Episode 50: Virtual Healing with Dr. Jay Shore

Dr. Jay Shore, a pioneer in telepsychiatry, offers an in-depth perspective on the journey from the early days of telehealth to the present and where he sees it going with new technology such as AI. The COVID-19 pandemic highlighted the need for and adaptability of telehealth services, pushing the boundaries of traditional psychiatric care and redefining what patient/clinician relationships look like in the 21st century. For Dr. Shore, telehealth began as a response to the need for mental health services in underserved and hard to reach populations, such as rural townships and Native American communities. Initially, the focus was on replicating the in-person psychiatric experience through video conferencing. However, the recent global health crisis has accelerated the use and availability of telehealth services, proving that remote sessions can be as effective as face-to-face interactions when conducted with careful consideration and adaptation to the virtual medium. 

 Dr. Shore discusses the nuances of virtual health relationships, including the unique sense of security some patients may feel during virtual sessions. A therapy session in a patient's personal space brings new dynamics into play, offering therapists unexpected insights into their patients' lives while also challenging them to maintain professional boundaries. The rapid rise in virtual services during the pandemic revealed a gap in preparation, with many clinicians adapting hastily without formal training. Given his decades of experience, Dr. Shore emphasizes the importance of acquiring a solid foundation in telehealth practices to ensure quality care and the effective use of technology. 

 “Each patient has a range of technologies and the challenge to be a great clinician now is to know the boundaries, strengths and weaknesses of each medium, and correctly applying them to your patient to render the best care,” said Dr. Shore 

 Looking towards the future, Dr. Shore envisions a world where artificial intelligence and advanced technologies like micro expression analysis and biomarker detection such as heart rate and blood pressure monitoring could further transform the practice of telepsychiatry. Innovative technology promises to enhance a therapist's ability to understand and respond to a patient's needs more accurately but raises questions about privacy and the importance of preserving the human connection at the core of therapy.

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Transcript

Dr. Bob Boland: 0:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland and Dr. Kerry Horrell Twice monthly.

Dr. Kerry Horrell: 0:14

We dive into mental health topics that fascinate us as clinical professionals and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in.

Dr. Bob Boland: 0:43

Lucky to have Dr Shore on today. Dr Jay Shore. He is the Executive Director of the Brain and Behavior Innovation Center at the University of Colorado Anschutz Medical Campus. He is Vice Chair for Innovations and a professor in the Department of Psychiatry and Family Medicine and the School of Public Health Centers for American, Indian and Alaskan Native Health. Dr Shore is Chief Medical Officer for Access Care Services and a Population Scientist at the Department of Veterans Affairs Office of Rural Health Rural Veterans Resource Center.

Dr. Jay Shore: 1:15

The Veterans Rural Health Resource Center Salt Lake City.

Dr. Bob Boland: 1:19

His career has focused on leveraging innovations to improve access and quality of care and mental health. He currently is participating in multiple projects, which include development, implementation, assessment of programs in community, native, rural and military settings. Dr. Shore has consulted for tribal state and federal agencies and served on planning and or grant review committees for several federal agencies, including Department of Defense, Indian Health Services and the National Institutes of Health. Though it doesn't say it exactly, and all that, he's an expert on telehealth and that's why we're talking with him today.

Dr. Kerry Horrell: 1:54

I'm thinking just even from your bio, dr Shore. There's so much we could talk with you about.

Dr. Bob Boland: 1:59

So many interesting things.

Dr. Kerry Horrell: 2:02

But that actually makes sense to me, especially given perhaps your work with rural veterans and like rural health, that then you would be an advocate and somebody interested in telepsychiatry. That makes so much sense to me. The connection there, Right, so welcome. Welcome. Thank you so much for coming.

Dr. Jay Shore: 2:17

Thank you for having me.

Dr. Bob Boland: 2:19

All right. So for starters, like I said, I first got to know you because of your expertise in that, and for a while you've been talking about how we could be doing telepsychiatry better. But can you tell us a little bit about your career and how you got interested in telepsychiatry?

Dr. Jay Shore: 2:34

Well and just as you said, it was my initial career.

Dr. Jay Shore: 2:39

Interest and focus was working with American, Indian, Alaskan Native populations.

Dr. Jay Shore: 2:47

Focus was working with American, Indian, Alaskan Native populations and so my major career mentor when I started video conferencing this was in the late 1990s, early 2000s wasn't a standard part of the practice of psychiatry and so it was really beginning some initial programs and pilots in more of the early days of video conferencing and what drew me to it was the ability to use the technology to increase access and quality of care. I think some people are drawn into tech and mental health. They get drawn in from the tech side of it. They're very interested in the different technologies and how it could be applied. I came at it from the patient side. I'm still, compared to many of my colleagues in informatics and technology, sort of a Luddite in terms of my ability to run and use the latest tech, but it was really working, and initially working with the American and the Alaska Native populations, both in the community but then through the VA and veterans where I got my initial experience and then expanded to other technologies and broader foci, including the delivery of health services.

