Table 3:

Impacts of Telemedicine on the Quality of Psychiatrist-Patient Interactions

Impacts	Illustrative Quotes
Positive Impacts on Quality of Psychiatrist-Patient interactions
Helpful to see patient’s home environment	“One advantage is that I really get to see people in their environment, so that gives me a little bit of an extra information and they are less, not that people come in in a formal attire, but often, they are in the midst of, in the middle of work, so now I see them in a more informal environment. That’s more information.” -Participant #8 in private practice in California
	“If their home is disheveled, you can see that, so that’s useful. I mean, sometimes I do have patients who I know their apartments are a mess. With those patients, I should, even when this is over, do one video session just to see what their homes look like, to get that information, the reality of the situation, and how bad it really is.” - Participant #4 in private practice in New York
Some patients are more relaxed at home or over the phone and can be more forthcoming	“In other ways they’re more relaxed and so they tell you a lot more about things you would not otherwise hear about just because it’s like you’re a friend on the phone, so it has plus and minuses.” -Participant #11 in private practice in Washington state.
	“I definitely had one patient with social anxiety who told me that was explicitly why he wanted to do a phone session and was actually much more forthcoming than he’s been before.” - Participant #3 in private practice in New York.
Improved access for certain underserved patients who could not be seen in-person prior to the pandemic due to logistical challenges	“I’ve been able to reach some people for intake for new clients who maybe wouldn’t have come, because they weren’t that motivated, but because I did call them at home or they had forgotten about the appointment, but because I did call them at home and they weren’t otherwise busy, even though they wouldn’t have planned to come into the clinic, I reached them and they were willing to speak with me.” -Participant #18 working for a non-profit agency in California.
	“It’s allowed us a chance to engage with the patients that previously were having problems engaging because of either logistics or time.” -Participant #15 working for a federally qualified health center in New York
Negative Impacts on Quality of Psychiatrist-Patient Interactions
Less information to support diagnosis and treatment/inability to use all senses	“From a clinician perspective, it makes my job a little bit harder because especially for newer clients where I’m trying to do an assessment, I’m losing a lot of information of being able to observe them directly and their mannerisms and again, especially if patients maybe have psychosis and you’re trying to assess, well did I just not hear that clearly or was it something that really just didn’t make sense? - Participant # 18working for a non-profit agency in California.
	“It definitely affects the efficacy of the assessments, to me. Especially for intakes, I don’t even know who this patient is and how they look, and sometimes, especially when I want to choose a medication, I ask their height, their weight. I am trying to figure out if they have obesity or something, it is more difficult now, in this way. And also in general, I really like interacting with people, the facial expression’s very important to me, so I’m missing this part, is definitely not great with telemedicine.” - Participant #17 employed by a New York hospital
	“There’s an austerity to it that is … there’s just it creates a distance. Sometimes it’s harder to tell is someone tearing up because things like that, if someone tears up, that’s like big red flag that says, “Go. Follow that. What’s going on now?” That’s a really important … one of the visual cues as an example. Sometimes, you just can’t see quite as well, it’s not as favorable or just the connection isn’t as good. Some of the nuance around more subtle emotion, I think, is lost.”- Participant #2 in private practice in California
	“There’s a lot of information you can’t get [via video]. Also, must be in person for forensic evaluation- like if someone’s in jail, I have to go see them in jail. None of the jails that I work with at this point have video capacity. And just trying to think, if someone’s, some of the forensic evaluations, like if you’re trying to assess if someone’s in the malingering or lying, you’ve got to be in person.”- Participant # 1 in private practice in California
	“I want to see the patient in the waiting room, how they’re interacting with other human beings. I want to hear their voice through the door, if they’re arguing with the nurse. I want to watch them, the nature of their gait when they walk into the room. I want to see how much effort it takes for them to sit down or get out of a chair. I want to, and this is a little gross, but it’s reality, I want to smell them. You know what I mean by that. I want to smell if they’re malodorous or not. I want to see if the lady has gone through a lot of effort, or the gentleman, of putting cologne on. I want to use all my senses, in this experience.” – Participant #6 in private practice in New York
Less privacy in the home setting	“Right now patients have to go hide in the bathroom, right, and they might be talking about their family members who they’re having conflicts with and they have to kind of whisper. And when they’re in my office they don’t have to worry about who’s listening.” - Participant # 11 in private practice in Washington state.
