Telehealth Burnout and Boundaries With Dr Steven Chan

(Part 2 of 2)

In a live Q&A session at the recent Psych Congress Regionals virtual meeting, Psych Congress Steering Committee member Steven Chan, MD, MBA, answers questions from the audience about note-taking best practices, burnout, and how to set standards with patients for telehealth sessions.

In this excerpt from the session, Dr Chan also discusses how clinicians’ office setup, ergonomics, and scheduled breaks are important to provide the best telehealth care possible to patients.

In the previous part 1, Dr Chan and Dr Jain converse about the benefits of telehealth, prescribing psychostimulants remotely, and the future of the practice.

Saundra Jain, MA, PsyD, LPC moderated the “Ask the Experts” discussion with Dr Chan addressing best practices for providing telehealth care.

Read the transcript:

Dr Saundra Jain: This is an interesting one that I imagine if we were meeting in person, we could just ask for a show of hands. This clinician wants to know, how do I deal with online fatigue and exhaustion?

Dr Steven Chan: Oh, my goodness. So, you know, it's incredible, I think with what Zoom has allowed us to do? Right. And remotely. But we also feel exhausted, even if we were in-person too, not just during zoom sessions or telehealth sessions. So thinking about ergonomics, but also the comfort for your own office set up, is going to be important so that you can work at your best. So, thinking about how your table is set up, how is your chair set up, how the computer is set up as well?

And if you're able to use 2 monitors and having enough light as well. And making sure that there are enough scheduled breaks so you can stretch and move around to also give yourself some time so that you can relieve your eyes of any sort of strain from looking at the computer monitor for too long. It's going to be important.

So there are a variety of techniques to do that. And finally, remembering to take do some yoga and exercising during the day, maybe midday, can be helpful.

So, there's a lot out there to learn. And what's you know, I think that there's no one silver magic bullet with a lot of these techniques. But I do think it is exciting that we can use a variety of options to tailor it to our own needs to reduce Zoom fatigue.

Dr Jain: Yeah, and as you were describing that, Steve, I was kind of thinking back when we were still meeting in the offices with our patients, and how many times have we all experienced this or heard our colleagues talk about seeing too many patients in one day, not having a break, working through lunch, sitting all day long without getting up and moving around other than to walk to the waiting room and back?

And so I'm wondering, maybe there's not a gigantic stretch between good self-care, whether it's online or whether it's in person, that those are really helpful wellness techniques. That whether we're doing this virtually or in person. It would behoove us to keep this conversation going.

Dr Chan: Absolutely.

Dr Jain: Here's another one on self-care. And again, I've tried to be as transparent today during Q&A as I could be as a clinician. Some of my notetaking is a little bit in arrears. Notice I said “a little bit”, but this clinician must be related. They're saying, “I'm so behind on my notes that I find myself writing the notes later and later. Dr. Chan, how do you deal with this? How do you get your notes done in a timely fashion?”

Dr Chan: Yeah, you know, I think that in the Clinical Informatics, the study of technology in health care settings, a lot of folks call this “pajama time”. This is when we're in pajamas and we're also logging on to the electronic health records system to try to get notes and work done. And, you know, having that power is incredible. But at the same time, the boundaries are broken there because one night can easily become multiple weeks in a row, or multiple months ,or multiple years in a row trying to get notes done.

Getting notes done during the day is important. Getting it done during the encounter can really, really help speed things along. So that you don't feel overwhelmed at the end of the day. When I was in training and practice, I remember having to get feedback that I was submitting notes a bit too late. Days late, when I should be doing it, during the same day. Not only is it good practice, but also it relieves your mind of having a lot of the knowledge of the encounter hang around.

So, during the encounter, find ways to get notes done. Type during the session, or you can have a time when you're doing no typing at all, just dedicated to eye contact, one on one talking, and then having a segment of the conversation where you're doing more computer time, typing things in and also sharing the screen so you feel like you're collaborating with the patient. I often would have the screen positioned between the patient and myself so that I can move the screen, so that I can point at things while we're talking. And that way I can just ensure that things in writing are accurate, but also so that they feel that they have a say in any sort of decisions that are made in terms of their medications and such.