Dr. Kerry Horrell: 4:07

I'm not remembering exactly which podcast right now, but we've had someone on and I want to say it was early on where we talked about how per individual in the United States the amount of psychiatrists like psychiatrist-individual ratio is like out of control, like there's so few psychiatrists per individual who even just might need support. And then I think you add you know geography in there, like a lot of psychiatrists are in populated areas.

Dr. Bob Boland: 4:32

Right, I mean what we do. Even though the numbers sometimes look good, they're clumped in major urban areas.

Dr. Kerry Horrell: 4:37

Yeah, it looks good, though, and then you add the clumping and then again to think about people in rural areas that just access to care and yeah I'm, it makes so much sense to me that like this would be something important and I'm so grateful and it seems like the VA has been such a part of like pushing and trying to to help kind of solve this problem. And one thing on my mind, and what some of what we were talking about too, is that the pandemic clearly also then changed the landscape of this. Like this is already happening as a field.

Dr. Bob Boland: 5:06

Yeah.

Dr. Kerry Horrell: 5:07

And I think it was actually probably, if I had to guess, a little more controversial pre-pandemic People would be like, no, we need in-person services.

Dr. Bob Boland: 5:14

I would go as far as saying if we were doing this podcast, say, five, eight years ago, we'd have to spend a fair amount of time you explaining what telepsychiatry is, and I suspect we don't have to do that now.

Dr. Kerry Horrell: 5:27

no, I think everybody knows like telehealth, exactly like what it means to sort of communicate with a patient via video and so I wonder if you can speak a little bit to even in your career, like what you've noticed has shifted and what factors are at work, and like if this is becoming really like the preference for most people.

Dr. Jay Shore: 5:48

And, yeah, curious what you've seen in your time working in telepsychiatry yeah, no, I was very fortunate in my career over the last few decades to start a focus in in telehealth, starting with video conferencing, expanding other technologies, and as my career matured I watched the field mature. So there's certainly sort of a noticeable pre and post-pandemic time. So pre-pandemic, the field started, really really began to take off in the 90s when the computer revolution happened and it became easier to do video conferencing. But we started in the field basically seeing if we could replicate in the 90s and the 2000s what we were doing in person over video conferencing. So it was like, wow, can we do an intake? Wow, can we prescribe a med? And they do a bunch of studies and they'd be like, wow, we can. And you know the patient doesn't spontaneously combust over video and it'll be okay.

Dr. Jay Shore: 6:53

But there was a lot of issues to work out safety protocols, coordination, adaption of clinical styles. But then with the advent of cheaper and more accessible video conferencing tools web video conferencing the field continued to evolve. So it wasn't just what we were replicating, what we were doing in person, but we began to look at reconfiguring how we approach people, how we put services together. So the technology began to be used to sort of invent new types of processes and services. So I think the best example for that is modern day integrated care services, which nowadays are a combination of complex teams of different providers, different patients, patient panels. They use EHRs, video conferencing, email. You know all these technologies blended together how a big integrated care service work, which just would not be possible. And in the 2000s we just weren't practicing integrated care that way. There's many examples like that. So my career early on was just convincing people that telepsychiatry was safe, and then just safe.

Dr. Bob Boland: 8:14

What were they worried about? It being not safe.

Dr. Jay Shore: 8:16

And people are always worried about how you manage emergencies right, safety issues, emergencies right Safety issues, acute lethality. You know how you work with a patient remotely who's in distress, sort of forgetting the parallel half century of lessons from phone management and right, we have been doing this and the two fields didn't really come together. But you know, I mean clearly you can manage patients effectively over distance and crisis and there's an argument that doing it over video conferencing gives you added data to do better management and you can do it in their home. So there's lots of arguments, but particularly systems and individual providers new to this, that was always their first, you know, concern that you needed to address and then, after safety and feasibility, you have to, we have to sort of prove effectiveness. Could you get the same outcomes?

Dr. Jay Shore: 9:14

And clearly the literature demonstrates that it's equally effective doing in-person versus virtual treatment. A huge caveat you have to modify your clinical style. You have to adapt what you're doing. You have to do it very thoughtfully. I don't believe you get the same outcomes if you don't do that, because just like you can do bad in-person care, you can do bad remote and virtual care, and we've seen that. And so before the pandemic, it was this advocacy to get people to adapt, to begin to think of using it and integrate it into their systems, the highest functioning systems with telehealth, before the pandemic maybe 10 to 20 percent of their visits would be virtual, maybe a very high, functioning, forward thinking, virtual type of system, right.

