Telepsychiatry Exposure, Interest, and Intention to Use Among Young Psychiatrists in the Philippines

ARTICLES and ISSUES | PJP 2020 Combined Issue

Joffrey Sebastian E. Quiring, MD, EMSRHS, FPPA

Department of Behavioral Medicine University of the Philippines-Philippine General Hospital

Published: January 2020
DOI

ABSTRACT

OBJECTIVE: This was a descriptive study to determine the telepsychiatry exposure, interest, and intention to use among young psychiatrists in the Philippines in December 2014. METHODOLOGY: This was done through a 14 to 25 item online survey adapted from Glover et al. (2013)1. Through purposive sampling, the population of third and fourth year residents and graduates within the last two years of accredited psychiatry training institutions was included in the study. RESULTS: Seventeen young psychiatrists participated. Exposure to telepsychiatry of the respondents varied with 10 (58.82%) having had independent study, three (17.65%) having had didactics, and 11 (64.71%) having had awareness about telepsychiatry initiatives in their training institution. Ten respondents (58.82%) expressed interest in telepsychiatry as well as the importance and usefulness of telepsychiatry exposure. Despite this, only six (35.29%) young psychiatrists thought that telepsychiatry should be part of the residency training curriculum. As for intention to use, only eight (47.06%) respondents expressed receptiveness to it, two did not (11.76%), and seven were undecided (41.18%).CONCLUSION: Though more than half of the respondents had exposure to telepsychiatry and considered it interesting and relevant, less than half of them had any actual intention to use it in their clinical practice.

KEY WORDS: telepsychiatry, young psychiatrist, residencytraining

INTRODUCTION

Telepsychiatry is the method of providing psychiatric evaluation, diagnosis, treatment, consultation and education by a psychiatrist to a patient or client from a distance through a technological device2. It is part of the broader telemental health (TMH) initiative, which also includes telepsychology, telemental health nursing and telebehavioral health, that primarily uses video conferencing technology to provide mental health services3,4. It was the first form of telemedicine, which originated in 1959, and has since been proven to be a cost-effective intervention that can improve outcomes and patient satisfaction, with some studies claiming it to be at par with face-to-face consultation or at least “a useful alternative when face-to-face therapy is not possible”2,5. Telementoring, which is consultation between a specialist, such as a psychiatrist, and a general practitioner through video conferencing, is also an alternative way of cascading care for patients 6.

There have been few telepsychiatry initiatives in the Philippines7,8. The most prominent of these, was the program in Infanta, Quezon in 2007, which was a collaborative effort of the University of the Philippines and Philippine General Hospital’s Department of Psychiatry and Behavioral Medicine, the National Telehealth Center (NTHC), and the World Association for Psychosocial Rehabilitation – Philippines9. It was a response to the after-effects of a super typhoon in the area and the recognition of the need for psychiatric care for their constituents. The said initiative, along with a comprehensive community-based mental health program progressed and was recognized as an outstanding achievement in local government initiative and project implementation in 20119.

In the program, rural health workers based in Claro M. Recto Memorial Hospital consulted with a psychiatry consultant or resident-in-training at the UP-PGH through off-the-shelf software (skype) accessed at the NTHC on regular and scheduled dates. A pre-agreed protocol for de-identifying patients was followed as the workers presented their case histories. Diagnoses and treatment were discussed and agreed upon. Consultations were recorded in a logbook and workers were reminded to review their manual in providing mental health care in the community 10.

Other telepsychiatry initiatives were documented also in Naga City (by the UP-PGH and NTHC) and Dagupan City (by the Philippine Mental Health Association) 7,10. Anecdotal evidence also revealed a couple of established consultants who employ this practice with a few of their patients, especially those who are Overseas Filipino Workers (OFWs) who preferred to continue treatment with the psychiatrist even if they are already based outside the country.

Despite evidence to support the value of a telepsychiatry program in literature and local success stories to support it, telepsychiatry initiatives in the country have also been met with anecdotal reservations mostly from the psychiatrists themselves. While application of telemedicine in the country has progressed in the fields of radiology, dermatology, ophthalmology and surgery it has yet to be maximized for psychiatry.

