Connecting to the Future: Telepsychiatry in Postgraduate Medical Education

Abstract

Objective: This study characterized and examined factors influencing psychiatry residents' and fellows' interest, exposure, and future plans to use telepsychiatry. Subjects and Methods: A 17-item electronic survey was distributed to 485 psychiatry residency and fellowship programs in the United States. Each program director or administrator was asked to voluntarily distribute the survey to his or her trainees. Chi-squared tests were performed to test differences in proportions. Stepwise multivariate logistic regression was used to model outcomes of interest. Results: In total, 283 respondents completed the survey. A majority of respondents were interested in telepsychiatry and felt that it was an important part of training. Of the 50 respondents who had clinical exposure to telepsychiatry and completed the survey, most reported that their experience increased their interest level, and two-thirds reported having either a one-time encounter or less than 6 h of multiple patient experiences via telepsychiatry. Clinical exposure to telepsychiatry was significantly related to level of training (p=0.001) and program location (p=0.005). Residents in their postgraduate year (PGY) 4 or fellowship were 2.6 times more likely to be exposed to clinical telepsychiatry than PGY 1–3 residents (95% confidence interval [CI] 1.41–4.95). Residents and fellows in rural programs were 4.3 times more likely to be exposed than those in urban or suburban settings (95% CI 1.07–17.28). Factors affecting trainees' plans to use telepsychiatry in their future practice include program location (p=0.013) and interest level (p<0.001). Residents and fellows in rural locations were 9.3 times more likely to report future plans to use telepsychiatry (95% CI 1.88–45.71). Conclusions: There is a practice gap between resident interest and resident exposure to telepsychiatry. Training programs should consider incorporating a brief telepsychiatry experience to fulfill both resident interest and the growing demand for psychiatrists.

Introduction

Telepsychiatry through interactive videoconferencing enables physicians to provide psychiatric care at a distance and increases access to care in underserved and remote areas. The use of telecommunications for medical treatment and education was first introduced in the 1950s via two-way closed-circuit microwave television. The growth of telepsychiatry was halted until technological advances decreased the size and cost of equipment in the 1990s.¹ Since the 1990s, the number of telepsychiatry and telemedicine programs has significantly increased. Despite the challenges of sustaining a telepsychiatry program, such as financial feasibility, administrative concerns, and inadequate technical support,² there were 116 U.S. telemedicine programs identified in 2005.³

As the number of telepsychiatry programs has increased, there have been several studies to examine their diagnostic reliability, clinical outcomes, and patient satisfaction. Researchers have established that telepsychiatry can be used to reliably diagnose a wide range of psychiatric disorders, including anxiety, depression, cognitive disorders, and psychosis.^2,4,5 Fewer studies have compared the clinical outcomes of telepsychiatry with in-person psychiatry. One randomized controlled trial found that psychiatry consultation and short-term follow-up care delivered by telepsychiatry can produce clinical outcomes that are equivalent to face-to-face care.⁶ Another study found no significant differences between depressed Veterans who were randomized to 6 months of outpatient treatment in-person or via telepsychiatry. Both groups were comparable in regard to treatment outcomes, satisfaction, adherence to appointments, and medication compliance.⁷ Initial studies indicate that overall patient satisfaction is comparable for in-person and telepsychiatric care, but provider satisfaction has been less well evaluated.⁴

Although telepsychiatry has not yet been fully integrated into routine practice, it has the potential to mitigate workforce shortages in remote and underserved areas.⁸ Recent reports indicate that the number of graduates from psychiatry residency programs is declining.⁹ Unfortunately, this trend will only further contribute to the continued shrinking workforce of practicing psychiatrists.¹⁰ The shortage of specialty and subspecialty psychiatrists is especially prominent in underserved areas. Results from a 2010 survey of rural hospital administrators found that almost half of respondents reported shortages in psychiatry, which was the most frequently reported non-primary care shortage.¹¹ Telepsychiatry has been suggested as a possible means to reduce the impact of physician shortages. A study of four non-metropolitan communities in Washington State demonstrated that telepsychiatry was a feasible and acceptable approach to providing psychiatric care to youth in areas with chronic shortages of psychiatrists.¹² Telepsychiatry has the potential not only to improve access to care, but also to reduce healthcare costs. The cost of telepsychiatry has been cited to be 10% less per patient and 16% less per visit than in-person care.⁶