Dr. Jay Shore: 10:13

And then the pandemic hit and everything became virtual. And now, as we emerge, many systems are still more virtual than in person. So the pandemic, what, what I was trying to do, what I accomplished 10 percent of in uh, in uh, and it took me 20 years.

Dr. Bob Boland: 10:32

The pandemic did in one day yeah, well, it is amazing right to reflect on that like right, because I know, like in my own institution at the time, there's this kind of sense of like well, first of all, we didn't do any telepsych and the sense was like, well, you know, yeah, we could, we're aware of how to, but you know, why would we give like second tier treatment when we can do it in person and be like the best place and like and there are all these arguments back and forth about the quality of it and stuff, and you're right and all of a sudden, within like a week, we're like everything had to change.

Dr. Kerry Horrell: 11:05

Well, and I remember there was no choice I was a, I was a postdoc um the in 2020 and uh, we didn't have, we weren't given laptops. The postdocs really didn't need laptops. We, we had like desktops that we would use and all of a sudden, like they're I mean, it happened so fast. They were like, well, crap, we need to be able to have our trainees be able to join meetings virtually, and all this and it was just like this total also rush to get enough technology for all of us, which I'm sure was. We're not Lone Rangers in that, but I'm interested, especially because I feel conflicted about this.

Dr. Kerry Horrell: 11:38

If I'm being honest, I still feel conflicted about this as an attachment specialist sort of person is the idea of like what gets lost, or like what happens virtually, that can or cannot be replicated, and balancing that and this is where I'm like this is a mess Cause I don't think there's one right answer. It's balancing that with some is better than nothing, like access to care is better than not access to care, and is it? You know, ideally maybe we'd all be in person, but what gets, and maybe that's not true, okay. So those are my. My question, to be more clear, is like and maybe that's not true, okay, so those are. My question, to be more clear, is like what are your thoughts on this Of the balancing of, like, what gets lost virtually and what gets asked virtually?

Dr. Jay Shore: 12:15

Those are great questions. I think the framing should be a little different. Frame it for us, the framing. We're entering an era of what we call hybrid relationships, both in our personal lives and our professional lives, and that means we manage relationships through a range of technology. I have a relationship both let's forget about our personal lives but with a patient. I have it in person, I have it over video, I have it over email, I have it over a patient portal, I may have it over an app now, and in each of those settings there are strengths and weaknesses to each of those, including in person. Let me give you an example.

Dr. Jay Shore: 12:56

When I first started doing this work, I was and I still do, remote work with Alaska Native populations. But you know, 20 years ago and I was working with Alaska Native females with trauma, many of them at the hands of domestic violence and as as, as Bob knows, I'm sort of an outdoor toy, I'm six, five, I'm loud, I'm male. So I would meet with these women who had been traumatized for initial intake over video and at the end of the session they would say Dr Shore, wow, I was able to share things with you that I've never told anyone else. And at first I was like, yeah, because that's because I'm such a great interviewer. But then I began to ask them why they were able to do that. And it turns out I'm probably a mediocre interviewer at best. Bob knows me. But the distance and sense of space that they had in that initial session with not being in the room If they were in the room with me you can tell I talk loud anyways, I'm tall, I'm an outsider I'm not sure I would have gotten that feeling of safety and comfort that the virtual space created. So I'll tell you what if you give me a traumatized Alaska Native woman, I would probably prefer to do my first visit virtually, and probably the first few, and then meet with her in person person.

Dr. Jay Shore: 14:31

On the flip side, I've had many patients who are slightly intoxicated, which is a lot harder to tell over video, where in person I'd be like you're intoxicated, we're going to pause because I don't do intoxicated therapy but let's reschedule. Whereas over video you can't tell and you don't want to come out and say are you intoxicated? So you have to beat around the bush and like oh, when was the last drink? And they're like 30 minutes before I came to see you. And then I'd be like well, we're going to do things different. So potentially intoxicated patients I want to see in person. Right, am I communicating with an adolescent that I know for therapy via text? Maybe I'm going to get more information in the text format with them, right? So each patient, you have this a range of technologies, you have the diagnosis, you have the timing in the diagnoses and the challenge to be a really good clinician now is to know the boundaries, strengths and weaknesses of each of these mediums to communicate when and how to use it to render the best care.

Dr. Jay Shore: 15:32

So to me it's never an either or with this.

