|Year : 2022 | Volume
| Issue : 1 | Page : 26-33
Clinician's experience of telepsychiatry consultations with elderly patients
Chandrima Naskar, Sandeep Grover, Aseem Mehra, Swapnajeet Sahoo
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||01-Jul-2022|
|Date of Acceptance||01-Jul-2022|
|Date of Web Publication||03-Aug-2022|
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: During the coronavirus disease-2019 pandemic, telepsychiatry became a norm as a primary method of health-care delivery across India. However, not much evidence is available regarding the experience of psychiatrists in providing a telepsychiatry consultation. Objective: This study aims to assess the experience and satisfaction of the clinician in providing teleconsultations to elderly patients/their caregivers. Methodology: Clinicians scored their experience, satisfaction, and their perception of therapeutic alliance in providing the teleconsultation to patients of age 60 years or more, in a detailed Google Forms-based questionnaire. Results: Ninety-eight teleconsultations were assessed by clinicians. The patients had a mean age of 69.5 years, with an equal number of males and females. In more than 80% of the teleconsultations, patients were accompanied by their relatives. In about one-fourth of the consultations, psychiatrists encountered connectivity issues from the patient side. Overall, for three-fourth (72%) of the teleconsultations, clinicians reported being satisfied to a large extent; for two-thirds (66%) of the consultations, the clinicians rated their teleconsultation experience as that of providing an in-person consultation; and for about 10% of consultations, the experience was rated as better than the in-person consultation. In terms of a therapeutic alliance, in almost 85%–90% of consultations, the clinicians noted that they could build a rapport, empathize with their patients, and build a relationship of trust with the patients and their caregivers. Conclusions: Teleconsultation with the elderly might not be as difficult as intuitively thought and clinicians are in general satisfied with the same and consider that they can establish a good therapeutic alliance with the patients and their caregivers.
Keywords: Elderly, experience, India, teleconsultations
|How to cite this article:|
Naskar C, Grover S, Mehra A, Sahoo S. Clinician's experience of telepsychiatry consultations with elderly patients. J Geriatr Ment Health 2022;9:26-33
|How to cite this URL:|
Naskar C, Grover S, Mehra A, Sahoo S. Clinician's experience of telepsychiatry consultations with elderly patients. J Geriatr Ment Health [serial online] 2022 [cited 2022 Aug 16];9:26-33. Available from: https://www.jgmh.org/text.asp?2022/9/1/26/353164
| Introduction|| |
Telemedicine has made a significant progress across the globe, including in India in the last 1–2 decades., However, the expansion of telepsychiatry and telemedicine has shown exponential growth and expansion fuelled by the lockdown related to the coronavirus disease-2019 (COVID-19) pandemic. As the elderly population is considered to be the most vulnerable population for developing COVID-19 infection and experiencing a host of negative consequences of the pandemic in the form of experiencing social isolation, loneliness, and other negative mental health outcomes, the issue of providing teleconsultations has been widely discussed and some of the authors have also brought forward the challenges faced by this population when seeking teleconsultations and barriers to their seeking telepsychiatry consultations.,,, Some of the most important barriers that authors have discussed about providing teleconsultations to the elderly are the technical problems such as internet connectivity, poor technological literacy among older adults, negative or cynical attitude of physicians, difficulty in close monitoring of vitals that might be necessary for the care of elderly, and the lack of inclusion of certain necessary medications such as antidementia medication in the list of drugs that can be prescribed through teleconsultations. In comparison to the younger generation which readily delves into mobile-based e-health apps and other methods of teleconsultations, the elderly population is usually assumed to be less comfortable with technology such as video calls, internet-based communication systems, and telephonic health-care seeking.,
In contrast to the Western countries, India still has a family system in which the elderly are cared for at their home and the family members are directly involved in the care of their ailing elderly relatives. However, these caregivers face different kinds of challenges in accessing health care. They have to travel long distances and miss their work and livelihood to reach the health-care services, especially to assess tertiary care centers. Because of these barriers, many times, the needy elderly are deprived of the services of the experts and resultantly experience high morbidity and mortality. When we look at telepsychiatry services for the elderly in this context, it can be said that some of the barriers can be overcome by the presence of the caregivers.
