Remote Working: The Experiences of Two Trainee Psychiatrists

Dr. B Harman-Jones, (Psychiatry Trainee)
Dr. C Harman-Jones (Psychiatry Trainee)

Introduction

Shortly after the World Health Organisation declared COVID-19 a pandemic, the UK Government published a list of individuals whom they considered to be extremely vulnerable to complications of the disease.1 For these individuals, who suffer from a wide range of pre-existing risk factors, stringent measures to protect against infection were advised, including remaining at home and limiting contact with others to an absolute minimum.

This advice had implications for a large and extremely heterogeneous group of people, ranging from very young children to the elderly, and affected a large number of working-age individuals. Many were able to make adjustments to their working arrangements very easily – e.g. those in office-based jobs already undertaking some home working prior to the pandemic. However, the situation for many others, including doctors, was more complex.

Medicine is one of the few professions that has, until now, remained largely untouched by the possibilities that improved connectivity provides in working effectively from home. This is in contrast to other economic sectors where home working for at least part of the week has largely become the norm, especially in the private sector where long commutes into central urban areas, especially London, are commonplace. Medicine has traditionally been considered a “hands-on” profession only, with a firm emphasis on bedside manner and the therapeutic benefits of close proximity between doctor and patient. However, COVID-19 has made this impossible in many cases due to social distancing requirements, and for those shielding the only possibility to continue clinical work has been through remote working.

Clearly, there are some areas of medicine where remote working is simply not possible, for example for those performing surgical procedures. Some areas, however, may be uniquely well-suited, with psychiatry being close to, if not top of the list. With a well-established doctrine of examination of the mental state based on the expression of thought through speech, with only a few modifications it is entirely possible for psychiatrists to conduct a very high quality consultation remotely. Additionally, the utilisation of information technology in psychiatry is high in comparison to other areas of medicine, with widespread use of portable laptop computers and electronic patient record systems.

In this article, we examine the experience of two trainee psychiatrists (one in an inpatient post, the other in a community post) working entirely remotely during the pandemic due to shielding advice. We explore how adjustments were made to their working patterns, the results of these interventions, and the potential future implications of this experience on psychiatric practice, and on medical practice as a whole.

Inpatient Trainee Experience

Working arrangements
The inpatient trainee was to continue to attend daily ward meetings and ward rounds over video conference, to scribe notes based on the discussion, and to follow up on any jobs identified as part of the ward round. They were also responsible for completing any tasks delegated from medical staff physically present on the ward, for example the completion of reports, and communication with other healthcare agencies involved in care of patients on the ward.

Effects on patient care
In the early stages of remote working, it was noted that it was important for the trainee to introduce themselves formally with any new patient due to the unfamiliarity of having a doctor present via video conference. Once this had been done, all patients were comfortable to continue the meeting with the trainee present virtually. A benefit of the trainee’s attendance at these meetings being virtual was that the number of staff who could be physically present while social distancing rules were in place was effectively increased, possibly improving the patient experience. For particularly aggressive patients, this also allowed the presence of an extra staff member who could assist in the eventuality of physical aggression, which likely contributed to staff safety while social distancing was in place.

As our Trust has not yet moved to electronic prescribing, it was not possible for the inpatient trainee to prescribe for inpatients remotely. These responsibilities were accordingly taken up by more senior members of the ward medical team, who would usually delegate this to the junior doctor. For prescriptions for psychiatric medications, this was not an issue, as were prescriptions for straightforward physical health complaints such as paracetamol for headache.

Where a more significant physical health concern was identified, involvement of the on-call SHO for the site was required, because a physical examination was likely to be required in order to prescribe appropriately or advise on management. This measure did not present any major issues to the running of the hospital.

Effects on training experience
As attendance at ward rounds and follow-up on relevant tasks forms the majority of work for any trainee psychiatrist working on an inpatient ward, the training experience was relatively preserved. In the vast majority of cases, tasks identified as part of the ward round were possible remotely, as in large part these involve completion of forms and liaison over the telephone with other medical teams and specialities. The trainee maintained regular contact with the ward’s nursing and medical teams both over the telephone and using e-mail which was adequate to facilitate most tasks requiring action on the ward. It was also straightforward for the trainee to discuss directly with patients by staff bringing them to the ward’s telephone.