Saeed et al. in 2012 identified several barriers to telepsychiatry implementation11. These are the institutional barriers, reimbursement, impact on practice, licensure, and infrastructure. Other studies identify providers, consumers, technological factors, ethical and legal concerns. Among the barriers, the providers play a crucial role to the conceptualization and success of the program.

Currently, there are only few studies about providers’ interest, technology acceptance and utilization, specifically on telepschiatry and none conducted in the Philippines. A study by Glover, et al. in 2013 among psychiatry residents and fellows in the United States revealed “practice gap between resident interest and resident exposure to telepsychiatry” 1. Psychiatry residents, fellows and junior consultants in this technological era are deemed to be generally more technologically adept than their senior consultants.

It is the hypothesis of the investigator that in the Philippines most residents, fellows and junior consultants are interested about telepsychiatry yet they have minimal exposure to it, if none at all, and are ambivalent about using it in their practice.

In the Philippines, where the health care system is predominantly consumer driven and heavy on out-of-pocket spending, telepsychiatry has its place. Being a developing country and an archipelago of 7,107 islands, access to general health care for many of its constituents have been hampered not only by poverty but also by geography. The situation for mental health is much worse, with low government prioritization as evidenced by a meager national budget and inadequate resource allocation for its program implementation and service delivery. Corollary to this, the country’s health human resources have been dwindling, with fewer applications to medical schools and the exodus of graduates to other countries, further decreasing the pool for mental health workers. Disasters in the country, which are common and come in various forms, have exposed both the growing need for psychosocial care to those affected and the lack of work force who can provide them.

This study aims to determine the telepsychiatry exposure, interest, and intention to use among young psychiatrists in the Philippines. It is intended to situate where telepsychiatry is in the Philippines and help promote greater awareness of it in the country. By identifying provider’s exposure, interest and plan to use, training curriculum and practice could be shaped, enabling the formulation of a more accessible, appropriate, affordable and culturally sensitive psychiatric care provided even to Filipinos in far-flung areas.

METHODOLOGY

This research was a descriptive study conducted in December 2014 using purposive sampling. Third and fourth year psychiatry residents and recent graduates of residency training programs (one and two years post-training) from the twelve institutions recognized by the Philippine Board of Psychiatry were invited through their training institutions and informal contacts. The whole population was included which was approximated to be about 70 young psychiatrists, based on the number of residency items per institution and past graduates.

Participants were invited through an electronic message that had a web site link to the survey. Those who fit the inclusion criteria who did not have electronic mail accounts or refused to give access to their electronic mail addresses were excluded from the study.

A survey adapted from Glover et al., with permission, was used to gather data. Survey questions were composed of Likert scales, yes/no, and multiple choice items. Questions were generated using Survey Monkey, a Web-based survey tool (Survey Monkey, Palo Alto, CA). Participants were given one week to complete the survey, with a reminder sent on the fourth day1. (Appendix 1)

This study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB) Panel prior to its conduct. All patient information was kept anonymous and confidential. Funding was shouldered by the investigator and the investigator had no conflicts of interest to disclose. This study did not claim to offer direct benefits to the participants but posited that useful material can be had for future references. There were no foreseeable risks to the participants.

RESULTS

Only 17 out of 70 (24.29%) answered the online survey. Seven (41.18%) of the 17 were third year residents, four (23.53%) were fourth year residents, four (23.53%) were one year post-residency graduates, and two (11.76%) were two years post-residency graduates. Of the 17 respondents, 13 (76.47%) reported training in a university hospital, three (17.65%) in a community hospital that was university affiliated and one (5.88%) chose the option “other.” Twelve (70.59%) respondents came from a training program that had 10-15 residents, four (23.53%) from a program with six to ten residents, and one (5.88%) respondent came from a program with five or less trainees. Majority trained in an institution based in Metro Manila, with only two (11.76%) respondents reporting otherwise.