	“There’s a few people for whom their home and the people they live with doesn’t feel as comfortable of a place to talk or as private of a place to talk as coming into the clinic.”- Participant #18 working for a non-profit agency in California.
	“I have patients who are sitting in the closet when they’re doing a Zoom call with me or people who go out on a walk, not because they prefer the telephone, but because it’s the only way they can not be overheard.” - Participant #2 in private practice in California
Challenges with hearing patients clearly by phone or video	“So at first for some people they also seem to have a problem sort of speaking clearly and this is probably more a characteristic of maybe their illness or just their communication style. But that can be very difficult over the phone too. And so I sometimes have to ask people, can you speak clearly? Can you keep a stronger voice? Or can you just try to speak a little bit louder?” - Participant #18 working for a non-profit agency in California.
More distractions in the home setting	“And then for some people they really, they do struggle and it seems that it’s hard for them to sort of stay present or just sort of focus on what we’re doing. Maybe they’re trying to multitask. Maybe they’re not really comfortable.” - Participant #18 working for a non-profit agency in California.
	“It’s like you’re not quite as emotionally connected to a person when they’re on video and it’s easier to get distracted.” - Participant #7 in private practice in Louisiana
	“But just attention, this is a doctor’s appointment. It’s kind of a big deal. It’s not you talking to your mom on the phone twice a day. You get this once every three months and you need to pay attention. You can’t be putting the laundry in the dryer. And I think that as someone who puts the laundry in the dryer when I’m on the phone all the time.”- Participant #1 in private practice in California
Inability to do a physical exam and take vitals	“I can’t do certain things like blood pressure like I would like to do, I’d like to follow blood pressure when people are on medications that can potentially affect blood pressures. That’s a little bit of a concern, so I’ve just been having people monitor it on their own instead.” - Participant # 7 in private practice in Louisiana
	“But then in terms of the tangibles, like just checking vitals…that’s really challenging.”- Participant #14 in a community mental health center in New York
Difficult to assess movement disorders induced by anti-psychotic medications	“When I’m prescribing anti psychotics… I don’t yet have a comfortable modality for evaluating patients for symptoms of any movement disorder by video. I mean I do have them perform a couple of maneuvers to just see if I can illicit any symptoms or signs of extrapyramidal symptoms. But, I haven’t yet come across a standardized proven version of being able to do that by video that would substitute for a live examination, because there are a few maneuvers that I like to do in the office that actually require me to actually physically examine the patient.” - Participant #10 in private practice in California
	“And I have a patient that is on Haldol so it’s been hard to look for any symptoms of EPS very well.” - Participant # 9 in private practice in New York
Visits tend to be shorter and do not go into as much depth	“I started with phone appointments and some of them really…they would sort of shorten the session and stop early, but if they could do FaceTime they could get more engaged with the process.” - Participant #11 in private practice in Washington state.
	“The [video and phone] sessions tend to be shorter sometimes, but I feel in-person you might be able to get more information.” - Participant #4 in private practice in New York
	“So far it seems like especially when they’re telephone, are experienced more as a check-in.” - Participant #14 in a community mental health agency in New York
Difficult to manage time in telemedicine visits	“So they’ll talk on and on [on the phone], it’s hard to stop them at the end of a session and, but the video really does help. You can see them, they can see you.” - Participant # 11 in private practice in Washington state.
	“It is difficult to end sessions. In-person, I do this thing at the end of the hour with patients where I lean forward in my chair and I don’t have to say anything.” - Participant #2 in private practice in California