Contingency measures for regular face-to-face supervision were put in place, using telephone calls or video conferences. These measures were adequate to provide the same level of support to the trainee as face-to-face meetings, with no periods where the trainee felt unsupported in relation to clinical decision-making. Teaching sessions were accessed via video conference, which allowed the trainee to maintain learning requirements in line with their colleagues.

How the trainee found the experience
Subjectively, the inpatient trainee found joining ward meetings and ward rounds over video conference to be a positive experience. High quality audiovisual equipment on the ward facilitated ease of notetaking and observation of body language important for the mental state examination. All members of the team were visible and audible, making it easy to participate fully in the meetings as if physically present. Patients and staff alike were found to be accepting of the modifications to the trainee’s working situation, and there were no major interface issues noted in this regard.

Working remotely was of course more isolating than being physically present in work, and it was more difficult for the trainee to feel actively involved in the running of day-to-day proceedings than if they had been physically present. However, this feeling was addressed appropriately in supervision through discussion, and was not excessive when compared to the psychological impact of shielding generally.

Community Trainee Experience

Working arrangements
The outpatient trainee was to continue to conduct their daily clinic remotely, in line with the rest of the community team who had also switched to remote consultation during the pandemic. Other duties would continue to include liaison with other teams and agencies involved in the care of patients as required based on individual patient requirements.

Effects on patient care
Telephone consultations formed the mainstay of remote consultations. The trainee felt that the quality of consultation over the telephone was not significantly impaired compared to face-to-face communication, particularly because those patients in the community are more likely to be stable and less agitated than in an inpatient setting, where patient visibility would be more important. It was felt by the trainee that it was perfectly possible to conduct even an initial psychiatric assessment over the telephone and formulate an appropriate management plan safely. Provision of patient telephone numbers required no extra work as these were available as standard in electronic patient records. Patients were contacted at the time of appointment booking to obtain consent for a telephone call, and no patients raised any concerns or issues with having a consultation over the telephone.

While telephone consultations seemed fit for purpose, the trainee felt that if videoconferencing were promoted more widely this would have slightly improved the quality and scope of consultation possible. There were significant barriers to achieving this. Early in the pandemic, the Trust had advised that video calls to patients were only acceptable if conducted using a particular proprietary software solution, requiring inputting a meeting code and password. This extra step presented a significant logistical barrier to engagement with this solution, and indeed, several patients declined to use this service when offered, opting for a telephone consultation instead. We discuss what alternatives may improve access below.

Effects on training experience
The trainee felt fully able to conduct quality assessments and reviews of patients over the telephone, and gain appropriate experience of managing community patients as if attending in person. There was no perceived negative impact on the quality of training opportunity provided.

Prescribing was not an issue, as this is routinely done via the GP in a community setting. An electronic signature was set up for requests for changes to medication, and these were sent electronically to GP practices to be enacted. More detailed communication with patients and GPs is also routinely conducted using postal letters, and as postal services continued to run at near-normal capacity during the pandemic, this method of communication was not disrupted.

How the trainee found the experience
Experience with supervision was equivalent to that of the inpatient trainee, with similar contingency measures employed to good effect, with the trainee feeling supported at all times in terms of clinical decision-making.

Similarly to the inpatient trainee, there was an inevitable impact on the trainee’s sense of inclusion in the team when compared to being physically present. Again, this was appropriately addressed through supervision and was not out of keeping with the psychological impact of shielding in general.

Remote working in this setting did, however, present an interface issue with other teams which was not observed in the inpatient setting. In a community setting, the trainee often acts independently during assessments and if, for instance, a need for crisis intervention is identified, it is their responsibility to arrange this. Some teams require face-to-face patient contact to be made before referral can happen, which was obviously not possible, and introduced an extra layer of complexity into the process. However, this was easily overcome by the increased role which the community team took on during the pandemic, with extended opening hours and an enhanced remit to take on crisis intervention work which would usually not form part of their role.