Dr. Kerry Horrell: 15:36

That makes so much. I think that makes so much sense. I appreciate the examples you gave too because again I'm totally tracking, especially with certain patients where the distance of the emotional distance and the ability to titrate that using video I think can be so helpful and again, I think also for other patients that would be not helpful. And yeah, it comes down to the individual. That makes so much sense.

Dr. Jay Shore: 15:57

And there's this whole really interesting concept that we haven't explored in psychiatry too, of what is this virtual space and examples of what is it. One example is this idea of virtual disinhibition, which we've seen. If you've treated patients in their home or their car and in some ways you get more information because they're not in your office or guard maybe down a little and they reveal more, and it's subtle. We see virtual disinhibition in our systems all the time, right with email, where people put things in email and then you're like, oh my gosh, that went out to 500 people and they didn't really intend that. But the median right isn't matched. But we see that on video conferencing. We see that you can also create inhibition, right, maybe the video conferencing is distance and you're not going to open up, but particularly when you're going into patient's home, I think it facilitates that.

Dr. Jay Shore: 16:54

And then you have to manage that boundary and we all probably have stories of colleagues, experiences ourselves, where you know you have to set limits. You're like Mr Smith, you really need to get out of your bathrobe, out of the bed, I will see you, but you need to be at your kitchen table. This is not appropriate. You know, mrs Jones, you've got some activity Go in the background, there's some family members. Can we get to a private room Because what we're talking about may not be appropriate, right, and so we all sort of have those types of examples.

Dr. Kerry Horrell: 17:30

Do you let patients smoke nicotine or vape in sessions with you virtually um, and I'm sure that's not a one-fifth answer, but I've struggled with. Because I work mostly with college students, I have struggled with this one.

Dr. Jay Shore: 17:38

I'm like it feels different than drinking so what do you do in that situation?

Dr. Kerry Horrell: 17:44

honestly, for the most part with most of my patients where this has happened, I just notice it. I'm like, hey, I'm noticing when we're talking about this, you tend to hit your vape a lot more. I wonder if you're feeling stressed.

Dr. Bob Boland: 17:55

So you use it as information.

Dr. Kerry Horrell: 17:58

Yeah, I just reflect it back to them and I haven't, unlike where I have. I have caught my patients drinking alcohol during virtual sessions and I've said, hey, that's not something that I'm comfortable with this sessions. And I've said, hey, that's not something that I'm comfortable with. This is not for therapy. I've not asked people not to smoke nicotine I would feel different if it was weed but I've not asked people just stop because we're in session. I've just noticed it.

Dr. Jay Shore: 18:18

So I think there's two issues. One you bring up a more general issue. One of the things I worry about is that from the provider standpoint so at the end of the day, if someone came into your office and drank or smoked or disrobed, you set limits and control the office Right. I think providers in general I counsel like, at the end of the day you're in charge of the session and you need to set the limits and boundaries, and I think on the provider side, in the virtual space, people may be a little more hesitant to be as directive as they need to be. So I think it's always good to be directive Now, with nicotine, you know, in the olden days, and Bob, we both know Pat O'Neill, who was a mentor of mine, who you know I don't want to over disclose, but yeah, esteemed psychiatrist.

Dr. Jay Shore: 19:09

Yeah esteemed psychiatrist and he doesn't use nicotine now, but when, like many, many years ago, I was with him and him and the patients would smoke, like staff used to smoke on the ward.

Dr. Bob Boland: 19:19

So, nicotine, I think each substance has sort of a cultural I used to see training films of like psychotherapy where, like, you could barely see the patient or the doctor because, like it's so full of smoke yeah.

Dr. Jay Shore: 19:32

So, and I'm also a harm reductionist and everything's grist for the mill. So again, is that vaping going to impair the session, is it not? But I do think commenting on it and then, as a general health care provider, even if you come across more luxury, first of all sort of noting it and noting the relationship, like if they're getting stressed, that's helpful feedback, and then finding the appropriate time to then use that as a window for education on nicotine cessation. But it may not be appropriate. It's just like they really get into something heavy and they take a smoke and all of a sudden you're like well, do you know? The nicotine's bad for you, it seems actually really bad for your health.

Dr. Bob Boland: 20:17

That's right. I'm going to share a picture of your lungs here.

Dr. Jay Shore: 20:20

But it could be the next session before you start. Hey, remember last session you were smoking. Look, I'm a healthcare provider. Obviously you can smoke and such. I'm not going to tell you not to, but two things. One, you know, we all know it's addictive and it's problematic, but it also seems to be part of your sort of managing your distress. Maybe we should talk and talk about that in your relationship with substance. And if you want to think about reducing or quitting, I'm here to talk about that and I think you opened the door. I don't think you say we're going to have to talk about this as making part of your treatment, but are there other resources you need? So that's how I would sort of. I would do it in the moment, like you're doing, but then looking for the window for an intervention later.