Clinicians themselves are considered to have certain inhibitions, apprehensions, and negative attitudes toward telepsychiatry services. These barriers can have a major block in expanding telepsychiatry services to the elderly. Hence, it is important to share the experience of providing telepsychiatry services. Across the globe, there are limited data on the experience of the clinicians in providing telemedicine services and telepsychiatry consultations per se., These studies in general suggest that the majority of the clinicians who rate their satisfaction with providing telepsychiatry consultations equal to the face-to-face consultation have reported about the technical difficulties encountered during the consultations and the impact of teleconsultations on therapeutic alliance.,,, However, none of these studies have focused on the experience of clinicians in providing teleconsultations to elderly persons. Thus, in this study, we attempted to assess the experience and satisfaction of the clinician in providing teleconsultations to the elderly (aged 60 years or more) patients/their caregivers, seeking treatment in the Geriatric Psychiatry Clinic at a tertiary care center. We also tried to assess the impact of patient-related (age, sex, and comorbidities) and other external factors (locality, distance from hospital, and presence of caregiver) that might impact the experience of the clinicians with the teleconsultation.
| Methodology|| |
The cross-sectional study was conducted from April 2021 to December 2021 in a tertiary care hospital in northern India, after ethical clearance by the institutional ethics committee. The participants were informed at the beginning of their teleconsultation that the clinician would rate their level of satisfaction at the end of the call. Verbal consent was sought for the same before the assessment was done. This study involved patients aged > 18 years, and the total study sample was that of 430 patients. In this paper we present the data of only elderly patients, the data of whole sample has been published separately.
At our institute, a Geriatric Psychiatry Clinic focuses exclusively on elderly patients since 2017. The new patients are assessed by the senior residents in a walk-in clinic which runs on all the 6 working days. After the walk-in assessment, the patients are given appointments for detailed workups that involve elaborate history taking, general physical examination, mental status examination, and rating on Mini–Mental State Examination, Neuropsychiatric Inventory, and Everyday Abilities Scale for India. Three psychiatry consultants supervise the clinical care.
During the countrywide lockdown since March 2020, this whole service faced initial jeopardy. However, with the expansion of the departmental telepsychiatry services, both the walk-in clinic and the detailed workups were restarted from April 2020 onward. The fresh consultations by senior residents were done as audio only, over phone calls. The detailed workups involved audiovisual interviews over Zoom or WhatsApp calls, initially by the junior resident, followed by the interview by the consultant on 2 consecutive days. The detailed workup evaluation by the faculty members was slotted for ½ h (with occasional exceptions). These could be utilized by the faculty and resident for case presentation, clarification of issues, interview with the patients and/or caregivers, and finalizing the diagnosis and management plan. As detailed workup involved the maximum amount of time spent by the faculty and involved video communications except for occasional exceptions, this was chosen to assess the satisfaction of the clinicians.
A questionnaire was developed specifically for this study, which included sociodemographic and clinical details of the patient and the informants partaking in the consultation, information about the mode of the providing telepsychiatry services (the equipment used for consultation, connectivity, and time spent), brief assessment of the patients' and caregivers' behavior, clinician's perception about the connectivity from the other side, and distractions on the other side. The questionnaire also included questions to assess satisfaction in providing online clinical care, their perception of the rapport, and the therapeutic alliance with the patients and their caregivers. The rapport and therapeutic alliance questions were adapted from the clinician version of the Scale to Assess Therapeutic Relationship. Following the conclusion of the interview, the faculty members completed this information on the Google Forms platform. The physicians additionally used the General Assessment of Functioning (GAF) Scale to assess the patients' degree of functioning (from 0 to 100).
The questionnaire's face validity was assessed by five psychiatrists, and their recommendations were added.
Due to time constraints, the physicians scored the satisfaction and therapeutic alliance as a single unit, regardless of the number of people participating (patient alone or patient and caregivers) in a specific interview.
The survey was completed by three faculty members. Based on the best behavior of any of the participants on the opposite side, the faculty members were told to rate satisfaction and rapport on the higher side.
In addition, the three clinicians were interviewed after some of the consultations randomly (total interviews: 10) and their experience was evaluated qualitatively using an open-ended question, “What was your experience with today's teleconsultation?” Further follow-up questions depended on their response and these interviews lasted for 10 min.
