The Telepsychiatry Advantage Episode 2

The Telepsychiatry Advantage

Episode 2: How to Create a Professional Telepsychiatry Setup that Builds Patient Trust

Hi everyone, and welcome back to The Telepsychiatry Advantage. I’m your host, Dr. Edward Kaftarian, and I’m the chairman and CEO of Orbit Health Telepsychiatry. The longest running telepsychiatry company in the world. 

I want you to imagine a patient walking into your psychiatrist office for the very first appointment. They’re anxious. They’re vulnerable. 

When they walk into the room the room is pitch black, except for a bright window directly behind the doctor’s head. The doctor’s face is completely in the shadows. You can’t read their expressions. And on top of that, there’s a loud metallic humming noise echoing through the room, making it almost impossible to hear what the doctors say.

Now the doctor is not maintaining eye contact with the patient. The doctor is continuously looking down. How do you think that patient would feel?  If a patient walked into a physical clinic like that, they would turn around and walk right back out. Probably. Or at least they wouldn’t want to come back. And as psychiatrists, we spend years looking how to curate our physical offices to project safety, warmth and professionalism.

We buy comfortable chairs. We adjust the lamps. We use white noise machines to protect privacy. But the moment we switch to telepsychiatry, some of us completely forget about that. Every single day highly skilled psychiatrists unknowingly create a terrible environment digitally. When you practice remotely, your video feed is your clinic. If your lighting is awful, if your camera angle is condescending, or if your audio is echoing, the therapeutic alliance is fractured before you even say hello.

It doesn’t matter how brilliant your diagnostic skills are, first impressions matter, and the patient feels like they’re being interrogated by a witness protection documentary. Though you don’t want to convey that to the patient. You want to give the patient a great first impression. And so today we’re going to fix that. We’re going to cover some of the essentials of setting up a professional virtual clinic so that your technology gets out of the way and your clinical skills can shine. 

We’re talking about lighting, camera placement, audio and your background. Now there are other elements to a professional environment, but these are the most basic. And in future episodes, we may dive more in-depth in each of these areas, but I want to give you a general overview so that at least you have the basics and you’re not creating a really poor environment for delivering virtual care.

In fact, do some basic things and the patient experience and your experience is going to be much better. 

 

Number one: Lighting. Don’t practice in the shadows.

Psychiatry is a field that relies heavily on microexpressions. We need to see the patient’s eyes tear up a slight furrow of the brow, or flattened the effect that might be slight, so slight that your expertise of years of training would pick that up. But guess what? They need to see that from us as well. Empathy is a two way street and that is important visually. 

The light can be really suboptimal if it’s coming from the wrong direction. For example, if it’s coming from one direction in a way that’s from your left hand side or right hand side, that can make half of your light, face lit up and the other half dark. If it’s coming from the window behind you, you can be completely silhouetted. And if it’s coming from underneath, it can look like you’re telling a ghost story. And then coming from the top also gives the wrong angle for light. 

So what you need to do is to provide a light source that is front facing, diffused lighting, and you never have your primary light source behind you. You want to position your desk so that you’re either, if you have a window, you’re facing the window to let natural light hit your face. And if you’re not in a room that has a window like that, invest in an LED lighting that is diffuse, that naturally comes from the front. So the best way to provide light is an LED source that is a pane that provides diffuse lighting. Ring lights are okay as well, but you’ll notice that you can see the light, the ring light in your eye, in the camera, so that’s going to be a little bit of a distraction. And so we have some recommendations in the show notes of various lights that you could consider. We are not endorsing any of them. But we have a selection for you that you can look at. But all of them would be soft, even light that diminishes harsh shadows and instantly builds better trust with the patient because the patient can actually see you and see your expressions. You also want to make sure that the patient’s face is lit up too, with diffuse light.

 

Number two. Camera placement. The illusion of eye contact. 

One of the most disorienting things for a patient in telepsychiatry is feeling like their doctor isn’t looking at them. This happens when your camera is placed in a position poorly, or when you’re staring at a completely different monitor to read an EMR. 

So, for example, let’s say that I’m talking to you like this, where I’m speaking in a direct line and looking in a direction that the camera is not faced in. Now I change my head angle and I’m looking straight at the camera, or at least close to the camera.

Doesn’t it look like I’m paying more attention? Doesn’t it look like I care more? This is a small thing that has big implications. As much as possible, you need to look at the camera. And I get it that sometimes you’re going to have to look down at the mirror, you’re going to look at your notes, but try to simulate an office environment where even though the doctor may be consulting the computer and looking at it from time to time, they have eye contact directly with the patient.

And you want to do the same. You want to pay extra attention because that’s an area that a lot of doctors fail to address. 

So if you’re using the laptop on your desk and you’re looking down at the screen like this, your camera is shooting up your nose. And psychologically, this makes you look domineering or condescending. Also, if your camera’s mounted up high, you look like you’re diminished.

