Abstract
Globally, telepsychiatry has been around since the 1950s. It is in the COVID era that it has gained the relevance and much-needed momentum amongst mental health care professionals. Given the restrictions imposed by the global lockdown owing to the fear of contracting the virus, the ease of access and safety offered by telepsychiatry makes it both appealing and “the new normal.” Despite some hesitation from mental health professionals, there is adequate research to support the role of telehealth services in the management of various mental health disorders. As with any formal system, the practice of telepsychiatry is regulated by professional guidelines to show the way forward to both health provider and seeker. The manuscript examines the ways telepsychiatry is redefining our virtual conduct. It emphasizes the evolving “netiquette” needed to navigate online consultations. It also elucidates the challenges faced by health professionals, and possible ways of maneuvering and circumventing the same. Telepsychiatry, a dynamic process which is interactive and personalized, adds a third dimension to the practice of modern medicine. It is here to stay. So, it is not a question of “if” instead “how soon” we can adapt to and get conversant with this revolutionary mode of connection, communication, and consultation, which will make all the difference.
Keywords: Mental health, netiquette, telemedicine, telepsychiatry, telecare
The blending of telecommunication and information technology into health care has given us the portmanteau words “telemedicine” and “telepsychiatry.” Tele, the prefix phrase, derives from the Greek meaning “far.” It is anchored to the root word that means “reaching over a distance, carried out between two remote points, performed or operating through electronic transmissions.” The word “medicine” derives from the Latin “mederi,” meaning “healing.” Telemedicine refers to health care delivery, whereby physicians examine distant patients through the use of telecommunications technology.1 “Telepsychiatry” holds a niche in the broader field of telemedicine. It is a complex set of tele-behavioral-health treatments. Hailey et al. (2008) reviewed 72 papers that described 65 clinical studies.2 Findings from these studies confirm evidence of success with telepsychiatry in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. The authors conclude that the evidence of benefits from telepsychiatry applications is encouraging, though still limited. A review of the abundant scientific literature supports the evidence that accumulating global experience in telepsychiatry consultation is positive and welcoming.3
In India, until early 2020, there was no specific legislation or guidelines on the practice of medicine through video, phone, and internet-based platforms. The Board of Governors, under the guidance of the Health Ministry, on March 25, 2020, formulated an amendment to the Indian Medical Council (professional conduct, etiquette, and ethics) Regulations, 2002 (“Code of Conduct”). It laid the regulatory foundation for the practice of telemedicine in India.4 In May 2020, the National Institute of Mental Health and Neurosciences, Indian Psychiatric Society, and Telemedicine Society of India collaborated. They published an operational guideline for psychiatrists to practice teleconsultations in compliance with Telemedicine Practice Guidelines 2020 of the Government of India.5
The goals of mental health care professionals, the service providers, traditionally have always been to promote, prevent, diagnose, treat, and rehabilitate individuals needing care. However, in recent times it is the mental health care service seekers who are becoming more demanding in terms of interaction and participation than ever before.6 They have never been more curious, interested, and responsible for their mental health. For the health seeker, the right to decide and deny remains paramount and the cornerstone of the current doctor–patient relationship.7 Health care seekers are looking beyond just medical care. They want the power, autonomy, and dignity related to their health, most notable being a possibility to refuse. These challenges, combined with the increasing need for a collaborative relationship between the professional and patient, have given telepsychiatry wings to fly and play a pivotal role in health care delivery.
The ubiquitous caveats of etiquette that apply to online communication are similar yet different from those employed for communicating offline, in person, or through audio and video. A telepsychiatry consultation, contrary to the face to face (f2f) consultation, begins much before the actual meeting. The portrayal of the professional in terms of affiliations and credentials, the multitude of services offered can influence health seekers’ perception in positive and negative ways. Prospective health care seekers may browse internet portals for physician ratings and reviews before opting for their choice. It sets the precedence to getting the first impression of the health care provider. Many times, these sites use arbitrary methods and are not regulated, thereby significantly influencing health seekers’ attitudes and beliefs.8 Ergo, the need to upskill oneself for a hassle-free transition from bedside to website. The objective of this manuscript is to appraise the evolving “netiquette” required for online consultations. It also highlights the challenges to circumvent in the process.