Exposure to telepsychiatry of the respondents can be gleaned from the results presented in Table  1.  While majority had encountered telepsychiatry in their independent study, only three (17.67%) reported having formal didactics on it. And while majority had awareness of telepsychiatry initiatives in their institutions, only a few had the opportunity to observe them. Of the seven who had an opportunity to observe, four (23.53%) said that their exposure was part of a required rotation while the other three (17.67%) qualified their experience as: (1) “part of Social and Community Psychiatry (SCP) didactics;” (2) “a consultant invited us to observe”; and (3) “previous program in collaboration with PPA on telepsychiatry for OFWs.” It is important to note that in the questionnaire, multiple responses could be provided for this question. (Table 1)

As for the location of telepsychiatry, three (17.67%) respondents said they were situated in a public outpatient office when they observed a telepsychiatry initiative, while four (23.53%) said “others.” When asked to specify, three (17.67%) of the responses pertained to the National Telehealth Center located at the UP-PGH while the other response was: “recorded videos of common clinical conditions uploaded in the website”. On the other hand, the patient’s or client’s location during the consultations were mostly in a public outpatient office (five out of seven or 71.43%), while one  (14.29%) was specified as “barangay hall” and the other as “OFW.”

For the question on time spent as observer in a telepsychiatry initiative, five out of the seven (71.43%) respondents said they had a single encounter and only two (28.57%)  respondents had multiple encounters, five hours or less total of patient contact. For the seven who had an opportunity to observe a telepsychatry initiative, only two (28.57%) had an increase in interest after the experience, while the five (71.43%) said that the experience did not affect their interest level.

Interest in telepsychiatry was determined by 3 questions. Table 2 presents the proportion of young psychiatrists who manifested interest in telepsychiatry. While majority of the respondents showed interest in telepsychiatry and appreciated its importance or usefulness in residency training, only 35.29% thought that it should be included in the actual training curriculum.  Furthermore, when asked about their intention to use, only eight out of 17 (47.06 %) expressed willingness to use it, two (11.76%) did not consider using it and seven (41.18%) remained undecided.(Table 2)

DISCUSSION

The findings in this study were consistent with the results of the study of Glover et al.1. More than half of the respondents were interested in telepsychiatry and perceived it to be important but formal training or didactics on it were reported by only three respondents. It is interesting though that there were actually telepsychiatry initiatives reported and that there were opportunities for observation. The questions in the survey, however, did not discriminate whether the initiatives were current or were in the past. UP-PGH had known initiatives before and most respondents who indicated the presence of an initiative may have come from that institution. However, a description of one of the initiatives (with OFWs) did not seem to fit the UP-PGH project, suggesting that at least another institution had its own telepsychiatry initiative.

Despite these findings, there seems to be an incongruence with the fact that less than half of the respondents had any actual intention to use it in their clinical practice.

Limitations

Considering that only about a fourth of those to whom the survey was sent actually responded, the results of this study could not be generalized nor placed under any statistical test for correlation. This study only relied on responses via electronic survey that was mostly forwarded by training institution heads and had only one week for data collection. It could be expected that those who were sent the message of invitation may have not yet read the message or were too busy to forward them to the residents. The two-step dissemination of survey form may have significantly decreased the number of responses.

Another limitation for this study was selection bias, which according to Glover et al., could have manifested as “those trainees with a greater interest in telepsychiatry may have been more likely to complete the survey” 1.

A mechanism to discourage multiple answers from a single person was put in place by allowing the Survey Monkey to accept only one response from each computer. However, this may also have decreased the sample size if some institutions had a common computer with internet access. This mechanism was not articulated in the invitation to participate. It would also be possible that someone could still have answered the survey twice. Someone who did not fit the inclusion criteria could have answered the survey, since there was no mechanism to check the veracity of their demographic profile.

Similar to Glover et al.’s study, a major limitation of this study involves the lack of qualification of the variable “interest level.” 1 By adopting the same question for this variable, it was not possible to determine whether the interest level stated by the respondent was pre-exposure, immediately post-exposure or current state. While this was recognized, it was deemed fit not to modify any questions anymore, as this would have made the survey more complicated, which in turn could have discouraged participants from finishing it.

Despite its limitations, this was the first study of its kind in the Philippines. With the growing interest in telepsychiatry, a study such as this could be a jump off point for further investigation that could impact training, practice, and policy.

Recommendations

In the future, several revisions could be done in the survey form to reflect a clearer demographic picture of the respondents, such as using private and public hospital categories and linking them directly with location (in Metro Manila or outside Metro Manila). Some details in the options (e.g. required rotation) should be defined to avoid confusion. A clearer articulation of perceived importance or usefulness could also be beneficial. The variable “interest” should also be qualified and given a time frame (e.g. pre-exposure, immediately post-exposure and current state) to be able to reflect clearer associations.