As more states develop telepsychiatry programs to improve the cost, quality, and availability of mental health services, more psychiatrists will be needed in this growing field. There are no current Accreditation Council for Graduate Medical Education requirements for telepsychiatric experiences during training.¹³ In an effort to increase exposure, the American Psychiatric Association (APA) Assembly recently called upon the APA to develop an education program on telepsychiatry that will be available to all members on its Web site.¹⁴ Given provider shortages and the continued growth of telepsychiatry, training programs will need to incorporate clinical experiences into their curriculum. There are few published studies on telepsychiatry training experiences for residents and fellows. A 2008 article described the use of telepsychiatry to train residents and fellows at Cedars Sinai Medical Center Developmental Disability Clinic and cited improvement in self-assessed clinical skills and knowledge.¹⁵ A follow-up pilot study in 2011 describes similar benefits in third-year medical students.¹⁶ Another study from the University of Colorado described a model for training third- and fourth-year psychiatry residents to care for rural Veterans via telepsychiatry at Community-Based Outreach Clinics of the Department of Veterans Affairs. One important finding from this study was that a majority of residents who participated in this experience continued with clinical work at the Department of Veterans Affairs, demonstrating that exposure can be a useful recruitment tool.¹⁷

In this study, we examined the interest, exposure, and future plans to use telepsychiatry among psychiatry residents and fellows. We hypothesized that a majority of psychiatry residents and fellows would be interested in telepsychiatry but that their clinical exposure during training would be limited. We also hypothesized that residents and fellows with more hours of clinical exposure would have a higher level of interest and plan to use telepsychiatry in their practice.

Subjects and Methods

This study was approved for exemption through our Institutional Review Board committee. We performed a cross-sectional study of the prevalence of telepsychiatry interest and exposure among psychiatry residents and fellows in the United States. A 17-item electronic survey, using Likert scales, yes/no, and multiple choice, was generated using SurveyMonkey^®, a Web-based survey tool (SurveyMonkey, Palo Alto, CA). Psychiatry residency and fellowship programs in the United States were identified using the Fellowship and Residency Electronic Interactive Database Access System.¹⁸ There were a total of 489 programs identified, including 180 in general psychiatry, 121 in child and adolescent psychiatry, 58 in geriatric psychiatry, 46 in psychosomatic medicine, 43 in addiction psychiatry, and 41 in forensic psychiatry. Of the 489 training programs in the United States, contact information was available for 485 programs. The individual Web sites for the four missing programs either did not indicate that the training program existed or did not list contact information. Electronic messages were sent containing a Web site link to the survey to the 485 program directors or administrators who were asked to voluntarily forward the message to all of their residents and fellows. Participants were given 6 weeks to complete the survey, with a reminder sent at 4 weeks. Of the 485 electronic messages sent, 14 were returned as undeliverable after the initial contact, and 17 were returned as undeliverable after the 4-week reminder.

Data Analysis

Statistical analyses were performed using Minitab^® version 15.1.30 software (Minitab Inc., State College, PA) and SAS version 9.1 software (SAS Institute, Cary, NC). Statistical significance was set at p<0.05. Differences in proportions using chi-squared tests were compared. The association of independent factors and exposure to clinical telepsychiatry using stepwise logistic regression was modeled. The same method to model future plans to use telepsychiatry was used. Independent factors included the following: level of training, program location, program size, and didactic opportunities.

Results

Program Demographics

Of the 300 surveys returned, 283 (94%) were completed. Respondents represented every postgraduate year (PGY) of training, and the majority of fellows who completed the survey were in a child and adolescent program. The primary location for respondents was a university hospital in an urban setting. Respondents represented a diversity of program sizes ranging from programs with less than 10 residents and fellows to programs with more than 50 trainees. More than half of the respondents reported that telepsychiatry didactic exposure was not offered in their training program. Only one-fifth of respondents reported that their program offered direct patient care experiences using telepsychiatry (Table 1).

Table 1.

Program Demographics of Respondents (n=283)

DEMOGRAPHIC VARIABLE	NUMBER	%
Level of training (n=283)
PGY1	73	26
PGY2	60	21
PGY3	46	16
PGY4	37	13
Fellow	67	24
Fellowship program (n=67)
Child and adolescent	50	75
Geriatric	9	13
Forensic	2	3
Addiction	3	4
Psychosomatic	0	0
Other	3	4
Program setting
University hospital	195	69
Community hospital
University affiliated	66	23
Not university affiliated	15	5
Military	5	2
Other	2	1
Program location
Urban	210	74
Suburban	64	23
Rural	9	3
Number of residents and fellows
50 or more	56	20
40–49	47	17
30–39	67	24
20–29	54	19
10–19	38	13
<10	21	7
Didactics offered
Yes	60	21
No	154	54
Not sure	69	24
Telepsychiatry direct patient care offered
Yes	53	19
No	159	56
Not sure	71	25

PGY, postgraduate year.

