Welcome to Reflections on Technology Use in Psychiatry in the Last 30 Years. And the way this talk happened was that John and I are on the scientific program committee for this conference. And we're on John Lowe heads the technology subcommittee. And we were just trying to brainstorm what kind of talks can we have. And I said, hey, aren't you an expert in this field? And haven't you been in this field for about 30 years? And let's invite Seth Palser, who's also been in this for at least 30 years, way before it was cool. And then that's how this happened. So that's just to say that it's very casual. Please join in. And everybody, let's just have a conversation about this, because it's really an evolving field. So I'm Dora Wang. I'm a former president of the Caucus of Asian-American Psychiatrists for the American Psychiatric Association. I have a dual career as a writer. And I blog for Psychology Today. Here is a blog I did in 2016 featuring the other speakers here. Seth Palser, MD, is a professor of psychiatry at the Yale School of Medicine, my former professor. And I remember when I was your student in the 80s, you said to me, one of the things psychiatrists can do on the consult liaison service is take the time, because we have the time. And so we did, what was it, five-page, 30-page write-ups? Something like that. But anyway, that's how much psychiatry has changed. We no longer do those lengthy write-ups. And Seth has been writing about the interface of technology and psychiatry since at least the 80s, and had this undergrad degree from MIT in computer science. Electrical engineering back then. OK, yeah. And has published on electronic health records since the 1990s with the legendary Edward Tufte. John Hua is professor of psychiatry at the University of California Irvine, formerly also at UCLA. As I meant, the recipient of dozens of teaching awards that I can't even name. The Roberts Teaching Award, the Irwin Land Teaching Award. John has been, as I mentioned previously, he chairs the subcommittee on technology for the scientific program committee for the APA. And one of the papers that I saw that John wrote was, let's see, a foundation for telepsychiatry. And this was in 2002. OK, so welcome. So as I was mentioning. and apps be a new way to cure mental disorders, which was in 2016. Not yet, according to psychiatrists who spoke at the annual American Psychiatric Association Convention on May 16th, 2016. Of approximately 40,000 smartphone health apps available, about 800 at that time were devoted to mental health, according to Robert Kennedy, then Executive Director of the American Association for Technology and Psychiatry. However, few of these apps are developed by clinicians, and there is little science to the vast majority of them, said Seth Pausner, MD. Seth was President of the American Association for Technology and Psychiatry at the time. Clinicians need to be at the forefront of app development, said John Lowe, MD, Chief Informatics Officer at the University of California Riverside School of Medicine at that time. And toward this goal, a Collaboratory for Psychiatric App Development was formed by Pausner, Lowe, Victor Buwalda here, from the Netherlands, and a Harvard Psychiatry resident at that time, John Toros, MD. And at that time, the Collaboratory for Psychiatric App Development, this was in 2016, and this is from a talk yesterday that John Lowe was a part of, and you see that apps are now a reality in psychiatry, and the APA indeed has a model for evaluating apps for mental health and app development. So in any case, I just, right now we sit on the verge of something really extraordinary, which is, I remember when I was, when I chose psychiatry as a career, it was kind of polar opposites with technology. I mean, psychiatry was the subspecialty of medicine that healed through the doctor-patient relationship only. It was through transference, through therapy. I was a child when I decided to be a psychiatrist. Medications were not used very much yet. That all exploded when Prozac came on the market in 87, and now psychiatry is mostly about medications. And alongside, technology has become increasingly taken a role in psychiatry. So in any case, let me just turn to our panelists now. Up until recently, psychiatry and technology were seen as kind of polar opposite interests in the eyes of most people, yet you both had longstanding interests and affinities with technology. What the heck were you thinking when you chose psychiatry as a career, given your longstanding interest in technology? Well, I think Seth and I come at it from different perspectives. I was really just a hobbyist. I still remember in high school, you could check out the TRS-80 from Radio Shack, which was a basic computer that used a cassette tape, and then an RF modulator, so you had to find a TV to connect it to. And I don't even remember what keyboard I used, to be honest. But I was starting, I self-taught myself to do basic, and wrote a few programs. I hope that was kind of cool. To me, that was way more interesting than using the, whatever that system was with the cards. You had to write the program. Tram. No, no, you had to punch the cards, put them in order, and then would read into the card machine, and would go into, I forget the name of that one. But anyway. She's right, Fortran. Fortran? Okay, anyway. And I think that was an early experience. And I just, I guess I just liked technology. And early on in medical school, technology has always enabled me to spend more time with my patients. I still remember, I got my dad's old IBM clone, and a 1200 baud modem I dialed in to the hospital back system. No HIPAA security then. Back in, let me think, 93. Because I saw, wow. I can get my labs on surgery rotation earlier than my colleagues. So while I'm eating breakfast at home, I'm getting the labs. So when I go to see my patients, I actually spend about five, six minutes with each patient instead of the usual 30 seconds that as a poor med student you have. Because you gotta queue up for the lab. There's only one terminal for the med students and residents. Actually, the residents may dump, that was back when you could give scut work to med students. And so med students had to stand