When Virtual Reality Becomes Reality

Written by Ashok Bhattacharya M.D., FRCP(C)

March 23 2020, 1:00pm

I was sitting across from my patient watching the words escape from her mouth as she inspired to make them. Then she exhaled…no mask, no gloves, no gowns. I was more than 6 feet from her face. I was listening, I really was, but there was something in the back of my mind. What if she has COVID? I was ‘wiping down,’ and had a few bottles of Purell salvaged from the box the Ministry of Health sent during the 2003 SARS crisis. I felt like a lonely soldier, low on ammunition, nervously defending a post as the enemy closes in. I couldn’t see or hear this foe—I could feel it. I should stay…but should I run? Dedicated doctors often suffer from presenteeism. I stayed.

The Practice

I have been practicing psychotherapy since 1986. I graduated in 1989 from the University of Toronto in the specialty of Psychiatry. The 1980’s marked the end of the dominance of psychoanalytic theory and the explosive beginnings of the biological revolution spearheaded by Prozac. For the first time, patients were asking to be placed on an anti-depressant: an SSRI. The arm-twisting efforts to encourage compliance with the tricyclic antidepressants were antiquated.  The vicissitudes of the mind had become the chemicals of the brain.

Setting up my practice was easy; I just opened the doors to my moonlighting practice a little wider. In two weeks, I was full and had more referrals than I could cope with. I started out doing 60-hour weeks. I know, this is a recipe for burnout. Since 2014, I have been presenting at conferences on the topic of burnout. By the time COVID-19 hit, my regular caseload was 45 hours a week. I see a lot of couples [Oakville has a high divorce rate], victims of PTSD, and depressed/anxious clients raging in age from 20-80 years old.  Being a psychiatrist is the only career I seriously considered. It’s the only reason I went to medical school. I love my job. I know that sounds cliché, but it never ceases to amaze me how you can aid a person by assisting them to alter their narrative. Yes, I am a psychotherapist at heart.

March 26 2020, 6:00pm

My patient emailed me, “I have a high fever and a cough.” She’d been tested. “I won’t know the result for a week.” My denial crumbled like a wall of salt being hit by a tidal wave. I realized my post was already surrounded, I had run out of ammunition, and the invisible enemy was here. “Scotty, beam me up!” There was no Scotty; there was virtual care. That was the last time I saw a patient in my office. I was scared, and I felt like a fool. I had put myself in this place. I’m the doctor! How could I put my patients and myself at risk? I felt shame. (Her test was negative. I’d dodged a bullet.).

Virtual Platforms

I applied to OTN to use the site to conduct eVisits with my patients. On March 23 2020, I downloaded Doxy.me, one of the virtual care tools curated by OntarioMD on OntarioMD.News. Luckily, my tech-savvy daughter was visiting, so she could help her old dad with the inevitable stupefying moments of learning a new computer technology. Incidentally, she lives in Italy and was stuck in Ontario during Italy’s worst times with COVID. She has since managed to return to Italy safely.

The Learning Curve

I was one of those ignorant die-hard believers in face-to-face therapy. Previously, if someone told me they had a ‘virtual session,’ I dismissed it as an irrelevant experience that couldn’t possibly replace a three dimensional ‘in the room’ session. I was utterly and completely wrong. The virtual experience became easy once the technology became familiar.

Advantages of Virtual Care

  • Patients can see me in the comfortable surroundings of their home. They are more relaxed, they haven’t had to commute, they don’t need to find a parking spot, and are ready for the session immediately.
  • Patients seem more motivated; like me, they have to work a little harder to make an impression on a little screen. It captivates them. They are also less intimidated by the ‘doctor’s office’ vibe. Their waiting room is their own familiar surroundings. They don’t have to spend their time reading out of date magazines in a waiting room full of sniffles.
  • Since TV, we have become used to learning from a screen. It’s a great teaching tool, and I have developed many props that make explaining things much faster. It’s as if you are the presenter and PowerPoint slide in one.
  • Sessions are much easier to close especially for the ‘sticky patient’ who has trouble with the session ending.
  • In a normal office visit, you see the patient and they see you. In a virtual session, you can see yourself, how you come across, and your facial expressions. Finally, you can see what your patient is seeing. Initially, it was a bit of a shocker. But like a golfer learning how to improve their swing, it’s very helpful to see yourself wind up and follow through from a third person perspective. In psychiatric training, you may watch a video of you interviewing, but with virtual care, you see yourself in real time. It has definitely improved my technique.
  • Face masks are a new reality for enclosed spaces. With virtual care I can see my patient’s face, and they can see mine. I can’t imagine someone crying vigorously while wearing a mask.
  • If direct physical procedures are not required, virtual care is the pinnacle of physically distanced medical care during a pandemic caused by an infectious agent.
  • Thankfully, it doesn’t come up often, but physician safety—especially when you’re alone in an office with a volatile, or dangerous patient—is much less of a worry with virtual care.

Disadvantages of Virtual Care

  • With some patients, especially those who live in close quarters, privacy has been a problem. They may take the call in their car, garage, bathroom, or behind a tree in their backyard. My office is very private and those clients prefer that environment.
  • Virtual platforms require solid Internet connections. Drops and disconnections do occur. I simply advise my patients at the beginning of the session that if we get cut off, we may have to use the telephone to continue the session. Luckily, this rarely happens.
  • Virtual care cannot replace direct patient contact for many necessary medical procedures at least with the present technology.