Discussion

Many clinicians have been surprised at how well remote consultations can work, with even the use of this approach for psychotherapy being well-received.2 While it is a valuable technique, there are several procedural barriers to its implementation, most importantly gaining consent and ensuring patients are comfortable with its use, as the Royal College of Psychiatrists identifies.3 Despite this, for some adults with certain conditions such as PTSD or panic disorder, it may actually be preferable to face-to-face contact.2 Telepsychiatry, referring to the use of video in consultations, has been wholeheartedly supported as a validated and effective practice by the American Psychiatric Association.2 The UK’s Royal College of Psychiatrists has taken a more reserved approach, suggesting it is used only as an adjunct to face-to-face consultation, but do acknowledge the necessity to explore any options to continue patient care during the unprecedented situation.3

From this experience, both trainees felt the experience of working remotely in their roles to be overwhelmingly positive. Existing workflows were relatively preserved, with any disruption to service delivery from the patient’s perspective being consistent with that seen in other areas during the pandemic. Patients were accepting of the alterations to consultations, with no objections to contact via telephone in the community setting, or via video conference in the inpatient. The quality of patient care and training experience was relatively unaffected once appropriate contingency measures were in place.

In the community setting, wider use of videoconferencing may have improved consultation quality, but this was hindered by procedural barriers. Despite the NHS advising it was appropriate to use existing and widely available videoconferencing technologies including WhatsApp and Facetime,4 the Trust issued guidance that it was only acceptable to use the proprietary solution in which it had invested, which is less accessible to patients at home as it requires inputting a specific URL and password. As noted above, this was less attractive to some patients than a telephone call, and did in our opinion result in a lost opportunity to engage these patients using telepsychiatry. We feel that if more accessible technologies were permitted for use, the quality of remote consultations could be increased.

The only marked negative aspect of working remotely for both trainees was a feeling of isolation from the work environment and the psychological wellbeing associated with seeing colleagues and patients in person. However, adequate contingency plans were made for holding regular supervision meetings remotely, which were sufficient to support the psychological wellbeing of the trainees. Overall, both trainees felt that the benefits of maintenance of their sense of professional identity facilitated by continuing to work through the pandemic greatly outweighed any such negative effects.

Conclusion

We already know that theoretically psychiatry is uniquely suited towards remote working, but this experience provides new evidence to support this novel method of working in psychiatry. Remote engagement in clinical work was relatively seamless and allowed both clinicians to continue their roles within their existing teams with relative ease. There are of course tasks which are not possible remotely, but these are few in number, and in this example alternative arrangements were made relatively easily and with little disruption to existing services.

We would therefore suggest that remote working is an entirely appropriate alternative to face-to-face working where it is required. Telepsychiatry via videoconferencing is the ideal, and because most people now own a smartphone, there are numerous existing services which put this capability in the hands of almost every patient. We would encourage widespread adoption and support of use of such services as the COVID-19 pandemic continues.

Additionally, this model of working has several potential implications for future psychiatric practice. Accessibility to more specialist psychiatric services could be increased, as reaching patients who cannot travel to specialist centres is now possible. This may be particularly relevant for child and adolescent services where geographical restrictions have been historically very significant in limitations in service provision. However, the implications also extend to other areas, for example those working in neurodevelopmental conditions, genetic syndromes with psychiatric features, and treatment-refractory mental disorders.

There is also a great history of attracting doctors internationally to experience how healthcare, particularly psychiatry, is delivered in the UK. The use of remote working technologies could open up these opportunities to trainees from all over the world who are not able to travel, and also to allow UK doctors to access learning opportunities internationally. The opportunities for international medical congress are also self-evident, and the traditional model of thousands of delegates travelling at great expense to meet in-person at a conference centre may rapidly become obsolete given the opportunities afforded.

Finally, the implications for widening the diversity of those involved in psychiatric practice are particularly exciting. Those suffering from disabilities that prevent them from engaging in traditional clinical practices may be able to overcome these barriers by using the model of working described here, helping to both widen the diversity of psychiatrists working, and address the staffing crisis which our speciality currently faces.

References

[1] Public Health England. Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19. 5 June 2020. Available at: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

[2] American Psychiatric Association. Telepsychiatry Toolkit. 2020. Available at: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit

[3] https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/digital-covid-19-guidance-for-clinicians

[4] https://www.nhsx.nhs.uk/covid-19-response/data-and-information-governance/information-governance/covid-19-information-governance-advice-health-and-care-professionals/