in line to get the labs while the residents, I don't know, eating breakfast or something like that. But you couldn't mess with the unit clerk. She was the one putting in orders, and so there'd be one person on one terminal, and then there's like 10 people waiting. It would take about 20 minutes to wait to get your labs. But I got them at home, so I spent more time with my patients. Actually, I remember one of the residents said, hey, John, the patients really like you. You spend a lot of time with them and ask really nice questions. I think you're gonna get a good grade on surgery. I have no surgery skills whatsoever. But that was a kind of early lesson that different tools and technology could really help me. And I remember getting my PalmPilot when I was a resident. So instead of carrying all those pocket guides in your lab coat, I started to use graffiti and handwrite them in until they developed keyboards for the PalmPilot. So I knew the DSM codes. That was way before APA decided to create an electronic DSM. It's also like a pocket information. And I don't know, at some point, I guess I decided to start writing about it and teaching about it. And part of it, I think, was just people wanted to learn, right? Like, hey, what's that, John? Oh, it's PalmPilot. Well, what do you use that for? Well, you know, I have bad handwriting. That's key one. So I cannot use a day timer because I can't read what I wrote there. And so my first organizer was, I don't know if anybody had one, the Casio Boss. It was just strictly- I remember that. Yeah, calendar, calculator, and an address book. That was it. But I had put all my patient appointments on that, even recurring ones. So it was kind of cool. But anyway, I just like to use stuff. Seth, I think, you learned how to program early on, right? So how was it different for you? Oh, okay. The truth will out. I wasn't thinking. There was no thought involved. Actually, the closer to meaningful answer I give when I'm asked about how did I move from electrical engineering and computer science to psychiatry is that it's all software. But that actually had nothing to do with, directly with how I ended up in it. My father interested me in electronics preschool in a stroke of some kind of genius or a really good popular mechanics do-it-yourself article. He built a little paper-sized wooden board with lights and switches and an electric bell. And he actually paid, and he was trying to save his money back then as a house store officer, paid for batteries. And the lessons I learned about electric circuits and electricity and magnetism back preschool from that stick to this day. Marching forward, my first exposure to programming was Fortran. But my first exposure to medical applications is my father's concern for doses in nuclear medicine to his patients. He was an earlier nuclear medicine practitioner and promptly grabbed one of the first computers you could have on your desk, a Programma 101 back in the mid-late 60s. And I was allowed to program it on weekends and things just kind of took off. My next exposure to medical computing was his work trying to computerize the laboratory at Detroit General Receiving, which led to my getting a chance to tag along as he went to see Digital Equipment Corporation. And finally, I went to MIT, where luck intervened in a big way. I was invited to be one of the students going over for a trial of off-campus academic research activity at Mass General Hospital's Laboratory of Computer Science. And that was back in 72. Enjoyed it immensely, programmed in MUMPS, which is the underlying language underneath EPIC. Basically, as a student, I took on the director, Dr. Barnett's pet projects for which there was no funding, which was laboratory utilization. So what you may notice in all of this is the word psychiatry or even psychology hasn't popped up at all. And I was not worried about any of that. And I just kept marching forward. And the directions at the Laboratory of Computer Science were very clear. If you had any interest in doing any computing in medicine, and, big and, you could put up with medical school, go to medical school. So I did. And there, in fact, I was able to work on an early natural language processing project, which got me my MD thesis and still didn't have anything to do with psychiatry until late part of my residency when some of my cohort and myself needed to generate computer-typed bills for our moonlighting. Hard to believe, but true. It's a long story there. But that's how I got into the intersection of computing and psychiatry and never really thought about it. Thank you for this background and your expertise and your interest as pioneers here. Go ahead, John, you had something to say? I was gonna say, I still remember, I was a first-year resident at Harbor UCLA in Torrance. And there was a Grand Rounds, a friend of the chairs, and Mel Miller was the chair at the time. And the presentation was on using Excel to track patient and patient outcomes. Like, well, okay, that's kinda cool. So I remember Dr. Miller said to me, hey, John, what'd you think? Because he knew I had some nascent interest in technology. And I said, you know, Dr. Miller, that's all nice and dandy, but this internet thing's gonna be big. And he's like, the what, John? You know, the internet. Like, what is the internet? Well, you know, it's like this connection of computers and stuff. And, you know, there's all sorts of information out there. And I think this is the next thing for medicine. And he looked at me and said, oh, we have a cancellation in February. Do you wanna do Grand Rounds then? I'm, of course, at that point, I'm terrified. I've never given a talk before, you know? And much less I have to actually give a talk to my department. And, of course, I had no choice but to say yes, because I was in front of my resident peers. And I still remember that there was no laptops then, so I had to drag my desktop in to the Grand Rounds room. They didn't have projectors either. They had the old standard, kind of the upgrade for overhead projectors, but they had this overlay that would then, you know, it would be like your screen. And I think that costs like $500 to rent for the day. And so my chair said, you know, we