Trainee Interest and Perceptions of Telepsychiatry

More than two-thirds of respondents were either very interested or interested in telepsychiatry. A majority also agreed that telepsychiatry direct patient care experiences were important aspects of residency or fellowship training and should be required. Despite this high interest level, less than one-third of respondents planned to use telepsychiatry after completing training (Table 2).

Table 2.

Trainee Interest and Perceptions of Telepsychiatry

	NUMBER	%
Interest level
Very interested	85	30
Interested	119	42
Undecided	63	22
Uninterested	16	6
Very uninterested	0	0
Telepsychiatry important aspect of training
Strongly agree	83	29
Agree	137	48
Undecided	46	16
Disagree	16	6
Strongly disagree	1	<1
Direct care via telepsychiatry should be required
Strongly agree	42	15
Agree	103	36
Undecided	100	35
Disagree	30	11
Strongly disagree	8	3
Trainee plans to use telepsychiatry in practice
Yes	82	29
No	39	14
Undecided	162	57
Trainees with direct patient care experience
Yes	52	18
No	231	82

Trainees with Direct Patient Care Experience

Although a majority of respondents were interested in telepsychiatry, only 50 respondents had clinical exposure and completed the questionnaire. These direct patient care experiences included required rotations, elective rotations, independent studies, and “other” rotations. A public outpatient office was the primary location for both the trainee and the patient during the telepsychiatry experience. Approximately one-third of respondents with clinical exposure agreed that their telepsychiatry experience was equivalent to face-to-face patient encounters, whereas 40% disagreed or strongly disagreed. Although a majority of respondents had either a one-time encounter or less than 6 h of multiple patient encounters via telepsychiatry, most reported that their experience increased their interest level (Table 3).

Table 3.

Trainees with Direct Patient Care Telepsychiatry Experience (n=50^a)

	NUMBER	%
Type of exposure
Required rotation	13	26
Elective rotation	14	28
Independent study	6	12
Other	17	34
Trainee location during telepsychiatry exposure^b
Private outpatient office	4	8
Public outpatient office	25	50
Inpatient psychiatric facility	4	8
Emergency room	1	2
Other	17	34
Patient location during telepsychiatry exposure^b
Private outpatient office	6	12
Public outpatient office	28	56
Inpatient psychiatric facility	3	6
Inpatient, nonpsychiatric	3	6
Emergency room	2	4
Other	10	20
Time spent
One-time encounter	9	18
Multiple encounters
≤5 h	24	48
6–20 h	5	10
21–40 h	4	8
>40 h	8	16
Telepsychiatry equal to face-to-face encounter
Strongly agree	4	8
Agree	13	26
Neutral	13	26
Disagree	16	32
Strongly disagree	4	8
Clinical telepsychiatry experience
Increased interest level	36	72
Decreased interest level	8	16
Did not affect interest level	6	12

Fifty-two respondents indicated that they had direct patient care exposure to telepsychiatry, but only 50 respondents answered the follow-up questions.

Respondents were able to select more than one answer choice.

Factors Associated with Interest Level

Four factors were found to be associated with trainees' interest in telepsychiatry. Trainees' interest level was associated with belief that clinical telepsychiatry experiences were important (p<0.001), should be required during training (p<0.001), and were equivalent to face-to-face encounters (p=0.016). Interest level was also associated with trainees' plans to use telepsychiatry after training (p<0.001). In addition, for those residents and fellows who indicated that they had clinical exposure to telepsychiatry, the number of hours spent seeing patients via this modality did not significantly affect post-exposure interest level (p=0.190).

Factors Associated with Exposure to Telepsychiatry

Level of training (p=0.001), program location (p=0.005), and didactic opportunities (p<0.001) were all significantly associated with clinical exposure to telepsychiatry. It is interesting that trainee interest level was not significantly associated with whether the trainee received clinical exposure (p=0.978). Results of the logistic regression show that trainees in their PGY 4 or fellowship training were 2.6 times more likely to be exposed to clinical telepsychiatry than PGY 1–3 residents (95% confidence interval [CI] 1.41–4.95). Trainees in rural programs were 4.3 times more likely to be exposed than those in urban or suburban settings (95% CI 1.07–17.28).

Factors Associated with Plans to Use Telepsychiatry in Practice

Two factors were statistically associated with respondents' plans to use telepsychiatry after training. These included program location (p=0.013) and trainee interest level (p<0.001). Level of training approached but did not meet statistical significance (p=0.063). The relationship between clinical exposure and plans to use telepsychiatry after training also approached statistical significance (p=0.06). Of those who had clinical exposure, the time spent in direct patient care via telepsychiatry was not significantly associated with future plans to use telepsychiatry (p=0.091). Results of the logistic regression showed that trainees in rural settings were 9.3 times (95% CI 1.88–45.71) more likely to anticipate using telepsychiatry after training.