Professional Upskilling for Bedside to Website Transition: Netiquette of a Telepsychiatry Consultation
The key to successful teleconsultation is not just the technology, it is also the delivery of care. There are potential prerequisites from both ends for a fruitful consultation. The technology serves the purpose of a means to an end. A productive telepsychiatry consultation is dependent on multiple parameters. It includes doctor–patient relationship, patient and professional requirements, technological requirements, the comfort of using technology, positive expectation from the mode of communication, and essential trust in the method of distance communication. Etiquette in technology is a relatively modern concept. “Netiquette” is a portmanteau, word blend of “network” and “etiquette.”
Creating the “Just Right” Netiquette Using the Goldilocks Principle
One can decipher the right netiquette using a metaphor. Here is an excerpt from the fairy tale “Goldilocks and the Three Bears.” The story where a tired little girl named Goldilocks enters the house of bears; her attention soon falls on the three beds. The first bed that she tries to fall asleep on is too firm, the second too gentle, and the third just right for her. That’s the beginning of the conflict in the story.
Goldilocks principle is a cognitive effect where similar choices tend to gravitate toward the more moderate option. Setting the telepsychiatry netiquette standards too high (too firm) to meet the studio norms can have a toll on the service provider. The consequent strain can interfere with providing optimum mental health care, while keeping the netiquette standards too low (too gentle) can affect the satisfaction levels of the service users, which may lead to a decrease in the utilization of the service. Hence, there lies the importance of the “just right” netiquette that is simple and straightforward to follow. It will impact the outcome of the effectiveness of the teleconsultation. With heightened awareness and practice, the service provider and service seeker can join together in optimum utilization of telepsychiatry service.
Capsuled, in a nutshell, the 13 “just right” netiquettes include the following:
Perform a trial run to ensure familiarity and use of the technology in hand. It will aid in minimizing technical challenges that can arise during the consultation. It is useful to have an audio/video quality control check in advance to every single session. Have alternative platforms or technology as a standby. It can aid in combating untoward glitches that can crop up during the consultation.
For teleconsultations, scientific evidence mulls the usage of a neutral background. It allows the optimum viewing of individuals with varied complexions.
Deploy and utilize standard quality equipment, latest software, and faster and consistent internet service. It shall ensure optimum audio and video quality.
Schedule a time in advance. Fixing the duration of the teleconsultation and making oneself available at that time ensures effective processing of the consultation.
Proactively communicate untoward delays and unavoidable cancellations. Ensure to reschedule again on a mutually convenient day and time. Being proactive is an opportunity to win. Active practices and communications create opportunities to demonstrate stakeholder attention, establish trust, and build connections. It can ease anxiety and aid in addressing problems before they develop.
Talking about a mental health issue can be nerve-wracking, uncomfortable, and embarrassing. Ensure the remote setting is safe, secure, and confidential as on the lines of a f2f session. It will enable the patient to feel comfortable and trustworthy to seek health care services.
Make sure the room is well lit. Conversations are more active and less anonymous in a brightly lit room. Have space devoid of distractions, both people and noise. Keep the background nonclumsy. A simple, clean, and nondistracting background with proper camera positioning will foster an environment that allows an uninhibited flow of information without compromising privacy. It is essential to be in control of what is seen, told, and experienced during the consultation.
Ensure to attire professionally always irrespective of the duration or mode of consultation. It can influence the perceived professionalism. Colors, designs, and patterns have their connotations, which can have a significant influence on people’s impressions and behaviors. Physician’s appeal plays an integral part in establishing faith and confidence as well as in perceiving empathy in the relationship between patient and doctor.9
Always have the health care seeker to dial in. It serves as implied consent with themselves opting to reach out to seek professional help. On beginning the consultation, place a warm request to the patient to confirm their identity. It will make sure that the right patient is receiving the consultation.