The data collected via the Google Forms were analyzed using the Statistical Package for Social Sciences, fourteenth Edition (SPSS for Windows, Version 14.0. Chicago, SPSS Inc.) version. For continuous variables, mean, median, standard deviation, and range were computed, and frequencies were computed for the categorical variables. Comparisons were made using Chi-square test and the t-tests. P ≤ 0.05 was considered statistically significant. The association of time spent in the consultation and satisfaction was evaluated by Pearson's correlation.
| Results|| |
The study included 98 patients, with a mean age of 69.5 years, with about one-fourth (23.4%) of the patients being aged 75 years or above. Equal number of male and female patients were evaluated. The majority of the patients were married, at least educated up to 10th standard, retired, and belonged to urban joint families. The average distance of the patient's location from the hospital was about 170 km, with the farthest connected location being 1650 km away. The most common diagnosis of the patients was mood disorders, followed by neurodegenerative disorders. The majority (85%) of the patients had at least one medical comorbidity as per the available history. The mean GAF score for the patients was 33, with a range of 8–88 and a median of 27 [Table 1]. Most of the teleconsultations (57.1%) were done through WhatsApp video call, while 38.8% were done via Zoom and only 4.1% of consultations were done via voice call only. In most of the consultations, the consultant connected via a mobile phone, and in 75.5% of the consultations, the consultant spent more than 25 min in the face-to-face interview with the patients and/or caregivers. In 93.8% of the consultations, one or more informants accompanied the patient during the call [Table 2].
|Table 1: Sociodemographic and clinical profile of the patients evaluated|
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|Table 2: Details of the teleconsultation (as assessed by the clinician providing same)|
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For 70.4% of the consultations, the clinicians rated the “overall connectivity” to be “very good” or “good.” In slightly less than half (44.9%) of the consultations, clinicians did not encounter any technical difficulties [Table 2]. About one-fifth (20.4%) of the consultations involved other technological problems from the patient's side. This included the need for changing from one device to another, the need for changing from Zoom to WhatsApp/voice call, difficulty in muting and unmuting, echo, and background noise disrupting communication [Table 2].
In terms of satisfaction with providing teleconsultations, on more than half of the occasions clinicians were satisfied to a 'large extent or 'very satisfied in terms of the amount of time spent in consultation, amount of information they were able to collect, the behavior of the patient and the caregiver during the interview, freedom in expressing self, providing information to the patient/caregivers about the illness and prescription, usefulness of the consultation for the patient's and the family, and quality of care provided. The overall level of satisfaction was rated as “satisfied to large extent” or “very satisfied” for 91.8% of the consultations. In terms of specific aspects of the patient and caregiver behavior during the interview, the clinicians rated the same in affirmation for the majority of the interviews [Table 3].
Clinicians rated two-thirds of the teleconsultation experiences to be similar in quality to their in-person consultations (67.3%); the experience for 10.2% of the teleconsultations was rated as better, while 22.5% rated to be worse than that of an in-person consultation. For about one-eighth (10.2%) of the consultations, the clinicians felt irritated by one or other issues during the teleconsultations. In general, clinicians rated their mood to be neutral (40.9%) or good (57.1%) after the completion of the interview.
Concerning the therapeutic alliance, for the majority of the consultations, the clinicians rated their experience as either 'to a large extent' or 'to be the best possible extent', indicating the development of a good therapeutic alliance [Table 4].
|Table 4: Therapeutic relationship during the teleconsultations as rated by the clinicians providing teleconsultation|
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Factors that could influence the experience and satisfaction with providing teleconsultations
As this was a pilot study, the satisfaction of the consultation, the experience of therapeutic alliance, and the extent of technological difficulties were compared among groups divided based on locality, distance from hospital (≤20 km, >20 km), mode and hardware used for teleconsultation, time spent in the call, presence of caregiver during the consultation, and certain patient-related factors (age 60–75 years vs. >75 years, gender, diagnosis of dementia versus mood disorders, presence of medical comorbidities, and GAF score [>30, ≤30]).
The GAF score, presence of medical comorbidities, diagnosis (dementia versus depression), hardware used for teleconsultation, and the distance from the hospital did not have any significant association with any of the domains of satisfaction, therapeutic alliance, and technological issues during the teleconsultation.