Another recommendation would be to increase time for data collection and to consider administering the survey face-to-face instead. By doing so, there would be enough data to study the association between the different descriptive factors and telepsychiatry exposure, interest, and intention to use, as well as the correlation of these three variables with each other. Additionally, increasing the population of young psychiatrists to include all trainees could potentially achieve this. A more in-depth study focusing on analyzing different factors influencing utilisation of telepsychiatry in an expanded population of all practicing psychiatrists in the country (and not just young psychiatrists) should be done to better capture the telepsychiatry landscape in the Philippines, from the providers’ perspective.

REFERENCES

  1. Glover JA, Williams E, Hazlett LJ, Campbell N. Connecting to the future: telepsychiatry in postgraduate medical education. Telemedicine and E-health. 2013 Jun; 19(6):474-9. doi: 10.1089/tmj. 2012.0182.
  2. DeslichS, Stec B, Tomblin S, Coustasse A. Telepsychiatry in the 21st century: transforming healthcare with technology. Perspect Health Inf Manag. 2013 July 1; 10(Summer): 1f, PubMed PMID:  3861676; Pub Med Central PMCID: PMC3709879.
  3. Boydell K, Hodgins M, Pignatiello A, Teshima J, Edwards H, Willis D. Using technology to deliver mental health services to children and youth in Ontario. J Can Acad Child Adolesc Psychiatry. 2014 May; 23(2): 87-99, PubMed PMID:  24872824; PubMed Central PMCID: PMC4032077.
  4.  RichardsonL, Frueh BC, Grubaugh AL, Egede L, Elhai J. Current directions in videoconferencing tele-mental health research. Clin Psychol (New York). 2009 Sep 1; 16(3): 323-338. PubMed PMID:  20161010; PubMed Central PMCID: PMC2758653.
  5. Garcia-Lizana F, Muñoz-MayorgaI.What about telepsychiatry: a systematic review. Prim Care Companion J Clin Psychiatry, 2010; 12(2). doi: 10.4088/PCC.09m00831whi PubMed PMID:  20694116; Pub Med Central PMCID: PMC2911004.
  6. Rho M, ChangY, Lee J. Determinants of physicians’ intention to use telementoring: an empirical study of task technology fit and quantitative overload. International Journal of Advancements in Computing Technology, 2013 Aug; 5(12).
  7. Shahani L. Breaking stigma: the question of mental health reform [Internet]. GMA News Online: 2014 [cited 2014 Dec 12]. Available from: https://www.gmanetwork.com/news/news/specialreports/352189/breaking-stigma-the-question-of-mental-health-reform/story/.
  8. National Telehealth Center. Orientation and training of telepsychiatry project in Infanta, Quezon [Internet]. University of the Philippines National Telehealth Center; 2008 April 28 [cited 2014 Dec 12] Available fromhttp://telehealth-ph.blogspot.com/2008/04/orientation-and-training-of.html.
  9. Galing Pook. Community-based mental health management Real, Infanta, Gen. Nakar, Panukulan [Internet]. Outstanding Local Governance Programs; 2011 [cited 2014 Dec 12] Available fromhttp://galingpook.org/wp-content/uploads/2020/05/2011galingpookwinners.pdf .
  10. Sarmiento RF. Integration of a mental health program in the programs of the National Telehealth Center of the Philippines [powerpoint presentation].2009.
  11. Saeed SA, Bloch RM, Diamond JM. Telepsychiatry: overcoming barriers to implementation.Current Psychiatry. 2012 Dec; 11(12) Available from: https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/1112CP_Saeed.pdf .

APPENDIX 1. ELECTRONIC SURVEY

(Adapted from Glover JA, Williams E, Hazlett LJ, Campbell N, 2013)1

1) Indicate your level of training
A. 3rdyearresident
B. 4thyearresident
C. 1 year post-residency training
D. 2 years post-residency training

2) Your residency training program setting can best be characterized as

A. University hospital
B. Community hospital,university affiliated
C. Communityhospital,not university affiliated
D. Military
E. Other

3) Your residency training program location can best be described as

A. InMetroManila
B. OutsideMetroManila

4) Indicate the total number of residents in your residency training program

A. <5
B. 6-10
C. 10-15
D. >15

5) Have you encountered telepsychiatry in your independent study?