Dr. Kerry Horrell: 21:07

In terms of the substance use, you are clearly such an incredibly thoughtful provider. I'm just yeah, I'm struck by that. I have a funny meme to share for a second, one of my favorite. I saw this around the holidays and the meme said doing teletherapy over the holidays from your childhood bedroom has very reporting life from the scene energy from your childhood bedroom has very reporting life from the scene energy. And obviously it's a joke, but it does. Again, I do think something else you said that struck me is just this idea of like we do get something interesting and important for many patients when they're doing therapy from their home, or like we're in their space, like we get these.

Dr. Bob Boland: 21:44

Interesting point, but sometimes it seems intrusive.

Dr. Kerry Horrell: 21:46

I bet we feel different about that.

Dr. Bob Boland: 21:48

Interesting. I don't know In the sense that stuff that you might see, that they wouldn't have naturally showed you, not sure?

Dr. Jay Shore: 21:53

So it's all about boundary management. I had the blur. I'm working from home because of the storm. If people, as a therapist, I never say this, but I even do this with my colleagues. Whatever you show on Zoom, right? I don't know if you guys do this when you're looking, but I'm always fascinated by people's backgrounds, right? Of course it seems rude, like if you're on like a Zoom meeting, but it's yeah. So you're looking, there's sort of a dog cage, there's a stack of things, there's just like toys or something up there.

Dr. Jay Shore: 22:28

I can't see what that is yeah, chips, right, those chips.

Dr. Bob Boland: 22:30

yeah, like toys or something up there. I can't see what that is. Yeah right, those chips. Yeah right. So sadly, the audience can't see any of this, but uh, it's a very neat office, I'll give you that well, but here's a little bit of a messiness there, right?

Dr. Jay Shore: 22:39

so this is all grist. I figure it's grist for the mill and that someone, even if they're not aware, if they're going to sort of share that, that you're, especially as a treatment provider, you're not judging. If they're going to sort of share that, that you're, especially as a treatment provider, you're not judging, you're just sort of noting the information. Where does the patient feel it's appropriate to meet with a provider in your house? Is it me? What does the room look like? Is there stuff going on in the background? It's almost, like you know, just sort of not judging, but just sort of assessing and generating some hypotheses you may discuss.

Dr. Jay Shore: 23:13

You may never discuss. I mean, like your guys' background is completely psychoanalytical. It's a white wall. I see you know a curtain and you have a microphone. It's like boring, right? The other thing you can do with backgrounds which I've thought about right is is is Taylor, so if I was working with you know someone from the West, this is one of my favorite virtual backgrounds, right, you may feel really more comfortable if you come from a rural community. I'm showing this background.

Dr. Bob Boland: 23:45

I'm showing a background of lovely. Where is that, this background? He's showing a background of a lovely. Where is that? This is?

Dr. Jay Shore: 23:48

Wyoming. This is the plains, this is a mountain in Wyoming, and Elk Like this may not do anything to you. You guys may be like what, but if I was working with a rural veteran from this area, this may be a lot better than that. Blurred background, right? We've never done studies, but I suspect right. Suspect right. As we know body language and visual 80 of our communication, I would love to see a study on what is zoom backgrounds. How do they impact?

Dr. Kerry Horrell: 24:19

someone needs to pick that up. Dr short has dropped an incredible opportunity for every it is interesting.

Dr. Bob Boland: 24:25

Yeah.

Dr. Jay Shore: 24:26

Or, you know, I could be narcissistic. That's a great picture.

Dr. Bob Boland: 24:31

Yeah, he's showing a drawing of himself now. Okay, great.

Dr. Jay Shore: 24:34

Right, or I could show you this a different favorite of my beer, right.

Dr. Kerry Horrell: 24:39

We're getting different background options.

Dr. Bob Boland: 24:41

Yeah right, Mostly of him.

Dr. Jay Shore: 24:43

Yeah, yeah, which again is which is right. Like this is another nice professional background. Now, this is very different than the one Another outdoorsy.

Dr. Bob Boland: 24:54

You like the outdoorsy scenes? I do, but it's like a ranch or something.

Dr. Jay Shore: 24:58

That one was. The sun was out, it was spring, this is winter. See the ice, you've got the moon, the moonrise, right. This is a different feel. Maybe mood the moonrise, right, this is a different feel. Maybe this is it, for I mean, I don't know, this could be a little spooky or a little bit more intimate, right? Uh, less open, right? Or maybe it's more cozy?

