It's 2:30 am on a Saturday morning and a psychiatric patient is having moderate coping difficulties over the recent loss of a loved one. He feels isolated and alone and with no one to turn to but his trusted therapist. What he does have on-hand is an emergency phone number for his therapist's answering service. He also has the numbers of several call-for-help hotlines.
Neither of these choices seem well suited to his present need to reach out to someone who he believes can help talk him through this troubling night. His, is clearly not a life or death matter, but he knows he would feel better communicating with the one person in whom he has confided the most during therapy - his psychiatrist.
A case study such as this one brings to light the controversial issue of using Social Media to enhance the therapist/client relationship. Could this patient have used E-mail and/or Social Media platforms to reach his therapist and converse with him, online? Actually, this is probably more of a "should" question than a "could" one.
Though it is unlikely - in the case above - the therapist would be awake and online in the early morning hours of the next day, a direct E-mail or a private In-mail to his Facebook account could be responded to very conveniently from the doctor's breakfast table, later that same morning. The Web exchange would certainly allow his client to express his worries and concerns in writing, while allowing the physician to review them, take a step back for careful thought before responding in a patient-centered way. This may seem logical and convenient, but it is not without several inherent liabilities. Among them are concerns about confidentiality, security, privacy, academic honesty, managing technologies in psychotherapy, timeliness of response and the clarity of the response.
Regarding the latter points, this individual was not contemplating suicide at 2:30 am on a Saturday morning, but what if he were? There are other impediments to developing more e-relationships in psychotherapy that must also be brought to light. Psychiatrists tend to be "late adopters" of new technology and, like most other physicians, do not prefer to communicate with patients outside office hours when their services are non-reimbursable.
Psychiatrists are also concerned about setting strict boundaries with their patients for a variety of professional and personal reasons. Also, E-mail and Social Media interaction is very informal and has the capability to blur the distinction between professional interest and friendship. Where does one draw the line between what is and what may not be appropriate in an electronic dialogue?
Then, there are the issues of the non-clinical business details, which are often handled by a third-party in the doctor's office. Routinely, the office manager and staff make and reschedule appointments; handle emergencies; facilitate prescriptions; answer spot questions, and clear up back-office misunderstandings often involving financial matters that doctors prefer not to be directly involved with.
For concerned psychiatrists, the ethical and legal aspects of e-mail use-including American precedents-are well covered in a recent article on e-mail and the psychiatrist-patient relationship by Recupero.
Practice tip No. 1. Ninety percent of patients who send e-mail or social media correspondence to their doctors are communicating sensitive medical information. Patients should know who has access to your e-mail. There are many security risks end-to-end on all unencrypted e-mail sent over the Internet, and patients must be so advised. They should sign prior informed consent.
E-mail correspondence outside of a secure system is indelible, it can be misaddressed, it can be forwarded, intercepted, circulated, and changed without the knowledge or permission of the sender, and the true identity of the sender of a normal e-mail is impossible to verify. Patients must also be advised that e-mail can be used as evidence in court and that it is subject to applicable rules on patient-doctor confidentiality. On open-source microblogging networks, such as Twitter, correspondence can be "cached" or copied forever on the World Wide Web. As such, it is accessible to anyone, despite the fact that the submitter retracts the original copies of "tweets. " Also, programmers with access to the Remote Application Programming Interface may retain access.
Practice tip No. 2. Take great care when addressing correspondence to anyone, patient or other care provider. Often e-mail software has an "auto-complete e-mail-address" feature so if you have 2 patients with the same first name, it is easy to send to the wrong patient. Be careful!
When writing a draft e-mail, it is easy to send it prematurely. (You mean to save the draft, but you hit Send instead. ) To avoid this, first write the e-mail and then address it. Send e-mail the way that you send postal mail: only add an address "on the envelope" when you have fully completed and signed the letter (ie, leave the "To" address blank until you have fully completed the e-mail). To reply to an e-mail, hit the Forward button instead of the Reply button. Write the e-mail and only then insert the e-mail address.