Clinicians rated a slightly higher frequency of experiencing “feeling inferior to the patient/caregiver“ (P = 0.03) and “feeling rejected by the patient/caregiver as a clinician” (P = 0.02), when the patient was a female. Similarly, they had a higher experience of “feeling rejected by the patient/caregiver as a clinician” (P = 0.008) when the patient was >75 years of age. Clinicians seemed to report significantly higher satisfaction concerning the amount of information collected (P = 0.04) when the call was via WhatsApp. They were significantly more frequently reported to have “got along well with the patient/caregiver” (P = 0.02) when the time spent was more than 20 min. The calls made with patients from urban localities had a significantly higher frequency of “good” to “very good” clarity of video (P = 0.01). The presence of a caregiver led to a higher level of satisfaction in the clinician with regard to “the amount of information I could provide about the illness and the prescription” (P = 0.001), “the extent to which I got along well with my patient/caregiver“ (P < 0.001) and “the extent to which I listened to my patient/caregiver“ (P < 0.001).
Qualitative analysis of experience of clinicians with teleconsultations
When we interviewed the clinicians after some of the teleconsultations, they reported some of the important issues encountered during the teleconsultations. One of the important issues which influenced their satisfaction was the level of impairment/disability the patient had at the time of the teleconsultation. One of the clinicians reported, “this patient would not have been brought to our outpatient services in the usual course of the consultation, and hence deprived of the mental health services. From this point of view, telepsychiatry consultation provided me an opportunity to see this patient in his home and decide about the treatment.” After another consultation, the clinician reported that “Today's interview was very gratifying, this person was bed-bound, not able to move at all, and has been suffering from depression for so long. In the usual course of action, this patient would have been called to the outpatient service and asked to wait for a couple of hours, traveling would have been cumbersome for the patient and the caregivers too, what we would have done–at best talked to him and his family for 15–20 min. Rather than this I reached his home, saw him in the home environment, advised all the investigations which we require before starting the medications.”
When evaluating a 70-year-old elderly female with dementia, the clinician felt that by evaluating this patient at home through telepsychiatry, “I was able to talk to multiple caregivers, which would not have been possible, in the routine outpatient services. I could talk to all the family members at the same time, and view the household setting. Due to this, I was able to collect the best possible information and suggest the desired changes in the environment. In the usual course of treatment, this would have required about 2–3 visits, or may not have been possible.”
Another important issue that influenced the experience of clinicians was the quality of connectivity. One of the clinicians reported-”it is frustrating, we had planned to start the consultation at a particular time, but due to the connectivity issue, the consultation could not be started as the connectivity at the patient side was poor, initially we kept on trying on Zoom, later shifted to WhatsApp, then the things appeared to be different as if I was connecting with a different patient, the connectivity was acceptable, the audio and video was clear, the consultation went smoothly when I wanted to examine the gait of the patient, things were smooth, the caregivers were able to move around easily with the patient to show me the gait, compared to previous experience when the patient had connected on Zoom with a laptop, from now onwards, whenever, I would have a problem with connectivity, rather than wasting my time on Zoom, I would immediately shift to WhatsApp.”
Some of the other issues which emerged to influence the experience and satisfaction of the clinicians were patient/caregivers sitting still during the interview, patient/caregiver's availability at the time of the interview, patient and caregivers asking the clinician to reschedule the teleconsultation, and nonavailability of the caregivers despite being asked to be present at the time of consultation.
| Discussion|| |
This study evaluated the different aspects of experience, challenges, and extent of satisfaction of the clinicians when providing teleconsultations to the elderly patients. Although there are a few surveys regarding the clinician's opinion regarding the benefits and challenges of telepsychiatry consultations, those previous studies have assessed the opinions of the clinicians in general, but not related to specific patient consultations., In this study, data regarding the experience of providing video consultations to 98 patients aged 60 or above by three clinicians were assessed in real-time, at the end of each consultation. To the best of our knowledge, no such data is available from India or abroad. Hence, it would be difficult to compare the findings of the present study with existing data.
The sociodemographic and clinical profile (in terms of psychiatric diagnoses and medical comorbidities) of the patients included in this study is similar to that described in previous studies on elderly patients seeking psychiatric services in various clinics in India. Almost 85% had one or more medical comorbidities, and the mean GAF score for the study participants was 33, indicating that most of these patients “had major impairments in several areas.” Despite this level of impaired functioning of the patients seeking teleconsultation, the notable finding of this study was that for majority (92%) of the consultations, the clinicians marked their overall satisfaction as “satisfied to a large extent” or “very satisfied.” The clinician's encountered technological problems in more than half (55%) of the teleconsultations, but only in 4% of the teleconsultations, the video consultations became impossible and making the consultation limited to audio consultation only. The most common technical problem faced was connectivity issues from the patient side and certain problems such as difficulty in muting/unmuting, joining with video, and echo from background from the patient's side. The patients from the rural locality had a poorer quality of the video, which indicates that the urban–rural gap in internet facilities can be one of the major deterrents to successfully using telepsychiatry as a means to improve outreach. Some of the authors from India have also highlighted this issue. The literature from other parts of the world also suggests that this problem is not unique to India. Accordingly, it can be said that there is an urgent need to improve the infrastructure focusing on internet connectivity to improve the use of telepsychiatry for elderly patients.
