Snap Shots

Resident and Medical Student Viewpoints on TheirParticipation in a Telepsychiatry Rotation

Kristina Dzara, Ph.D., Joshua Sarver, B.S.Jeffrey I. Bennett, M.D., Pravesh Basnet, M.D.

Telepsychiatry involves the use of electronic communi-cation and information technologies to provide psy-

chiatric care from a distance (1, 2). Treatment may be providedthrough the telephone, e-mail, the Internet, and television(1, 2). Videoconferencing is a useful and effective wayfor psychiatrists to treat patients (2, 3). Patients and pro-viders are satisfied with the use of telepsychiatry, whichprovides therapeutic outcomes similar to those of face-to-face encounters (2, 3). Because telepsychiatry is an evolv-ing form of treatment provision, we have much to learnabout its effective incorporation into medical training(4–6).The use of telepsychiatry as part of resident and medical

student training in psychiatry has not been adequately inves-tigated (4–6). Previous work tends to center around patientswith developmental disabilities (5, 6). Szeftel et al., in 2008,reported the findings of a pilot study, assessing the effec-tiveness of a developmental-disabilities telepsychiatry clinictraining and supervision model. Residents and fellows im-proved in psychiatric knowledge and skills. They note thata telepsychiatry clinic may be an effective way of providingdirect supervision (5).Our objectives were to better understand how psychia-

try residents and medical students evaluate the trainingprovided in the telepsychiatry rotation (R1), whether theyperceive direct supervision as useful (R2), and whetherthey find it useful as part of their training for futurepractice (R3).

Educational Innovation

The Southern Illinois University School of Medicine, De-partment of Psychiatry piloted a telepsychiatry clinic withtwo critical access hospitals in 2009. A unique componenthas been the involvement of both psychiatry residents and

medical students. Integrated into standard training, residentsenhance their interviewing skills by utilizing videoconfer-encing equipment to interview and examine patients fromremote sites. The residents provide patient consultation whilebeing supervised, on-site, side-by-side, by the attendingpsychiatrist. Medical students often participate as part oftheir psychiatry clerkship.

Method

Because no validated scale exists, a 27-item pilot surveywas devised by the authors, guided by previous literature.The survey asked trainees to evaluate the clinic and assessedtheir attitudes toward telepsychiatry as a treatment modal-ity. Most questions were Likert-type. Multiple responsecheckboxes assessed what trainees disliked and what couldbe improved. Open-ended comments were encouraged. Thesurvey was approved by the Springfield Committee forResearch Involving Human Subjects (IRB).We surveyed both residents (N59) and medical students

(N510) because the overall number of participants waslimited. Residents completed the survey post-rotation. Mostmedical students attended a limited number of sessions andwere surveyed immediately after their last scheduled ses-sion; 15 eligible respondents (8 residents; 7 medical stu-dents) returned surveys (78.9% response rate). Missing datawere limited.

Results

Residents attended between 1 and 10 telepsychiatry ses-sions (median: 5.5), and medical students attended between1 and 3 sessions (median: 1). Most residents (N58) andmedical students (N55) had heard of telepsychiatry. Beforethis experience, one resident and no medical students hadused it in a clinical setting.Overall, the trainees rated their experience favorably

(RQ #1); 100% of respondents (N515) agreed or stronglyagreed with the statements “Participating in the telepsychi-atry clinic was a good use of my clinical training time,”and “Using telepsychiatry enhanced my overall trainingin psychiatry.” Only one trainee disagreed that the clinicallowed them to address the needs of (his or her) patients.They had mixed feelings regarding the scope of disordersthat telepsychiatry can treat, although nearly all (N513;86.7%) indicated that telepsychiatry can treat patients witha wide range of psychopathologies.

Received May 23, 2012; revised July 17, September 24, 2012; acceptedOctober 16, 2012. From the Dept. of Internal Medicine, Yale UniversitySchool ofMedicine, NewHaven, CT, and theDept. of Psychiatry, SouthernIllinois University School of Medicine, Springfield, IL. Send correspon-dence to Dr. Dzara; e-mail: kristina.dzara@yale.eduCopyright © 2013 Academic Psychiatry

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The trainees find the rotation “a great deal” (N57; 46.7%)or “somewhat” (N58; 53.3%) useful as an orientation to theclinical responsibilities of practicing telepsychiatry. Train-ees also report that the rotation “a great deal” (N512; 80%)or “somewhat” (N53; 20%) served as a clinical tool rele-vant to their career path. Nearly all (N512; 80%) would bewould be comfortable using telepsychiatry in later practice.However, trainees reported disliking technical difficulties(N59; 60%), confusion in reading the patients’ affect (N59;60%), delays in patient response (N54; 26.7%), and in-creased staff involvement (N54; 26.7%).

When asked whether “The direct supervision I receivedduring my telepsychiatry rotation helped provide a com-prehensive learning experience,” 100% of residents (N58)and 80% of medical students (N54) agreed or stronglyagreed. However, more than half (N59; 64.3%) agreed thatthe rotation could have been improved by having had moreclinical telepsychiatry experience.

Although the qualitative comments did not yield enoughdata for formal analysis, they provide some valuable insight.One resident wrote that telepsychiatry is a “good service, buttechnology needs to be simpler.” Others noted that theydisliked the “poor patient/physician relationship/rapport”and that telepsychiatry is more useful in patients who arestable. Eight trainees noted the usefulness of telepsychiatryfor patients who are in rural areas without access to psy-chiatric care.

