Zooming Towards Bethlehem?


The office, we are told, is dead.  Give up your expensive consulting suites, abandon campus, stop paying rent.  Why commute when the world is a keystroke away?  Patients are eager to see you via remote technology and dread the trip to your inconveniently located office where (horrors) they might run the chance of encountering someone they know, have to deal with costly parking meters, and brave the surly receptionist.  Far better to put up with dropped connections, visual distortions, and e-stutters (including that common and very annoying strangled echo-type noise that ascends in pitch, like you’re shouting down some kind of electronic drainpipe—you know what I’m talking about). Of course, you’ve gotten used to seeing yourself as some strange, facially distorted creature, all chins and foreheads, peering out from some kind of electronic fishbowl onto a depopulated world where the only thing that exists is the equally distorted image of the patient in front of you (and no, your nose truly isn’t that big in real life, but think, e-therapy may not be the best treatment modality for patients with body dysmorphic disorders). 

This is the new e-normal, being accelerated by the pandemic but driven, of course, by the big technology companies out of Silicon Valley (some have declared that from henceforth all employees will work remotely). All meetings will be virtual, and this will become some sort of “worker’s paradise for the rank and file.”  Of course, increased worker autonomy means increased surveillance, so companies will be deploying ever more sophisticated programs to check on productivity and see who might be slacking off at work.  Devices that measure remote worker’s keystrokes, mouse activity, and track websites viewed have been around for a couple of decades, and are growing in sophistication (certainly an eye-movement tracker must be out there somewhere, with an electronic eyeball trained on every solitary worker, but frankly I’m too scared to look for it). 

Is it really true that telework is the new e-normal?  For every company that sees a completely officeless future, many others have tried that experiment and have ended up bringing workers back into the office.  Large international firms like IBM have stopped much telework, finding that productivity suffered in the all-electronic workplace.  Telecommuting has been a promise since the 1990s, yet still most of us dutifully trudged back and forth to the office—or we did until a few months ago.  And while the pandemic has forced certain solutions on us, I am not one who believes these solutions will be permanent.  Indeed, the longer this strange experiment that we’re caught up in continues, the more the weaknesses of remote work will become apparent.  It’s incumbent on us to examine what can be done efficiently and effectively via remote work and what requires in-person participation.  At the National Register, I’m very pleased with how effortless it was for our staff to switch to telework.  I dare say that few individuals who call into the office actually realize that they’re reaching staff working from many different locations, and queries from Registrants are being answered as promptly as before.  Staff has done a tremendous job orchestrating webinars, which we were for a time running as often as twice weekly, in order to assist Registrants in transitioning to telepsychology.  Webinars are watched and CE certificates issued as quickly, if not more rapidly, than they were before the pandemic.  Our last journal was edited and published entirely electronically.  There is not much that we cannot do remotely. 

But how much is “not much”?  That’s the question we have to grapple with right now.  This is a hard calculation for businesses that don’t produce widgets (electronic or otherwise).  Measuring productively in terms of lines of code written or number of sales made is one thing.  It is much more difficult to measure intangibles, such as an organization’s progress towards its distal goals, fidelity to its principles, or planning for the future.  I suspect that those organizations who once unreservedly embraced telecommuting and are now pulling back are doing so because they realize that these intangible but necessary goals are being inadequately addressed.  In certain respects, you can argue that universal telecommuting robs an organization of its collective identity or sense of self, and thereby imperils its survival. 

Make no mistake about it.  Teleworking is here to stay, and even after the pandemic telework will be a larger component of organizations’ modus operandi than before.  At the same time, sustainable telework depends on the organization’s ability to accurately determine which tasks are amenable to distance work and which are not—and what degree of in-office work is essential to maintaining an organization’s integrity. 

Individual psychologists will have to make similar calculations in determining how much to rely on telepsychology.  As I reported to you a few months ago, when the Register and the Trust surveyed our constituents several weeks into the pandemic, we found that an astonishing 84% had rapidly switched to telepsychology for at least some of their practice.  This was a cause of anxiety to me because I believed that psychologists unfamiliar with telepsychology might make simple mistakes with grave consequences, such as failing to enact an adequate safety plan for a suicidal patient being seen remotely.  Fortunately, if such errors were made, they seem to be rare. The profession has, after all, been talking about telepsychology in a systematic way for at least the last 20 years, with numerous task forces and reports and a growing literature, so it is likely that psychologists were very familiar with the concepts, if not the actual practice of telepsychology itself.  And telepsychology has, in many instances, been proven to be as effective as in-person therapy (we will leave aside thorny issues like remote administration of neuropsychological tests), and generally well accepted by patients—at least when no in-person alternative is available.  But as rapidly as we embraced telepsychology early in the pandemic, its use now appears to be leveling off.  Why?  No one is exactly certain.  As shelter-in-place orders expire, more providers and patients are comfortable with in-office treatment.  So gradual re-opening, particularly with appropriate hygiene measures in place, accounts for some reduction in use of telepsychology. 

But some authors have found not a slight decline, but a dramatic reduction in the percentage of care being provided via telehealth.  One group looking at primary care physicians’ practices found that in June telehealth provision had dropped to 8% of all visits, half of what it was earlier in the pandemic.  Those authors speculated that the expense of implementing large-scale telehealth solutions, particularly at a time when primary care practice income was dramatically hard-hit, made it feasible only for large group practices.  Uncertainty about whether third-party payors and state and federal regulatory agencies like CMS will extend waivers permissive of telehealth after the pandemic also caused reluctance to invest in large telehealth solutions. 

But in medicine like in psychology, intangible factors probably drive a great deal of decision making about use of distance technology.  You can’t administer many psychological tests over the internet, nor can you palpate a thyroid nodule or perform a breast exam.  It’s hard to gauge nonverbal cues in telepsychology in the same way that a physician may not notice if a patient’s ankles are unusually swollen or if their skin is more pale than before.  And in medicine as in psychology, it’s the things that patients don’t complain about that are often the most important.  Finally, although patients find telepsychology as acceptable or more acceptable than in-person therapy when the latter is not an option, how many will decide that the virtual experience equals the in-person experience once the pandemic ends?  The things that are hardest to measure may be the most important things to attend to. 

Once having stepped over the e-threshold, we are not going to completely close the door on telepsychology.  The profession has just this month made a significant stride in advancing telepsychology in that as of July 1 PSYPACT is now operational, allowing participating psychologists unlimited telepractice with patients in any of the now 14 jurisdictions that have voted to join the compact.  But I would not be the least surprised if, after the pandemic ends and a vaccine has been found, that most psychologists revert to primarily in-person treatment.  Of course, there will always be instances where telepsychology is the preferred and maybe the only option—rural areas, certain specialty practices, and the like.  But just as in the case of telework, its future will depend on our ability to determine which components of psychological practice are best suited for distance provision and which are not.  And that, I’m afraid, is less straightforward than it sounds.

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