- Communicating online has subtle differences from talking f2f. Establish the following ground rules in advance to ensure a productive and effective online consultation:
- Paralinguistic features like gesture and facial expression are absent. They help in communication and intonation patterns to convey the tone of a message. Hence, judiciously use nonverbal cues to show interest, and that you are listening to and understanding the other person. Acknowledge and respect others’ points of view (even if you disagree). Be tolerant and forgiving of others’ mistakes.
- Set clear boundaries and respect those set by others. Communicate, taking turns. Avoid stepping on each other feet by not having simultaneous talks. Be unambiguous, slow, precise, and pleasantly loud.
- Make an ongoing effort to face the camera while communicating. Maintain eye contact and practice “civil inattention” where necessary. Coined by sociologist Erving Goffman,10 this is the act of consciously acknowledging other’s presence. It can have one’s privacy uninvaded by making eye contact for a fraction of a second before averting the attention.
- Be supportive. Reassure and always make it a point to clarify specific questions raised. Regularly check to have been understood by asking questions or making mini summaries.
Evidence-based research indicates the presence of unique vocal patterns associated with the underlying emotions of anger, disgust, fear, happiness, sadness. In a telepsychiatric consultation process, with the limitation of being able to notice the finer nuances of emotional digressions, it is desirable to develop the ability to detect the subtle emotions in the tone. It can help the service provider to invest a little more time and be more compassionate to the anxious patient—thus influencing and motivating the individual to share more details for better care of the issue in hand.
Be thoughtful to use the chat box, primarily to communicate misunderstood terms or for reclarification of an indistinct converse. Use texts with emojis when appropriate for better empathy and communication. Nevertheless, be cautious and capture the context to avoid miscommunication.
Termination of the session with a thank you note is essential. It is usually much appreciated and goes a long way toward having a positive effect on patient satisfaction.
Mirroring of optimal postures by the health care provider and health care seeker can enhance rapport building. A well-established rapport leads one to feel comfortable in one other’s presence, thereby leading to accurate disclosure of information. Following are three good practices intended to supplement the mentioned 13 netiquette:
Set up an ergonomic consultation station as this will help one feel and give their best. Let the curve of the spine decide the choice of the chair. Rest both feet on the floor or footrest. Let the keypad be in level with or below the elbows. Elevate the laptop to ensure the camera on the screen is at eye distance.
Do not multitask as this could subsequently lead to multi-slacking. Be mindful of the session and avoid answering other emails or run errands online while still being in the meeting.
Turn off the notifications on the phone and stop social media for blocks of time with an app such as Self Control, available on either phone or desktop. Make the best out of the available online time tracking apps such as Toggl (web), the Work Break Timer (app), Focus Booster (app and web), or Tomato Timer (web) for efficient time-keeping.
Figure 1 illustrates netiquette as a mnemonic to provide a concise three-part framework crafted for a quick recall.
Figure 1. Telepsychiatry Netiquette Simplified.
A conversation on mental health is more than mere communication. It requires the establishment of rapport, trust, therapeutic alliance, and positive expectation for optimum outcomes. With virtual consultation, the overall ability to express, deal, label, and process emotions remain a challenge. Hence, for a professional, working on active learning of communication with texts, messages, voice, and video is an advantage. Here are some challenges to be mindful of for an audio-only and text consultation.
Audio-Only Consultation
Audio conversations without an accompanying video can be challenging. Any form of communication consists of visual and aural components, former playing a more substantial part. The elimination of the visual element forces the listener to “fill in” the gaps. This “filling in” occurs by judging the intonations and inflections of the aural component. It makes the process inherently imperfect and thereby likely to result in “lost in translation.” It further leads to challenges in communication.
Text Messaging
It is a frequently used and very convenient way to exchange information. With a loss of visual and aural components, there is an offset in the clarity provided by the written testament of information. In combination with audio-video messaging, the level of clarity gained is probably at its highest. We must be aware of spelling errors, faulty grammar, and poor language skills, not ignoring the frustration caused by automatic spellchecks that autocorrect words arbitrarily and generate amusing and often disastrous instances often referred to as “word salad.”