Discussion

Limited research has been published on the use of tele-psychiatry as a training tool (3–7). This survey is the firstto assess trainees’ attitudes toward participation in a tele-psychiatry clinic. Considering the growth of telemedicine,more attention should be paid to the evaluation of trainees’experience (3–7).

We acknowledge several limitations to the study. First,we report from one program, with a small number oftrainees. Results were not stratified to assess potentialdifferences by training year. Second, we did not performan objective pre- and post-test. Third, although the sur-vey was refined to ensure face and content validity, wecould not utilize a validated tool. Fourth, although thetrainees reported limited clinical exposure to telepsy-chiatry before the rotation, we did not assess whether anydidactic or clinical preparation might have influenced theirviews.

Importantly, respondents have mixed feelings regardingthe scope of disorders that telepsychiatry can be used to

treat. For example, fewer than one-third of trainees (N55)would want to treat patients with developmental disabilities(N55), movement disorders (N54), dementia (N51), orchildren (N51). Attending psychiatrists should more ef-fectively demonstrate the range of conditions treatable withtelepsychiatry.

Overall, the rotation enhanced trainees’ psychiatrictraining by providing an interesting and clinically relevantexperience. They viewed it as a good use of their clinicaltraining time and felt it introduced them to a usefultechnology. Importantly, all residents agreed that thedirect supervision helped provide a comprehensivelearning experience. Although some residents were hes-itant to use telepsychiatry, most reported being comfort-able with the technology and that they could use it infuture practice. Our findings add to the limited researchindicating that telemedicine can be an effective trainingtool, especially with direct supervision (4–7). Furtherresearch should provide a more in-depth assessment ofwhat trainees dislike about telepsychiatry, and how thoseproviding training can address these areas (3–7). Psy-chiatric issues such as the effect of telepsychiatry ontransference and countertransference phenomena shouldbe considered, as well as specific strategies for develop-ing and maintaining therapeutic alliance. Finally, edu-cational interventions, including didactic preparation,should encourage understanding of the rapid pace of de-veloping communication technology with videoconfer-encing capability.

Research was completed at the Southern Illinois UniversitySchool of Medicine. We thankfully acknowledge all trainees whocompleted the survey. Preliminary findings were presented asa poster at the 2011 Association for Academic Psychiatry AnnualMeeting, Scottsdale, AZ.

No financial support was provided for this study. The authorshave no financial relationships or conflicts of interest todisclose.

References

1. Nieves E, Parmar N: Telepsychiatry Training: What ResidentsNeed to Know. Psychiatric Times.com, 2009; http://www.psychiatrictimes.com/display/article/10168/1430347

2. Hilty DM, Luo JS, Morache C, et al: Telepsychiatry: an over-view for psychiatrists. CNS Drugs 2002; 16:527–548

3. O’Reilly R, Bishop J, Maddox K, et al: Is telepsychiatryequivalent to face-to-face psychiatry? results from a random-ized, controlled equivalence trial. Psychiatr Serv 2007; 58:836–843

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4. Oesterhold JR, Travers HP, Kofoed L, et al: An introductorycurriculum on telepsychiatry for psychiatric residents. AcadPsychiatry 1999; 32:165–167

5. Szeftel R, Hakak R, Meyer S, et al: Training psychiatric resi-dents and fellows in a telepsychiatry clinic: a supervisionmodel. Acad Psychiatry 2008; 32:393–399

6. Miriam J, Szeftel R, Sulman-Smith H, et al: Use of tele-psychiatry to train medical students in developmental dis-abilities. Acad Psychiatry 2011; 35:268–269

7. Fleming D, Riley SL, Boren S, et al. Incorporating Telehealthinto Primary Care Resident Outpatient Training. Telemedicineand e-HEALTH, 2009; 15:277–282

Call for Papers: Psychiatric Education and Neuroscience

Over the past few decades, psychiatric research has increasingly converged on the importance of neu-roscience for understanding psychopathology, the mechanisms of current treatments, and avenues for novel therapeutics. Despite these large scientifi c advances, education of psychiatrists in neuroscience has lagged signifi cantly. This lag may be attributable to numerous factors, the result of which is a psy-chiatric workforce presently unprepared for understanding these innovations, interfacing with patients over them, and integrating neuroscientifi c advances into their clinical care.

Insights into and attempts to bridge the science-to-training gap, however, have already begun taking shape. These efforts have started on a small scale, but may very importantly inform broader efforts by the fi eld to bring psychiatric practice closer into the fold of neuroscience. At the same time, there are concerns among clinicians that an exclusive focus on neuroscience may diminish the historically humanistic nature of psychiatry. To this aim, Academic Psychiatry is creating a special issue of articles that explore the nature of the gap, reasons why the training is lagging behind the science, and avenues for bridging this gap in creative ways, while being mindful to retain the many existing virtues of clinical psychiatry.

In keeping with the overall mission of Academic Psychiatry, papers ideally will be evidence- based, drawing upon data and outcome measures, and/or involving multiple sites. Compre hen sive reviews and case studies are also welcome. All submissions will be peer reviewed in keeping with the journal’s policy. Submissions are due by July 1, 2013.

Submissions should be uploaded to ScholarOne Manuscripts (http://mc.manuscriptcentral.com/appi-ap). Please indicate in the cover letter that the submission is for this special issue. For more information, please visit our Web site at ap.psychiatryonline.org. Please direct questions on the submission process to Ms. Ann Tennier, Senior Editorial Associate, at 262-346-1461 or acadpsych@gmail.com.

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VIEWPOINTS ON A TELEPSYCHIATRY ROTATION