From the Editor

After a short break, the Readings are back. And the world has changed over these past weeks.

We are all dealing with the stress of the pandemic, both at home and at work. I spoke recently with a physician who is a young mother, and she talked about balancing her different obligations, and working to keep her patients and family safe.

These are challenging times.

I want to acknowledge the frustration that we all have, particularly the PGY5s, who are so close to completing their studies but have had their Royal College examination postponed. It’s a tough moment for our young colleagues. But I have a few grey hairs, and have seen tough moments come and go – and I believe that things will work out just fine.

This week’s Reading includes three selections.

In the first selection, we consider innovation in the age of pandemic, with a new NEJM paper by Drs. Judd E. Hollander (of Thomas Jefferson University) and Brendan G. Carr (of Sinai). They discuss telemedicine and COVID. “Disasters and pandemics pose unique challenges to health care delivery. Though telehealth will not solve them all, it’s well suited for scenarios in which infrastructure remains intact and clinicians are available to see patients.”


Then, we take a practical turn. Many of us clinicians use telemental health; with COVID, many more are thinking about taking the virtual care plunge. In the second selection, we consider a new podcast discussing telemental health. I talk with Dr. Allison Crawford of the University of Toronto. And, yes, she has tips on how to up your virtual care game. And to those thinking about using telemental health, she offers simple advice: “Do it. Try it.”

Finally, in the third selection, we look at a NYT essay by an astronaut. Thinking about his time and isolation in space, Scott Kelly provides some clever advice. “I’ve found that most problems aren’t rocket science, but when they are rocket science, you should ask a rocket scientist.”


Selection 1: Virtually Perfect? Telemedicine for Covid-19

Judd E. Hollander and Brendan G. Carr

The New England Journal of Medicine, 11 March 2020


Recognizing that patients prioritize convenient and inexpensive care, Duffy and Lee recently asked whether in-person visits should become the second, third, or even last option for meeting patient needs. Previous work has specifically described the potential for using telemedicine in disasters and public health emergencies. No telemedicine program can be created overnight, but U.S. health systems that have already implemented telemedical innovations can leverage them for the response to Covid-19.

So begins a paper by Drs. Hollander and Carr.

The authors focus on some innovation using telemedicine:

  • They note that many hospitals are using “forward triage” – “the sorting of patients before they arrive in the emergency department (ED).” This involves: “Direct-to-consumer (or on-demand) telemedicine, a 21st-century approach to forward triage that allows patients to be efficiently screened, is both patient-centered and conducive to self-quarantine, and it protects patients, clinicians, and the community from exposure.”
  • “Health systems have developed automated logic flows (bots) that refer moderate-to-high-risk patients to nurse triage lines but are also permitting patients to schedule video visits with established or on-demand providers, to avoid travel to in-person care sites.”
  • “Electronic intensive care unit (e-ICU) monitoring programs, which allow nurses and physicians to remotely monitor the status of 60 to 100 patients in ICUs in multiple hospitals – such as services offered by Mercy Virtual Care Center, Sutter Health, and Sentara Healthcare – are ideal for monitoring sicker patients.”
  • And care has been moved closer to home: “Houston’s Project ETHAN (Emergency Telehealth and Navigation) has used telemedical oversight by physicians to augment care offered in person by 911 responders, reducing the need for transportation to the ED. In the face of Covid-19, Avera Health is preparing to send mobile home health care units directly to patients and is coordinating home-based testing. For sicker patients at home, such programs can facilitate evaluation before hospital transfer, potentially allowing them to bypass the ED and be placed directly in a hospital bed, reducing exposure for health care workers and other patients.”

The essay is concise and thoughtful, and makes a strong case that telemedicine has been invaluable during this pandemic – and beyond.

Of course, the paper doesn’t discuss telemental health directly. But it’s clear that a larger role for virtual care exists for psychiatry, where therapy and consultations can be provided without patients needing to leave their homes (and perhaps their self-isolation).

Telemental health is hardly new. Disruptive moments, however, accelerate change.


Selection 2: “What every physician should know about telemental health”

Allison Crawford and David Gratzer

Quick Takes Podcast, 25 March 2020


Mental health care is changing as we use technology to deliver services. What to make of it all? I sat down with one of the leading experts in telemental health, Dr. Allison Crawford, to discuss how it’s used in clinical care today – and what tomorrow may bring.

On the advancement of technology:

“It’s true: [in the past, we needed] monitors the size of this room. Now you can do it on your phone if you wanted to, and certainly on a desktop computer.”

On her big tip for providers:

“Do it. Try it. Don’t be afraid of it – that’s probably the number one.”

On practical advice:

“Don’t forget about privacy and confidentiality. So, for example, there are still prescribed ways that we can offer telehealth. You can’t do it on Skype or on Facebook. It has to be an accredited provider. Right now, those are all through the Ontario Telemedicine Network in Ontario, but I’m sure each province has guidelines around that. And don’t forget getting informed consent. It really is up to the individual provider to assess the capacity of the person in front of them on telehealth, about whether they’re suitable to receive telehealth, consult or treatment. And that needs to be documented in the chart, so don’t forget to do that.”

On the future:

“We’ll see very seamless integration. So when you open the electronic health record, there’ll be a button there, and you can connect with the client via that button… So it’s not going to feel like a lot of extra steps and it’s not going to involve really specialized equipment.”

img_7586_revisedInterviewing Dr. Crawford

The podcast can be found here, and is just over 17 minutes long.


Selection 3:I Spent a Year in Space, and I Have Tips on Isolation to Share

Scott Kelly

The New York Times, 21 March 2020


Being stuck at home can be challenging. When I lived on the International Space Station for nearly a year, it wasn’t easy. When I went to sleep, I was at work. When I woke up, I was still at work. Flying in space is probably the only job you absolutely cannot quit.

But I learned some things during my time up there that I’d like to share — because they are about to come in handy again, as we all confine ourselves at home to help stop the spread of the coronavirus. Here are a few tips on living in isolation, from someone who has been there.

So begins an essay by Kelly, a retired astronaut.

He offers tips. We highlight six of them:

Follow a schedule

“On the space station, my time was scheduled tightly, from the moment I woke up to when I went to sleep. Sometimes this involved a spacewalk that could last up to eight hours; other times, it involved a five-minute task, like checking on the experimental flowers I was growing in space. You will find maintaining a plan will help you and your family adjust to a different work and home life environment.”

Go outside

“For an astronaut, going outside is a dangerous undertaking that requires days of preparation, so I appreciate that in our current predicament, I can step outside any time I want for a walk or a hike – no spacesuit needed.”

Keep a journal

“NASA has been studying the effects of isolation on humans for decades, and one surprising finding they have made is the value of keeping a journal. Throughout my yearlong mission, I took the time to write about my experiences almost every day.”

You need time to connect

“Even with all the responsibilities of serving as commander of a space station, I never missed the chance to have a videoconference with family and friends… Technology makes it easier than ever to keep in touch, so it’s worth making time to connect with someone every day – it might actually help you fight off viruses.”

Listen to experts

“I’ve found that most problems aren’t rocket science, but when they are rocket science, you should ask a rocket scientist.”

The best line of the essay.

We are all connected

“Seen from space, the Earth has no borders. The spread of the coronavirus is showing us that what we share is much more powerful than what keeps us apart, for better or for worse. All people are inescapably interconnected, and the more we can come together to solve our problems, the better off we will all be.”

This is a nice essay. Who knew an astronaut had such practical COVID advice for us clinicians and our patients?


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.