Dr. Kerry Horrell: 25:19

how do you honestly I can't tell you why, but I am so averse to zoom backgrounds I never use them. I had to use one recently because I was presenting at a conference where they asked all of us to use the same background and they had our name and our credentials on it and I just was like I hate that because, quite frankly, usually I very well curate the back of any like, both in my home and then in my office here, but my background is very well curated to be seen on Zoom, so I'm like I don't want to be on, I just flourish.

Dr. Bob Boland: 25:50

Let's do the blurb, yeah.

Dr. Kerry Horrell: 25:52

This does feel like a good place, though, to go next or to kind of keep thinking about which is. We're talking about this already, but, like I'm sure you know our listeners who are in our broad swaths of mental health providers over the last few years, I think many people are sort of trying to navigate this before the research has caught up of, like, what is best practices and what are some of the best tips and hints for working.

Dr. Bob Boland: 26:14

Early on you said there's a right way and a wrong way to do like telepsych, so it's probably time to talk about the right way Like what advice do you have or what's your approach when you set something up for telepsych?

Dr. Jay Shore: 26:30

It is so, so complicated. Something up for telepsych, it is so, so complicated. But first, like my concern with COVID, is a best practices. So me and a colleague at some point we don't do this anymore, but we would do sort of a consulting through our academic work and help programs set up telehealth. So what we do is we go in and first we would help them sort of write out their protocols and procedures, emergencies, drop calls. We then come and educate the staff about the research and the background and get them up to date on the rules and regulations. So they had working knowledge. We know there's things you have to have working knowledge licensure, prescriptions, all of that. So you've got that and then we would do a separate training on processes.

Dr. Jay Shore: 27:18

Right, um, my experience early on I ran one of the first dedicated uh resident training for tele-site. This was like in the early 2000s. I had this clinic with three residents each in a room and I just wander back and forth between their sessions, taking notes, giving them feedback, supervision. My observation is it would take a minimum of 20 hours. It would take anywhere from once a week clinic from six to 12 weeks before, I would say, someone became basic competency in telehealth. So to me it was 20 to 60 hours depending on the individual. And most people think, oh and again, maybe it's because we Zoom and video conference, but using it clinically, and so I do worry that we don't do enough training in this, just watching how they use the technology, interacted with patients. So, anyways, when we were doing these consultations, we would do a half day and we would give people scripts and scenarios.

Dr. Jay Shore: 28:25

You're the provider, you're the patient, and then we wouldn't let them share with each other and we put them in rooms like down the hall and then we go in and we pull out their technology, we cut their bandwidth and like, like we give us a suicidal patient and we cut off the video and then, like, I'm like, well, what do I do? I like, well, what is your protocol, what did we talk? What is the right? So they're practicing. So to me that's really you get some practice, best times and probably the first 20 hours getting some feedback which people never get in supervision. So when, when COVID happened, I know that we instituted telehealth overnight, yes, and people were doing it and just assuming I still. I think my framing today, as you see, is pretty. This is pretty decent for telehealth. Now you can, if I wanted to sort of get a little more intimate, see I can become closer.

Dr. Bob Boland: 29:22

It's kind of close Right, sort of get a little more intimate.

Dr. Jay Shore: 29:24

See I can become closer. It's kind of close Right.

Dr. Bob Boland: 29:28

But, bob, if we're talking about some very serious things that you need to change, yeah, you got to cut that up.

Dr. Jay Shore: 29:32

Or let's say you're feeling a little timid on meeting you for the first time. A little bit more sense of distance, right, I have colleagues who you're like.

Dr. Bob Boland: 29:44

Oh yeah, the head. So now we're seeing just his head.

Dr. Jay Shore: 29:47

Yeah, you're like like basic competency. This is their 200th zoom. I'm like what are they doing with patients? Right, and so there are sort of skills knowing who's in the room, how to talk to a patient, that idea of not of empowering patients, but when you have to laying out the ground rules, like the first session, where you do like a, where you do a true consent, like they understand what the emergency, the boundaries are over telehealth, how to contact each other that they're comfortable, you know, sort of the basic things.

Dr. Jay Shore: 30:22

And I think, unfortunately, as modern telehealth gets integrated into our system, our clinics are patient after patient. You're just booming through, you're not really paying attention to processes, you're not given that time and space. So I do worry. That's why I said it's really easy to do bad telehealth and I hate to say this, this, but a lot of people say, well, it can't be done or it can't be done with that patient, and there are a few patients where really it's probably not appropriate or you need to be in person. But I've had a lot of patients who had initial bad experiences and I realized that and so I approach them differently. Right, I'll spend, I do think, professional disclosure with patients over telehealth. It can be a little bit more helpful because you're trying to bridge the distance, like so, you know, like today I talk to you guys about my weather and you know I could, uh, you know, show my background and it's snowing out. How you know I could. You know, show my background and it's snowing out. You know weather is such a great and safe topic, but what you're really talking about is here's where I'm at, here's where you're at. You're trying to bridge and make that connection. And I think and this can be true in person too when you're moving too fast and you forget about first, you have to have the connection to do the work and you have to prioritize that. So what are you doing to make the connection with the patient, setting the stage for the environment and thinking that through? Now there's some patients I can move really fast.