Differences between Residents and Fellows

The survey results were further analyzed by comparing the fellows as a subgroup to the residents. Results show that fellows were more likely to be in programs that offered clinical exposure to telepsychiatry (p=0.007) and were more likely to have had clinical exposure (p=0.016). In addition, fellows were more likely to report training in smaller programs (p=0.003). There were no statistically significant differences between fellows and residents with regard to program location, didactic opportunities, interest level, beliefs that telepsychiatry was important or should be required, and plans to use telepsychiatry in future practice.

Discussion

This study highlights the gap between trainee interest and exposure to telepsychiatry. The results show that a majority of respondents were interested in telepsychiatry and believed clinical exposure is an important aspect of training. Despite trainees' high interest levels, only 21% reported that didactic exposure was offered, and only 18% had direct patient care experiences via telepsychiatry. In addition, only 29% of respondents planned to use telepsychiatry upon completion of training. These results suggest that training programs may want to include telepsychiatry experiences into the curriculum. A majority of respondents with clinical exposure reported that their experience increased their interest. Therefore, increased exposure during training may ultimately increase the number of psychiatrists practicing telepsychiatry and improve access to care.

Program directors and trainees may argue that the time constraints posed by current rotation requirements prohibit incorporating telepsychiatry exposure into training. However, a majority of survey respondents reported having either a one-time encounter or less than 6 h of multiple patient encounters. In addition, the number of hours spent in direct patient care via telepsychiatry was not found to be significantly associated with post-exposure interest level (p=0.190). This suggests that in spite of its limited nature, exposure to telepsychiatry still impacts residents and fellows.

This study also found that trainee interest level was not significantly associated with clinical exposure to telepsychiatry (p=0.978). This suggests that other factors, such as the availability of clinical and didactic telepsychiatry opportunities, may determine exposure during training. Opportunities for didactic experiences were significantly associated with clinical exposure (p<0.001), which suggests a didactic introduction may spur trainees to pursue clinical experiences. In addition, over one-third of respondents with clinical exposure described their experience as “other” than a required, elective, or independent study rotation, indicating that trainees may be seeking telepsychiatry experiences outside of their training programs. These findings further emphasize the need for residency and fellowship programs to make these opportunities available.

The limitations to this study include a small sample size. The 2009–2010 APA census estimated that there were 4,887 general psychiatry residents and 1,057 subspecialty fellows in the United States.¹⁹ Based on these figures, the survey was completed by 4.6% of the total number of psychiatry trainees. The small sample size may have affected some of the results, including the association between clinical exposure and future plans to use telepsychiatry that approached, but did not reach, statistical significance. In addition to small sample size, there may also be selection bias as those trainees with a greater interest in telepsychiatry may have been more likely to complete the survey. Also, there was no mechanism in place to ensure that respondents did not complete the survey more than once. One way to limit this possibility would have been to assign user identifications and passwords to respondents; however, it was felt that this added step would deter some potential respondents from completing the survey and further limit sample size. Another limitation is that the sample of fellows contained a majority of child and adolescent trainees compared with the other fellowship programs surveyed. As a result, the comparison of residents to fellows may be biased by an over-representation of child and adolescent fellows.

Another limitation of this study involves the characterization of trainee interest levels. Respondents were asked to characterize their interest level in telepsychiatry; however, the survey question did not specify whether this was pre-exposure or post-exposure interest. As a result, we were unable to determine if interest influenced clinical exposure or if clinical exposure influenced interest. The survey did ask respondents who had direct patient care experiences to characterize their post-exposure interest level, and most reported increased interest after their experience.

Despite these limitations, this is the first study in the United States to characterize trainee interest and exposure to telepsychiatry. It included not only general psychiatry residents, but also fellows in various subspecialty programs. This study provides a starting point for future studies in that it makes clear the interest in telepsychiatry and demonstrates the current gap in meeting this interest. Studies are needed to further examine the different methods of implementing telepsychiatry experiences into training.

Conclusions

This study reveals that among U.S. psychiatry residents and fellows who completed the survey, there is an interest in telepsychiatry that is not being consistently met by training programs. As the population continues to grow, the demand for psychiatric physicians will also increase. One way to meet this need is to expand telepsychiatry services and also to ensure that trainees are exposed to and comfortable with using this medium of service delivery. As telepsychiatry programs continue to become more integrated into routine practice, the need and quality of telepsychiatry exposure during training should be further evaluated.

Footnotes

Disclosure Statement

No competing financial interests exist.

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