All over the internet, we see commercials for ‘telehealth’, ‘doctor on demand’, ‘dial a doc’, ‘instant doctor’, ‘therapist on demand’ and ‘text your therapist’. It sounds like a dream. Licensed and skilled healthcare practitioner at your beck and call. Ethical telepsychiatry does not work this way. A psychiatrist should not prescribe for you, without knowing who you are, your background, causes or your symptoms, past treatments, causes of treatment failure, side effects and confounding variables. One psychiatrist was jailed for nine years for prescribing Prozac to a patient online who subsequently committed suicide because he was not licensed in the state of California and the patient was a California resident. The doctor most likely didn’t mean any harm, and perhaps this could have happened to any of us. But this highlights the point that telepsychiatry is not a shortcut, for practitioners or a way to make easy income.
Telehealth is the best thing that has happened to healthcare this century, but only if both patients and practitioners understand that seeing a patient/doctor online does not mean you can bend the rules. Exactly the same protocols, safety measures and standards of care apply to when you see a doctor in an office. When seeing a doctor online, certain rules need to be followed:
- The doctor should be licensed and insured to practice in your state of residence.
- The doctor should not be communicating with you over phone or text message, except during emergencies, but via a HIPAA compliant video platform.
- The overall experience should be similar to seeing a doctor in an office.
- The doctor should complete a comprehensive psychiatric evaluation, including, developmental and psychiatric history, medical history, occupational, personal, legal and family history.
- The doctor should explore current symptoms, past symptoms and possible causes of past treatment failure.
- The doctor should request blood work, for baseline bloodwork, liver, renal and thyroid function tests, especially if prescribing medication.
- The doctor should explain the treatment plan, modalities of therapies suggested, and any medication prescribed.
- The doctor should evaluate response to treatment and treatment outcomes.
- The doctor should request a next of kin, or emergency contact for emergencies. It is reasonable to be suspicious of a doctor or therapist who does not want your friends or family to know that you are seeing them.
- Boundaries and standards of conduct required for an in-office practice have been developed over hundreds of years, through trial and error by various analytic institutes. Although telepsychiatry allows instant access and easy scheduling, this does not mean a therapist should tell you to ‘call whenever you like.’ and charge you for a call. This is a usual practice for a psychic, not a therapist. There is a temptation through telepsychiatry for untrained practitioners to bend these rules, which can result in an adverse outcome for patients and violation of the appropriate doctor/patient relationship.
- Fees should be clear and stated upfront.
- It is reasonable for practitioners to work on a sliding scale and reduce charges for patients of modest means. However, fees should otherwise be relatively standard and therapists should not be ‘bargaining”. with you or be giving you ‘discounts’ for being a special patient.
- Practitioners should not be accepting expensive gifts from patients. Generally, there is a cap at $100 rule and not more than once a year.
- Unless seeing a trained analyst, psychodynamic and supportive therapy should not generally last more than 2-3 years, and reasons for ongoing therapy should be clearly stated. It is reasonable to transfer a patient to another psychiatrist after the 2-3 year mark as therapy has often reached a saturation point, and something new can be learned from a new provider. The purpose of therapy is to develop insight, and coping strategies as well as modify destructive behaviors, not to foster dependence.
- It takes many years to train to be a therapist, and it is reasonable to ask for the qualifications of your provider.
- Your therapist should not be calling you for ‘ chats, ‘ claiming to be your friend, or meeting you in person for coffee, or other types of socializing.
- It is never acceptable for a therapist to have a romantic relationship with a patient.
- If your work performance and your social/personal relationships are deteriorating since starting therapy, this is something which should be paid attention to.
It is important that telepsychiatry providers pay attention to treatment protocols, and follow APA guidelines and standards of care, in order to ensure patient safety, patient well-being, a healthy doctor-patient relationship, and good treatment outcomes.