Dr. Jay Shore: 31:51

I had clinic yesterday remotely out of state and, geez, I only had 10 minutes. I know this patient is like the fifth time I checked in I'm like how's your sleep? And he's in the rhythm and we're just shooting because I'm like, oh, I'm so sorry, we need to do a quick check-in, but I've got that rapport and that relationship and we just had to get some work done right Versus the first time I saw him. I took some extra time and work to establish that base. So I think there's a lot more nuance and sophistication in training and approaching telehealth than we've really addressed as a field. I'm trying to get the basic information out there right now still like through the APA's website and toolkit. Like state licensure and boundaries. The things we're talking about is sort of next level telehealth that many providers don't think about.

Dr. Kerry Horrell: 32:41

It's such a good I mean it's such such a good point, though, that this is a field and there's so much to it, and yet nearly the whole field just got pushed into. Most people had no train and like just we went with it and yeah, doing some of the back work, of like let's, let's finesse this and let's, let's do this well and right here's a practical question I always wonder about how do you manage eye contact?

Dr. Bob Boland: 33:00

um, like right now, when I look at you, you look like you're looking more or less at me. It's because of where you're standing in relation to the camera. So I noticed when you got closer I could see the difference more and you know you were right. At that point You're not looking at me, so it has to do with sort of your angle to the camera and things like that, and that's the fault.

Dr. Jay Shore: 33:20

Like this is like we could solve this problem in an instant if Apple wanted to invest it. I mean, the technology is already there to probably align our eye contact.

Dr. Bob Boland: 33:32

I'm amazed they haven't embedded a camera right into the screen.

Dr. Jay Shore: 33:37

That'll come and what they have is what we do know is more than a 7% off gaze angle. People will notice. So, again, I think also, we all sort of just accept even our patients the limitations of video conferencing. So you can get away with a bit more, right, and you'll watch your colleagues on these Zoom calls, right. Some of them are really good now multitasking, other people can't. They're not good at it, right, and so you know, there's that whole thing.

Dr. Jay Shore: 34:07

I think there's also some space in forgiveness. I mean, in the early days the literature was all about eye contact and you're right, body language that's another thing in addition to background, right. Do these changes impact the session? And if they do, do they change the outcome? And maybe they impact the session. They don't change the outcome or maybe they really change the outcome, particularly in the therapy realm, and we just don't know. We just don't know how because we don't have the data. You know there's antidotal and suspicion, but you know treating people based on your gut is a favorite thing to do in medicine, but it's not as effective for your outcomes, right?

Dr. Bob Boland: 34:49

Do you tell patients how to position the camera on their end?

Dr. Jay Shore: 34:52

I will be directive. I know some patients, but if a patient's cut off I'll just be like I can't see you. Do you mind? Just sort of adjusting a little bit? Oh, great, I can see. Love to see your, your smiling face.

Dr. Kerry Horrell: 35:04

that's so much better a lot of my college students. When they're getting, I'm holding my phone up to show this. But when they're getting sort of a win in or we're talking about something, all of a sudden their phone's facing the ceiling and I'm like, could we keep your phone facing you? I would love to keep seeing you because they'll like, all of a sudden they're drifting. I'm getting just like a quarter of their face. They're looking at the ceiling and I'm like, come on, let me keep looking at you. You've given me a lot to think about. I think this is an area where I've struggled, in that I would much prefer to see my people in person and there's been times, especially working with, like, college student folks where, like it's made sense to make that transition and like for the sake of the therapeutic relationship and their progress. And, yeah, I'm just appreciating the work and the language you've put to some of this. It's been really helpful.

Dr. Jay Shore: 35:46

Yeah, yeah. So my whole career has been virtual, not just with patients, but I've worked for DOD and the VA, with teams around the country and even today, because it's snowing, even when I go to campus I have more virtual than in-person meetings. That being said, I've had some in-person practice. If we had the technology, like the Star Trek beam, where I could beam to a patient. You know, being in person has its advantages, but obviously I can see more patients in more diverse locations and move more efficiently. That's the benefit.