When you send a group mailing to patients, use the "bcc" (blind carbon copy) feature so that names and addresses of recipients are kept private. Avoid Reply All. The patient may have copied others, but your reply should go back only to your patient.
Practice tip No. 3. Consider the source of your e-mail chain. Institutional e-mail is a problem because the institution has access to it. Free e-mail and Internet services are best avoided because they may be accessible to unauthorized persons. The same is true for mobile devices where "eavesdropping" is possible. Open-source or searchable social networks such as Twitter or Facebook open themselves up to exponentially larger unauthorized access.
Practice tip No. 4. To use encryption software, the patient is required to also install the same software. The hassle factor of installing such software on computers on both ends of an e-mail is why such encryption software has not become standard. There are excellent Web-based services, such as e-Courier. ca, that offer the highest security possible without the installation of any encryption software. e-Courier. ca also permits massive e-mail attachments, such as CT scan results for instance, that normally would get bounced. Moreover, you receive notification when the patient has opened your e-Courier. ca e-mail.
Practice tip No. 5. Electronic exchanges should all be kept within the patient's file and the patient should be so informed.
Practice tip No. 6. Because it is impossible to guarantee that e-mail will be read and responded to within a set period, emergency messages and time-sensitive material should not be sent by e-mail. While generally received by the recipient's e-mail server within seconds, e-mail can sometimes take a circuitous route and arrive hours later. Moreover, a patient may not review his e-mail for hours or even days, so ask patients to acknowledge receipt of e-mails by reply e-mail or telephone. Subject lines can contain words denoting urgency or deadlines, such as "Time-sensitive, please acknowledge receipt. "
Practice tip No. 7. Because speed of typing results in typos and the perception of curtness, take great care with clear wording and be as brief as possible.
Practice tip No. 8. Prepare standard, courteous messages for unsolicited mail that you do not wish to respond to (e. g. , "Thank you for your e-mail. Due to the high volume of e-mails, I will not be able to respond. To reach my assistant, please phone during office hours. For after-hour emergencies, please contact so-and-so. For immediate needs, please contact the physician on call or visit your nearest emergency room").
Be sure to provide accurate Web links and current telephone numbers for all referral information. Such standard responses may be set up in a variety of ways, depending on the sophistication of your e-mail software. One simple method is to prepare a variety of e-mail "signatures," each with a different response.
Practice tip No. 9. Steer unknown e-mailers seeking medical advice to a local physician or medical center. Increasingly sophisticated e-mail filter technology can advise you of who is and who is not a current patient. In all instances, it is your ethical obligation to provide referral information to all those who contact you.
Practice tip No. 10. Before sending an e-mail, always scroll down to the very bottom of your almost-ready-to-send e-mail. This step is good general practice because not only can you learn important information in a potential e-mail thread but there may be confidential information that you do not want to pass on.
The tips offered above seem sound and well advised at the time of this writing, but keep in mind that Social Media technology is evolving much quicker than the case law and professional advice needed to guide users of it. This is problematic to the many of us, who essentially are guinea pigs in a society fraught with distrust and litigation-minded people and their attorneys. This should cause everyone to tread very lightly in Social Media by staying abreast of its appropriate uses by fellow professionals and thinking everything carefully through before sharing with others through this medium.
Marc LeVine is Vice President of Community Outreach for The Center, a therapeutic program affiliated with Advanced Behavioral Care Services, serving the needs of Monmouth, Ocean and Middlesex County residents suffering from mental illness or substance abuse Licensed by New Jersey Division of Mental Health Services & Division of Addiction Services and with two regional locations in Neptune and Lakewood, The Center is recognized for advocating a focus on goal setting and attainment, commitment and structure. The program urges and challenges its members to take their places in the community as healthy, productive, contributing and vital individuals. To learn more, call 732-774-1500 or visit http://www.advancedbehavioral.com
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