A Success Story with Virtual Care

My patients who suffer from Post Traumatic Stress Disorder (PTSD) are all doing better. Initially, I didn’t know why. I think the physical separation and the virtual distanced format make them more comfortable, less triggered, more grounded, and able to focus on the psychological effects of their trauma. We can get to those psychological issues faster and achieve a deeper quality in the work. Therapeutic progress seems to be occurring twice as fast as office-based care. Interestingly, the men appear to be benefitting more from the virtual experience than the women. I think men are more comfortable sharing their feelings when they are not facing someone, especially another man. In office sessions, men don’t cry as much as women in therapy session. They do now in virtual care! Those patients have all asked me to see if we can continue with virtual care after the pandemic is over. I hope we can.

After an intense session with a patient with severe PTSD, I may worry about them getting home safely especially if they were very dissociated. That worry is gone. With virtual care I can quickly and easily check in with them and improve continuity of care. That ‘bridge’ between sessions is allowing the therapy to have a steadier flow. Patients are calmer and I feel more confident as a therapist.

Future Plans with Virtual Care

I am hoping that virtual care will be a substantial part of my psychiatric practice going forward. No more ‘snow days’, no more ‘empty hours,’ and a huge saving in time for patients with the elimination of transportation issues. As technology improves, I think this could surpass the ‘office visit’ as the gold standard for psychotherapeutic care.

It’s likely that there will be events in the future that will require us all to physically distance ourselves again. With a foundation of well-established virtual care, we will be ready to act immediately, and not be that lonely soldier standing guard in a battle that can’t be won. Virtual care is safe, easy, and the right thing to do.  

About the Author

Dr. Bhattacharya graduated from Memorial University Medical School in 1984. He completed his specialty training in Psychiatry at the University of Toronto. Since 1989, he has been in private practice as a psychotherapist for individuals and couples. He has been married for 33 years, has three adult children, bikes and runs, and writes, records, and performs musically.

He is the author of two books:

CAKE   A Guide to Reciprocal Empathy for Couples 2006

Deep Fried Nerves   A Study of Burnout in Doctors 2016

Virtual Care is Here to Stay – by Dr. Darren Larsen, Chief Medical Officer, OntarioMD

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The last four months have seen the rapid rise of the use of virtual care tools in practice.  This has been a remarkable change. Doctors went from about 7% use of virtual care to 89% of primary care physicians using a virtual care tool, and 80% of all visits happening virtually. Due to the rapid spread of the coronavirus pandemic, doctors and nurses went straight into problem-solving mode (which I am very proud of, I must say!) and changed the way we provide care almost overnight. Having said that, there are major gaps in care that we must get to very soon or the downstream effect will be a challenge.  Virtual care is here to stay. The horse is out of the barn and cannot really be corralled again, but some order needs to be applied to the current disarray.  Where do we need to direct our attention next? 

1) Provision of virtual care in some of our most challenging care environments:  long-term care and congregate housing like group homes for disabled adults, shelters, hospices, jails, etc., are perfect examples.  Some of these places have started to apply virtual care.  Many have not.  There needs to be a consistent approach to making sure location and living conditions are taken into account and prioritized. 

2) Many medical problems require examination and the laying of hands to diagnose or treat.  Paramount at this point in time is cancer screening, preventative health visits, palliative care, lung disease, neurological disorders.  How will we do better with virtual to get these programs up and running again?  We will have ago to rethink our processes.  Physical exams are still possible virtually, but they take on an entirely different form.  This will require retraining and knowledge transfer. 

3) We must focus on areas where inequity of care prevailed before COVID-19; remote communities with poor internet access, indigenous communities, homeless communities, refugees and recent immigrants are all at a disadvantage when it comes to high tech solutions like video visits.  The reasons are obvious.  They must be faced head on and planned for.  The approaches needed here will be different. 

4) Some high-risk areas are left behind: seniors care, the mental health system, and home care come to mind.  We must pay attention to these as they are ripe for care redesign and virtual care may actually be very impactful. 

5) Integration of products into the point of care is important. This largely does not happen now.  For this, we require APIs from EMRs and hospital information systems, rules allowing open data flow and a reduction of the competitive nature of the virtual care and data business.  We need a more unified approach focused on creative co-design and outcomes. 

6) Standards for virtual care tools are important now, and certification to these standards must follow to ensure safety. “Caveat emptor” thinking applied at the start of the pandemic crisis, but we are past that now. Security and privacy can and must be guaranteed.   

7) Attention to the blending of virtual and in-person care is needed.  We can never be permanently ”all virtual” or even “80% virtual”.  In a recent CMA survey, 60% of patients stated that they still want an in-person visit as the first option for their new problem  This is because we are human, and trust between humans evolves by looking into each other’s eyes, interpreting body language, and even holding a hand in tough times. This is important as the physician-patient relationship is special, and trust matters. 

OntarioMD is helping to lead the pace of change for clinicians in adopting virtual care.  We want to be there for you.  You are living the change and crafting your practice for excellence in real time.  We need your ideas about where your energy in making your technology life better is best spent.  I encourage you to bring them to us.  We are developing a plan for the future that responds to your practice needs.  Help us design it.  Reach out to me with ideas at darren.larsen@OntarioMD.com.