Okay, so the camera needs to be at the eye level. You can use a laptop stand. You can use a monitor arm. And again, we’re going to have some suggestions for devices that you can use to prop up your camera, and help you establish direct, eye contact with the patient or at least virtual eye contact. 

Now, what you want to do, one of the tips that you want that I can give you to help simulate eye contact is to drag the window containing your the patient’s video feed and place it toward the center of your screen, right underneath the webcam lens. Even when you’re looking at the patient’s face, in the video screen, it’s so close to where the camera is that it looks like you’re looking at the patient. So the more you can look directly at the camera, the better the experience is going to be for the patient. 

 

Number three: Audio. The unsung hero of telehealth.

So here’s the golden rule of broadcasting. That perfectly applies to tell us psychiatry people will forgive bad video, but they will never forgive bad audio. If your video is a little grainy, the patient will still talk to you. But if your audio is cutting out, echoing, it’s being interrupted, it’s picking up the sound of a dog barking or loud typing, the therapeutic connection shatters instantly. 

So you want to make sure that your technology is up to the task, and relying on the built-in microphone on your laptop or your computer is usually a big mistake. These mics are designed to pick up every single sound in the room, including the hum of your computer fan. If you still have a computer fan. You want better quality audio by investing in a dedicated external microphone. A high quality USB condenser mic that’s placed on your desk right below you, or a professional headset with a boom mic or one of those clip on microphones. They’ll isolate your voice and make you sound incredibly clear.

And additionally, if you wear headphones or earbuds, that might be a slight distraction, but that might be better than poor audio. So the main point here is audio is very easily diminished, and it can make an incredible difference in the patient’s experience and the quality of your, your, rapport with the patient. So invest in high quality audio devices and also make sure that the patient also has a device that is reasonable and, reasonably effective in transmitting the audio in a clear way. 

 

Number four:  The Background. Clean, clinical and undistracting. 

So let’s talk about what the patient sees behind you. I advise against using digital blurred or fake backgrounds. If you can avoid it. I mean, sometimes it’s unavoidable. And if your background looks unprofessional, then a digital background is probably better than an unprofessional background. Definitely. It definitely is better. And you need to make sure that you choose the right type of a digital background that shows professionalism. 

But the problem with some of these backgrounds is that they clip around your hair or make your hands disappear when you gesture, which can be really distracting for a psychiatric patient. And it just takes away from the polish of the encounter, the professionalism of the encounter. Somebody experiencing anxiety or paranoia or depression, they don’t want to be distracted by all of these things. 

Okay, so the fix is to curate your background, to have a real background, a physical one. It doesn’t have to be fancy. A wall with a nice piece of art or a bookshelf or a plant is pretty good. Try to keep it relatively neutral, tidy, professional and it signals to the patient, I’m at work, my focus is on you, and I’m a professional. 

Now, you may have noticed if you’re watching this with video, that my background has a combination of really professional things and also a couple items that make it more warm. For example, I have plants and I highly recommend plants because it gives that nice warm feel.

People love plants, I’ve never met anybody who doesn’t love a plant except for the poisonous ones. Of course. 

Now I have books in my background that show that I’m well read, that I’m keeping up to date on the psychiatric literature, and that I’m competent as a professional in this field. I also have a splash of color with a little piece of artwork that’s neutral. And then I also have this figurine here of a jujitsu man who is at top of his field and, it’s, an interesting little piece of art that can be a conversation starter.

So it’s not that your background has to be boring. You can have some interesting elements to spice it up and to, you know, make it more interesting for the person viewing it.

You don’t want to make it too distracting. You want to choose your pieces of art carefully so that they can be conversation starters, but it’s not going to be all about the artwork, and it’s not going to give the patient some sort of weird, bad feeling. Also, you don’t want the patient to be distracted by the artwork for the entire appointment.

Another thing to note is that you want to keep some of your personal touches away from the camera. I mean, it’s okay to give a little bit of your personality. For example, this jujitsu guy behind me, conveys my personality as somebody who likes to do Brazilian jiu jitsu, but I don’t have pictures of my family, I don’t have really personal things up there because you don’t want the session to be about you. And the patient is going to read deeply into everything that you display behind you. 

So I’ve worked at the intersection of psychiatry and technology for almost two decades now. I’ve partnered with doctors all over the country, mostly in California, but all over the country as well.

And I promise you that there is a great variety of how people address their virtual clinic. And I promise you, that taking 30 minutes to optimize your lighting, your camera, your audio is going to fundamentally change the way the patients respond to you online. And it’s going to make the appointment more pleasant, you’re going to achieve better rapport with your patients.

But it requires that you pay attention to it because there are a lot of doctors that don’t consider it, they don’t think about it, and as a result, they could be the best doctors in the world, but the patient gets a bad impression. 

 

 

So the goal of The Telepsychiatry Advantage is simple to raise the standard for clinicians, for systems, and ultimately for patients. And when your digital environment is flawless, the technology fades into the background and the human connection takes center stage. And that’s what it’s all about. It’s about the connection between you and your patients. 

So thank you for joining me today. Keep raising the standard.