A. Yes
B. No
C. Not sure

6) Does / Did your residency program offer didactic exposure to telepsychiatry such as lectures or conferences?

A. Yes
B. No
C. Not sure

7) Are / Were you aware of any telepsychiatry initiative in your training program?

A. Yes
B. No
C. Not sure

8) Choose the option that best characterizes your interest level in telepsychiatry.

A. Interested
B. Undecided
C. Uninterested

9) Indicate your level of agreement: I think that exposure to telepsychiatry is an important aspect of residency training.

A. Agree
B. Undecided
C. Disagree

10) Indicate your level of agreement: I think that experience in telepsychiatry should be a required part of residency training.

  1. Agree
  2. Undecided
  3. Disagree

11) I plan to utilize telepsychiatry in my practice:

A. Yes
B. No
C. Undecided

12) Does / Did your residency program offer any opportunity to observe a telepsychiatry initiative?

A. Yes
B. No
C. Not sure

13) Does / Did your residency program offer any opportunity to directly participate in a telepsychiatry initiative?

A. Yes
B. No
C. Not sure

14) I have had an opportunity to observe a telepsychiatry initiative.

A. Yes
B. No

(If the respondent answered Yes to question 14, he will be directed to question 15. If he answered No to question 14, he will automatically exit the survey)

15) Your clinical experience in telepsychiatry (as observer only) was:

A. Required rotation
B. Electiverotation
C. Independentstudy
D. Other (specify)

16) Please select the option(s) that best describe/s your location(s) during your clinical experience (as observer only) with telepsychiatry.

A. Privateoutpatientoffice
B. Public out patient office
C. In patient psychiatric facility
D. Emergency room
E. Other (specify)

17) Please select the option(s) that best describe/s the patient’s or client’s location(s) during your clinical experience (as observer only) with telepsychiatry.

A. Privateoutpatientoffice
B. Public outpatient office
C. Inpatient psychiatric facility
D. Inpatient, nonpsychiatric
E. Emergency room
F. Other (specify)

18) How much time did you spend as observer in a telepsychiatry initiative?

A. One time encounter
B. Multiple encounters,5 hours or less total of patient contact
C. Multiple encounters,6-20 hours total of patient contact
D. Multiple encounters,21-40 hours total of patient contact
E. Multiple encounters; greater than 40 hours total of patient contact

19) My experience in observing a telepsychiatry initiative:

A. Increased my interest in telepsychiatry
B. Decreased my interest in telepsychiatry
C. Did not affect my interest in telepsychiatry

20) I have had an opportunity to participate in giving direct patient or client care via telepsychiatry.

A. Yes
B. No

(If the respondent answered Yes to question 20, he will be directed to question 21. If he answered No to question 20, he will automatically exit the survey)

21) Your clinical experience in telepsychiatry (direct patient / client care) was:

A. Required rotation
B. Elective  rotation
C. Independentstudy
D. Other(specify)

22) Please select the option(s) that best describe/s your location(s) during your clinical experience (direct patient / client care) with telepsychiatry.

A. Private out patient office
B. Public out patient office
C. In patient psychiatric facility
D. Emergency room
E. Other (specify)

23) Please select the option(s) that best describe/s the patient’s or client’s location(s) during your clinical experience (direct patient / client care) with telepsychiatry.

A. Privateoutpatientoffice
B. Public out patientoffice
C. Inpatient psychiatric facility
D. Inpatient, nonpsychiatric
E. Emergency room
F. Other (specify)

24) How much time was spent in direct patient / client care via telepsychiatry?

A. One time encounter
B. Multiple encounters, 5 hours or less total of patient contact
C. Multiple encounters, 6-20 hours total of patient contact
D. Multiple encounters, 21-40 hours total of patient contact
E. Multiple encounters; greater than 40 hours total of patient contact

25) My telepsychiatry patient / client care experience:

A. Increased my interest in telepsychiatry
B. Decreased my interest in telepsychiatry
C. Did not affect my interest in telepsychiatry