Dr. Jay Shore: 36:21

But I do understand that in-person thing and, bob, you may have been part of these conversations, but at the college someone brought up like the fact that some of the residents in COVID have never got training in person. I think this is a huge thing for the field. What's the appropriate dose of in-person and virtual-based training? We don't know, but I firmly believe people need both. Even if you're going to do a full telepsychiatry career, which many of our colleagues now do, I think I was lucky to have a blend of both early on in my career and even though I've done more telepsych than in person, I did have some healthy in-person experiences. So I think if all you and moving forward, like you said one of the future issues is both patients and providers may not have as much experience with in-person in the future. I don't know what that.

Dr. Bob Boland: 37:21

Well, a whole generation was trained. You know, whole group was trained, not not to psychiatrists, all doctors with very limited um in-person contact, right, yeah, what do you see for the future? What are you looking for? What technologies or other things are you looking forward to? So?

Dr. Jay Shore: 37:36

I think ai is really interesting. Um, I mean, there's so many and and now you know I have a couple different leadership roles, but one of them is director of this innovation center. So video conferencing right now we use it as an adjunct to other technologies, apps, AI. So I think the most exciting and interesting and risky thing is sort of where AI takes us, both AI and video conferencing. So video conferencing, you could see, I think we will get there, whether this is two years or 10 years to get there, because you know it always takes longer.

Dr. Jay Shore: 38:17

But let's fast forward to some point in the future. We're having this conversation. I'm doing couples therapy with both of you, so I have this platform and right now you may know that this platform has an auto dictation summary function. So that summary function is going to generate the full medical note for me that I just gave you, and they're already working on this in many systems. So I think documentation will change and go away, and there'll be other things with AI and documentation which we can't. I'm just talking about video conferencing. I think it is very possible that I will have a video overlay I can click on that will be analyzing your micro expressions in your face and giving me potential, and I've heard people proposing this for a decade now, but I think the technology is getting there.

Dr. Jay Shore: 39:13

Like Bob is slightly sardonic right now. And what do?

Dr. Bob Boland: 39:19

you think? What do you think Carrie's doing? She shakes her head. No, this point, I don't like that too much for me. I don't need a microcomputer, she's getting burned out with your sardonic nature, bob.

Dr. Jay Shore: 39:31

And it might even, like some people are, claiming through biomarkers voice I've seen this but it hasn't been proven to me but voice detection of depression or stress. So not only video but the audio could be giving me sort of a printout at the bottom of the screen of things to look for, and it could be pulling from your medical record and saying here's some information from the medical record. So I've got like like you guys won't see it as patients, but I have a heads up like dashboard, like a fighter pilot, so you know fighter pilots. Now, like there's a I don't know if you read there's like a thing, it's like a six hundred thousand dollar helmet that the f-32 pilots have. That's completely mapped into them. They don't ever get to put it on. They get to use test versions till they're flying. The plane tracks their eyes.

Dr. Bob Boland: 40:22

They can yeah, so we're going to get those too. Do you think Like we could have those for our patients?

Dr. Jay Shore: 40:26

I think that the heads-up display in a future Zoom would do our medical, would give us information and do our charting for us. That could give us readouts about audio and video biomarkers that are present at minimum, and I see again how quickly the technology is there that we could put together a prototype. If Elon Musk decides that, instead of going to Mars, we could do this now. It's too spooky.

Dr. Kerry Horrell: 40:56

I don't like it. It's a very black mirror to me All right, well, sign me up.

Dr. Bob Boland: 40:59

That sounds like fantastic.

Dr. Jay Shore: 41:00

Well, like I said so, it's more the system integration and the testing of effectiveness. And does it work?

Dr. Bob Boland: 41:07

Yeah.

Dr. Jay Shore: 41:08

But it's beyond conceptualization and in my work I've been hearing these concepts for a decade. But I think the technology is there to put them together.

Dr. Bob Boland: 41:16

Dr Shore, it's been really exciting talking with you, yeah so much to think about.

Dr. Kerry Horrell: 41:20

Yeah talking with you. Yeah, so much to think about. Yeah, well, you've been listening to Dr Jay Shore talk to us about telepsychiatry and his career and the advancements, and, gosh, we so appreciate you being here with us, dr Shore.

Dr. Jay Shore: 41:31

Yeah, my pleasure. Thanks for having me.

Dr. Kerry Horrell: 41:34

And we've been your hosts. I'm Dr Keri Harrell.

Dr. Bob Boland: 41:36

I'm Dr Bob Bowen.

Dr. Kerry Horrell: 41:37

And thanks for diving in. The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

Dr. Bob Boland: 41:49

For more episodes like this, visit wwwmenningerclinicorg.

Dr. Kerry Horrell: 41:54

To submit a topic for discussion. Send us an email at podcast at menningeredu.