Shielding Netiquette Standards Against Becoming too Firm or too Gentle
Professional consultation involves primarily human interaction; hence, it can go awry due to various reasons. Telepsychiatry, with its unique features and demands, is also prone to specific challenges. A nonprofessional setup, appearance, or handling of technology can have a significant impact on the outcome of the consultation. The individual’s sensory, motor, communication, and cognitive deficits can restrict the usage of virtual consultation. Thus, it is a good practice to assess user feasibility beforehand to choose the best mode of communication.
Text, audio and video only convey minimal data. Teleconsultation, therefore, has the downside of unintentional miscommunication. Establishing and maintaining trust remains a crucial component for a fruitful telepsychiatry consultation. Real-time consultation has a clear boundary to mark the end of consultation when the patient walks out of the consulting chamber. Telepsychiatry consultation has the ease of accessibility through instant messages or call. Hence, one of the challenges to note is that the patient can continue to reach out multiple times after the completion of a scheduled appointment to clarify or share more information. It may result in resentment which may impair the effectiveness of telepsychiatric session(s). Also, patient behaviors can turn out challenging during a telepsychiatry consultation. Some of the problems include self-harm, suicidal behavior, abuse, addiction, and disinhibition. Professionals, therefore, need to develop their basic strategies in advance to deal with the challenging online behavior of their patients. Also, ensure that there is no compromise on ethics and legality. A comprehensive consent form detailing the do’s, don’ts, expectations, and limitations from the telepsychiatry consultation duly explained, discussed, and accepted in prior shall be useful during times of crisis. It may be helpful to obtain personal demographic information, alternative numbers of trusted family members or friends, particularly when working with people who are at an imminent risk of suicide or self-harm. Having a list of local resources for emergency care hotlines and other crisis intervention setups could be handy.
Telemedicine guidelines recommend that the professional decide on the feasibility of initiating and continuing consultation. At any point in time, the expert can consider termination and recommend in-person consultation for reasons of safety and effective care to the patient. Keep a list of alternative resources to make available to the patient. It will enable to provide first aid to the patient until they connect to the required service.
The remote and virtual presence of the patient rules the need to collect data and the constant interaction with technology. It can make the practitioner less empathetic and more protocol driven, which can dilute the human aspect of the consultation. With power comes responsibility! Telepsychiatry consultation is never a more natural alternative, but rather another mode of health care service delivery, suitable in certain circumstances.
Technical glitches at either end of service provider or receiver shall create obstacles for the overall effectiveness of the consultation. Being prepared and having alternative strategies shall remain key to handling these glitches, which could be inevitable. Teleconsultation sessions can continue to influence interpersonal interactions. There is now ease of access to one’s personal and social life on multiple platforms. There are digital traces left behind. Implicit biases can contribute to questions of transference and countertransference. To know the real impact, this area requires systematic studies. Avoid abuse and reduce bias, against any modality of care. Balancing different patterns of health care available for the benefit of the community at large shall remain the key.
Conclusion
Telepsychiatry is an evolving form of health care service. It holds on to the basic principles of autonomy, beneficence, confidentiality, nonmaleficence, and equality. Telepsychiatry advances are an indication of a changing and adapting world, needing us to embrace the change and uncertainty. It has its potential effectiveness, possible limitations, and its place in the health care ecosystem with no compromise in confidentiality, ethics, and legality. A commonly held belief among health professionals is that there is no replacement or equivalent to in-person consultation, which need not be true always. The in-person consultation has its drawbacks as well. The lack of training, experience, and exposure to virtual consultation leads to further barriers in many professionals delaying the adoption of telepsychiatry consultation.
Telepsychiatry has the potential to be a convenient, customizable tool to bridge the gaps in the existing mental health care ecosystem. It can benefit all the stakeholders in the ecosystem, thereby helping nations to create robust health care. With more and more consultations going the telepsychiatry way, the data generated shall provide the fodder for future changes and incorporations. The process of telepsychiatry consultation is not an all-or-nothing affair, where one becomes an expert immediately starting to the consultation online, like turning on a light switch or vice versa. Instead, it is a gradual and incremental expertise one acquires like the dimmer switch, albeit slow and steady that dims or brightens the space.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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