used to more of it-that and having the PA or NP do your evaluations because no physician is available. We are already seeing entire psychiatry practices run by one physician and a team of psych NPsand PAs..


  2. There are many positives to your telepsychiatry practice, one of them being that you won’t get hit again!! I think it’s a great thing for patients as well!


  3. I understand what you mean. You aren’t dissing the electronics, you just wish that you could see the patient’s body language- twitching hands, agitated feet hands, general body stiffness, and any adjustments they are making from being on TV. Probably less physical reaction-like not being punching you in the nose. When my son is on a phone-he has a flat monotone-I can’t tell how he’s doing. His face is usually expressionless. The chances are that in a tele visit-that he’d just fall asleep on you. That’s from being a sailor and a cowboy—waiting for hours for a cattle truck to show up, most just learn to sleep. Being at general quarters for 18-24 hours-when there’s a lull- you sleep on the burning or cold steel deck. In person, you’d see the twitching foot, the white knuckles- and if your office had Texas Longhorn stickers or pennant-he’d make a rude joke about your mentality and education-which-normal people do. When he came back from one of his visits to Texas, he’d bring a stuffed-plush little Longhorn, a coffee cup, paper weight, etc. I know that because that’s what he does with his psychiatrist- Just remember what the speech pathologists say- wear good running shoes- and stay next to the door for a quick exit.
    Meanwhile, talk to the techs and see if you can click to a full body view or a foot view.


  4. This seems similar to the questions I get asked about on-line relationships – how can they be real and meaningful when your only interaction is via tweet ,facebook post, or email. Where are the hugs, the laughs, the cries? They are all there – and in some cases, they’re more real than in many “in real life” relationships.


  5. Pingback: Ah, to be 16 again | My Eyes Are Up Here

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