The findings from the present study also indicate that as of now, despite Zoom being the officially subscribed means of providing teleconsultation by many institutes, WhatsApp video call remains the mode with which the majority of the patients are most comfortable. This is likely due to the widespread use of the application among the general population. Other reasons for higher acceptability and better user experience (for the clinicians) for WhatsApp could be ease of use in terms of lack of need to generate a meeting ID, sticking to fixed timing, better voice quality, better video quality, and a better understanding of the patients about the software. Due to this, the clinicians do not have to spend time making the patients and their caregivers familiar with the software. Another reason for a better experience of using WhatsApp could be the fact that WhatsApp calls can be completed using the mobile calls, whereas conducting a teleconsultation using the Zoom platform can be very cumbersome when used on a mobile phone. Thus, it can be said that when planning a telepsychiatry service, especially for the elderly, there is a need to keep in mind that using the popularly used mobile apps might reduce the technological barrier to help seeking.
One of the reasons that clinicians consider teleconsultations to be challenging is the difficulty in building a rapport, failing to collect adequate information to reach a satisfactory diagnosis, and the inability to deliver satisfactory treatment., However, numerous previous studies and reviews have shown evidence of reliability and validity of both clinical assessment and psychological testing in the geriatric population over teleconsultations. In the present study, we found that in the majority of the consultations (85%–90%), clinicians were “satisfied to a large extent” or “very satisfied” with the amount of information that they could collect and the quality of care that they could provide; for about 90% of the consultations, the clinicians noted that they could build a good rapport with the patients or the caregivers “to a large extent” or “totally.” In terms of satisfaction with the prescription that they could provide, only 15% of the times the clinicians noted “satisfied to some extent” or “dissatisfied to some extent,” while for the majority of the consultations, clinicians reported being “satisfied to a large extent” or “very satisfied.” That two-thirds of the time clinicians found the consultation to be as good as an in-person consultation and findings regarding satisfaction further bring home the fact that teleconsultations might not be as difficult in the elderly as inherently thought. For 10% of the consultations, clinicians reported that teleconsultation is better. This was further highlighted in the qualitative responses of the interviews. These findings suggest that clinicians possibly derive more satisfaction in providing teleconsultations to the elderly patients who are bedbound and cannot reach to the hospital due to the same.
Two important factors that were found to impact the experience of teleconsultation were the amount of time spent and the presence or absence of caregivers with the patient. In this study, caregivers were present in almost all the consultations (only 6 consultations had the patient attending alone), and it was found that clinicians felt more satisfied with the amount of information that they could provide and the extent to which they could listen to the patients when at least one caregiver was accompanying the patient in the video call. Furthermore, though the average time spent in the call was 25 min, the duration ranged from 8 min to 90 min depending on the requirement of the individual consultations. It was found that clinicians felt that they “got along well with the patient or caregiver” to a significantly larger extent when the duration of the call was more than 20 min. These findings could be interpreted in different ways. First, the clinicians were flexible to extend the duration of the interview depending on the need of the patient and the caregivers, and the overall behavior of the patient and caregiver dyad influences the clinician's behavior. Accordingly, while formulating the etiquettes for the patients and caregivers, this issue needs to be highlighted, as this can influence the overall outcome of the consultation. These factors might also help plan the mandates when preparing a telepsychiatry service for the elderly.
The study has a few limitations. Because of the complete closure of physical visits to outpatient services, a comparison group of in-person consultations could not be included. The questionnaire has not been validated beyond the face validity. Multiple comparisons were carried out, as this was an exploratory study. Hence, some of the correlates of satisfaction cannot be relied upon and require further replication. The findings of this study can be used to plan a future study with validated instruments and on a larger population with the inclusion of a control group.
| Conclusions|| |
This study indicates that even though technical problems are common barriers to teleconsultations for the elderly, providing teleconsultations to the elderly can be a satisfactory experience for the psychiatrists. Hence, there is a need to promote teleconsultations for the elderly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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