Tele Health

“Tele Vision”

If you have followed the Lindsay Clancy case as obsessively as I have, I wonder what your thoughts are regarding telehealth…..

Access to healthcare has become progressively more challenging, and telehealth has undoubtedly helped bridge that gap. It provides access to people who otherwise may receive no care at all.

But when does virtual care become inappropriate?

As defense attorney Kevin Reddington has brought up multiple times, you cannot truly assess the physical body of someone through a “television.” (He’s like the Robert De Niro of attorneys, by the way.) And beneath the theatrics, he raises a legitimate question.

Through a screen, how much of a patient can we actually observe?

Typically, we see the face, head, neck and maybe the upper chest. We can a basic mental-status examination. But what about the rest of the objective assessment?

Are the patient’s pupils dilated or pinpoint? Are they sweating? Tremulous? Picking at their cuticles? Is a leg bouncing uncontrollably beneath the desk? What is their heart rate? Blood pressure? Respiratory rate? Are there physical findings suggesting medication effects, withdrawal, intoxication, severe anxiety or another condition requiring further evaluation?

What are their damn vital signs?

These observations cannot diagnose a psychiatric condition, but they can provide pieces of the clinical picture that simply aren’t available through a screen.

So perhaps the question isn’t whether telehealth is good or bad. Perhaps it’s when should telehealth become triage?

I believe there are circumstances in which concerning symptoms should trigger an in-person evaluation or higher level of care…..particularly when treating vulnerable or higher-risk populations. Suicide risk is not distributed equally across the population, and risk factors, symptoms, history and clinical presentation should matter when determining the appropriate level of assessment.

And if “television” is the only available access point, shouldn’t we be especially intentional about using evidence-based guidelines and validated screening tools to help identify risk?

Take the PHQ-9, for example. Many of us have completed it at a doctor’s appointment. It is a standardized and validated depression screening tool.

A depression screening tool.

It is not an anxiety screening tool.

That distinction caught my attention while watching the Clancy trial because postpartum anxiety was part of her clinical presentation.

Reddington also questioned the psychiatrist about the Edinburgh Postnatal Depression Scale (EPDS), a standardized and validated 10-question screening instrument developed specifically for use during pregnancy and the postpartum period.

HER PSYCHIATRIST NEVER heard of it and testified that she did not use the EPDS.

That doesn’t automatically mean the care was wrong. The PHQ-9 itself is a legitimate screening instrument, and no questionnaire replaces a comprehensive psychiatric evaluation….

But it raises a larger question for me:

When providers are offering psychiatric care virtually, especially to someone presenting with significant postpartum anxiety, depression or suicidal thoughts, shouldn’t the limitations of the screen make comprehensive risk assessment even more important?

I have tried virtual talk therapy myself. After a couple of sessions, I noticed my therapist becoming distracted, possibly texting, with her grandson playing guitar in the background. I did enjoy the cat walking across the screen, though.

I digress.

Another theme from this trial that I cannot stop thinking about is the discussion surrounding suicidal thoughts and whether someone was considered an emergency because they did or did not have a specific plan.

A suicide assessment is more nuanced than a single question:

“Do you have a plan?”

Having a plan certainly matters. But so does intent, access to means, previous attempts, escalating symptoms, psychiatric history, protective factors, medication changes, agitation, hopelessness, RISK FACTORS?

Telehealth can be an extraordinary access point. It can connect people with clinicians when geography, transportation, childcare, staffing shortages or countless other barriers might otherwise leave them with nothing.

But sometimes an access point needs to become a triage point.

Please don’t interpret any of this as me assigning blame to one individual. These are questions and thoughts I have had while watching this case unfold.

As both a mother and a healthcare provider, I have tremendous empathy for everyone affected by this tragedy, most especially three beautiful children who were its ultimate victims.

I will continue following along with the rest of the online “TikTok jurors.”

But beyond whatever verdict ultimately comes from this courtroom, I hope this case forces a much larger conversation:

How do we make mental healthcare more accessible without allowing convenience to replace comprehensive care?

Because access matters.

And so does knowing when a screen is no longer enough….

XOXO @kbyoganp

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