A few other useful tips. Copying and pasting the plan to their discharge papers can help so that they get a copy of what you both have talked about. And then finally, having the keyboard shortcuts can really save time. So, a variety of ways to get those done.

Dr Jain: Great advice. And I love the one I was going to say a moment ago, as you were describing it, sharing the screen so that it's more of a collaborative, shared decision making and making them part of the experience. That's really great advice.

All right. We have maybe 3 or 4 minutes. So, I definitely want to share a few more questions with you, Steve. Here's one about metabolic changes. Asking, “How concerned are you about metabolic changes with low dose SGAs when prescribed in telepsychiatry when the monitoring is not accessible?”

Dr Chan: You know, I think that it's important to continue monitoring it. I know that within our institution, for instance, they still look and see whether such labs are done in a timely manner.  So, for instance, the second-generation antipsychotics, as folks know, it's going to be important to look at weight, lipids, cholesterol changes and such.

So finding ways to collaborate with other doctors, for instance, other providers who are also ordering labs to streamline the labs so that they're done at the same time can help motivate people to just get it all done at once. Instead of having to go back and forth between the lab and clinic and their home. So that's one idea.

The other idea certainly would be finding other barriers to getting labs done. I think with covid-19 initially, back last year, we were discouraged to get labs and actually encouraged to reduce people's risk of exposure to others. Thankfully, I feel like in most places, we're doing a lot more lab work such that it's not as much of an issue. If folks are concerned about exposure or folks are having other barriers.

I think it's a great time to have some motivational interviewing and seeing if there's any roadblocks that you can both try to plan around. So those are just some initial thoughts.

Dr Jain: Yeah, love it. Well, we are down to a couple of minutes and a question just popped up in Q&A, and we've not had anyone ask this before. So I'm going to toss it out to you, Steve. I think we could spend a good 10, 15 minutes just on this question. But maybe if you could just kind of hit some high points, I think it's worth addressing.

So clinicians says, “I love the flexibility of telepsychiatry, but I worry sometimes that it's just a little bit too relaxed,” and the person gives examples, “sometimes patients show up for video visits half dressed. They might be lying in their bed or in their bedroom. They could be driving in their car or sometimes even they're taking the call or the video call in a public space. How do you approach these kind of issues? Any tips you can offer for keeping someone engaged during the visit?”

Dr Chan: Setting parameters for visits up front will be important. Similar to how you might ask folks to not come in half dressed to your office or no shoes, no shirt, that sort of thing. And so you can set those parameters ahead of time. But also, during the visit at the start, you can say, you know, “I'm concerned. I've noticed this happening and I'm concerned about why. I'm noticing that you are in Home Depot on speakerphone and I'm concerned about privacy.” “I'm noticing that you're in the car with 5 other people. And I'm concerned that when we talk, we might not get into some sensitive detail. So for the best possible care, I'm going to recommend that..” you can give options, certainly go to a private space… “we reschedule or we just hit some highlights of some things that you feel comfortable talking about, and then ending the session early.” But it can happen. And I, I think reducing the frustration and thinking about solutions can be helpful.

Dr Chan: Yeah, I love what you said about being proactive and up-front before it becomes a problem.

Well, thank you so much, Steve. We so appreciate you spending time with us this afternoon, because really having these conversations is so important to us. I agree that we're probably looking at some hybrid version of this moving forward. So, it seems that telehealth telepsychiatry is here to stay and I hope that we continue to have these fireside chats, if you will, and continue this important conversation.

Dr Chan: Thank you so much for having me.

Dr Jain: Yes, of course.

Reference:

Chan S, Jain S. Ask the Expert: Telepsychiatry. Presented at: Psych Congress Regionals; July 16–17, 2021; Virtual.