By Cindy McGlynn
Summer 2005, Vol 8 No 4
When pediatric psychiatrist Dr. Tony Pignatiello begins a session, he makes the usual introductions, chats about the weather and laughs about the long winter. The atmosphere is relaxed and friendly and people are connecting. No small feat given that the doctor and his client aren’t even in the same room.
It’s an ordinary day in an extraordinary program – the Telepsychiatry Program run by the Hospital for Sick Children and the University of Toronto. The program began as a successful pilot project almost a decade ago. Like other programs across the country, the service is designed to address the dearth of child psychiatrists in rural Canada. Today, 14 rural Ontario communities and nine additional satellite sites are set up with video cameras and televisions so healthcare workers in remote areas can receive live video consultations from Toronto psychiatrists. Elizabeth Manson, director of the Sick Kids program, says it’s the largest program of its kind in Canada, with 75 consulting doctors providing 95 per cent of the service for Ontario, consulting on more than 800 cases a year.
Local mental health workers seek advice on everything from diagnosis to appropriate medications to therapy. “We get involved at any point along the way,” says Pignatiello, the program’s medical director. "It's important to note that we’re consultants, so we don’t treat patients; we consult with local healthcare workers on their cases. The idea is to strengthen the resources locally.”
It works like this: Someone in the community – a teacher, mental health practitioner or GP – requests a consultation for a client through the local mental health agency. They fill out a detailed assessment form, which is sent to the hub site in Toronto. Manson triages the cases by urgency, books appointments and lines up the appropriate consultant. In most cases, the consultations are made within 20 working days. Urgent consultations are dealt with within 48 hours.
The need for services is great. In Ontario, the ratio of child psychiatrists to children with mental health issues is about one to 6,148. The greatest need is in rural areas, where 18 per cent of Ontarians are served by less than three per cent of child psychiatrists. Before telepsychiatry, kids and families had to travel, sometimes hundreds of kilometres, to get help in urban centres; more often, kids simply went untreated.
The psychiatrists are paid at the rate set by the Ministry of Health, but the Ministry of Children and Youth Services foots the bill. Pignatiello says this works to the program’s advantage because it means people can access the program without a specific GP referral – important at a time when GPs are in short supply in remote communities.
Education is also an important part of the program; Sick Kids runs regular seminars in specific areas of children’s mental health. “We learned that the educational component was as valued by the front-line workers in Ontario as was the service itself because these workers simply have no educational opportunities [locally],” says Manson. “And to fly three or four people from a northern site to London, Toronto, Ottawa or Hamilton is far too expensive for most agencies.”
Often, the educational seminars are tailored to the specific cultural needs of the community. Fire-setting, for example, is a behavioural problem that is handled differently in First Nations communities, where it also has a role as a legitimate cultural activity, says Pignatiello. “Education has to focus around how to distinguish fire-setting as a normal, community-sanctioned behaviour from one that’s more pathological.”
Sitting in on a session with Pignatiello shows the technology in action. A small video camera perches atop a large TV, with the doctor sitting across the room at a table. He watches images of the clients while his image is sent out through a digital network. The video interface creates a barrier that some adults – doctors included – struggle with, says Pignatiello. But for kids, it’s a no-brainer. “Most of the kids we see tend to enjoy the process. They’re media friendly. They’ve grown up with video games and web cams. Most of them seem to think it’s wonderful,” says Pignatiello.
Just how wonderful is the program? An evaluation of the program published in a 2004 issue of the Canadian Psychiatric Association Bulletin found that clients and professionals were impressed: Families didn’t have to travel to get service and mental health workers could access an expanded knowledge base. The program has provided more than 2,000 consultations since its inception and Manson says the number grows by five percent each year.
Kathy England, senior manager for Children’s Mental Health at Algonquin Child and Family Services in Parry Sound, Ontario, says working with the telepsychiatry program has changed the face of treatment in her community. “It used to be that a psychiatrist came to town once a month from Ottawa. Other than that, we had access to a regional centre in Sudbury. But they only had two doctors and people still had to travel to get to them. The reality is that we kind of did without,” says England. “Today, our experience with Sick Kids has put psychiatry in a different light. I truly feel they are a member of our team.”
In some ways, a remote consultation is just like a face-to-face one: Practitioners strive to develop a good rapport and relaxing atmosphere. But clearly, distance and technology create a barrier between practitioner and client, which gives telepsychiatry its own unique dynamic. Here are some tips from Canadian experts on how to best navigate the technology and conduct successful consultations.
At the start of each session, consultants should introduce themselves and anyone else in the room, says Toronto pediatric psychiatrist Dr. Tony Pignatiello. Introduce the program fully and explain what’s going to happen. New clients will feel more comfortable if they understand basics like where to sit and how loudly they may need to speak. And they should be forewarned about any delay time they may notice while talking over the video interface.
Pignatiello says humour can be a good way to break through the barrier of distance. Although many kids are not intimidated by telepsychiatry’s video interface, they may be bored at the prospect of sitting in a room with a talking head on a screen. Pignatiello uses a friendly demeanor and light humour to engage and involve kids.
Lack of personal contact makes it challenging to keep telepsychiatry sessions focused. Halifax pediatric psychiatrist Dr. Herb Orlik suggests that consultants should confirm each session’s objectives at the beginning and work hard to stay on topic. Doctors should beware of the tendency for sessions to slip into what Orlik calls “general advice mode.”
Orlik says kids often become most engaged with the process when they are given control. He lets teenagers operate the camera zoom lens, letting them decide how close-up or far away the screen shot will be. "A camera on a teenager’s face can feel very intrusive. If they have control over the zoom, they can get more comfortable with the session.”
Nova Scotia is one Canadian province that is almost completely “wired.” “Our provincial department of health had tremendous foresight to develop province-wide telehealth services and fund 42 sites in the mid-90s,” says Dr. Herb Orlik, chief of psychiatry at the Isaac Walton Killam Health Centre (IWK) in Halifax. The IWK program offers mental health clinics that visit remote sites monthly and therefore have a good understanding of the specific communities’ needs and resources. The IWK also uses the network for research, conducting individual interviews with remote clients and linking up remote sites into focus groups for study. IWK also participates in Canada’s first inter-provincial telepsychiatry project, which services Prince Edward Island with travelling clinics and telepsychiatry services.
Orlik says the main challenge is that the system is under-utilized. “I think that’s a national if not international problem. Some psychiatrists embrace the program but others feel it creates more demand than they can handle. They feel it is an ‘add-on’ to their functions as doctors.”
The Alberta Mental Health Board (AMHB) launched the province’s telemental health program in a 1996 pilot project involving five communities. Its success led to a province-wide telepsychiatry service. Pediatric services are delivered province-wide on a shared-care model with organizations like the Child and Adolescent Services Association (CASA). Psychiatrist Dr. Robert Drebit says the CASA program handles about 100 cases per year. The program also offers educational seminars. Drebit says local health workers value these learning seminars as highly as the consultations: “In the city, you get support and talk to each other about cases. Rural therapists are often by themselves. They’ll have a heavy caseload and be treating children and adults. Support is so much a part of what they desire.”