normally pay honorarium, but since you ate that up in your equipment rental, nothing for you, John. Fair, fair. I'm still processing this, that you dragged your desktop into a talk. And there was no live internet. So the only way I could show anything was I used Lotus ScreenCam 1.0 and recorded myself, you know, surfing the internet. And then I would play the clips. And back then, PowerPoint 1.0 did not have integration of where you can click and show the video. You would have to kind of go out, play the video, go back into PowerPoint. But I still remember, I think I learned something then, which was, I still, I remember being very nervous, of course, much in comparison to now, where I've been doing this for a while. But I remember mostly that, you know, I was saying, oh my God, they're gonna ask me all these questions. And what if I don't know the answer? And there was this sort of stunned silence from my faculty and resident colleagues. None of them knew what this was. And after all, it seemed like an eternity if only somebody, one of my attendings said, hey, John, my Quicken's not working. Can you come by and take a look? I realized, hey, I too can be an expert in something. And I guess this is it. This is teaching people about technology and how to use that in their practice. Because, you know, I was one that, while I wasn't always good at reading manuals, I could figure things out. I still remember spending an afternoon post-call trying to install some extra board on my PC clone and having to learn how to use the switches for changing the IRQ, because otherwise the mouse wouldn't work if the modem worked. It was just, I mean, my wife said, are you done yet? And she's like, I'm like, no, I gotta get this thing to work. And I was like there for hours. And finally she said, well, just show me what you did. I'm like, oh, I see. I think you made a mistake here. I'm like, oh, so that's when you learned. Oh, explain it to somebody. You could figure out, you know, to quit pounding your head on the bloody stone as I was at that point. You know, you shouldn't really try to fix computers in your post-call. Back in the day, oh, I guess I can say that now. Back in the day when there were no duty hours. So I have no background in tech. I'm actually a historian. While I was in medical school at Yale, I did a master's degree in English literature with an emphasis in medical history. And I've been historian for the University of New Mexico School of Medicine and written histories of the Yale System of Medical Education and the University of New Mexico. But what I see as a historian is this trajectory of technology becoming more and more important. And so I'd like to ask our panelists about where technology was when you first entered medicine, where it is now, and what is the future? Because CHAT-GPT came out last year. AI is on the horizon. I live in Palo Alto right now, and that's all anybody talks about is artificial intelligence. You mentioned natural language processing. Since I was a teen, so I've always hung out with computer geeks, I will confess, which is why I've known these guys for so long. And as a teenager, I was friends with Dan Jurafsky, who later on went on to write textbooks on natural language processing. And so before I came here today, I talked to Dan, and he sent me papers about how computers will replace psychotherapists. I mean, this is stuff in publication. I mean, of course, there's ELISA from the 1960s, which was an AI-based therapist, and right now there's an app called Wobot based on ELISA from the 1960s. But this is just gonna explode right now. So yeah, let's talk about this trajectory and what you see in the future coming. Yeah, I think, I mean, part of it is it's a combination of things, right? It used to be, oh, you're the nerd. You like computers, that's fine, right? I wasn't playing sports or anything like that. Typical, but I think part of it also is the user interface, the power, right? I've said before in another talk, I remember I would buy a new Palm Pilot every time one came out because I already maximized the other one. I ran out of space for apps or whatever else. I was using apps to kind of find hidden ROM space to store more things or encrypt stuff. I'm not a programmer to be upfront, but I do think that, I mean, I look at my daughter. She didn't take typing in high school. She just learned it sort of organically, I think. And I'm actually catching myself not knowing all the features of, say, Instagram. I can post and I can tag, but there are things like I don't know where the heck the button is to do whatever that is. And so I get chided for not having much style when it comes to posting, but that's okay. But the bottom line is technology has gotten a lot easier now. And I think that where it's headed, obviously, with AI, natural language processing, all these other things is, the goal is to actually make it useful, right? So that way, when you say, into your tricorder, beam me up, Scotty, your AI assistant takes care of things for you, whether that's asking Siri or, hey, Google. It does basic things now. I think the big hot thing is, and I didn't get to check all the vendors here, but AI transcription, right? I can tell you on Instagram, there's at least a dozen companies saying, hey, give us your recording sessions or we can live record your patient with you and we'll do all your notes for you. And some of them put up front that they're very HIPAA compliant and don't store any data. Others, I think it's probably buried. But I do think that as technology has gotten easier to use, and that's partly user interface, I also think younger generations are using it now. So of course, their brains are still very, has such great plasticity, they can learn how to do things kind of natively. I've watched my niece's daughter, who I think was four, was given a old iPhone without any service, just strictly wifi. And when her parents were off at some show, she was like texting them and no one taught her how to do that. And so I think things are changing kind of quickly, rapidly, but we'll still need to see how useful some of these things are. But it's kind of an exciting time. Exciting time. Dr. Palsner, you were one of the early thinkers about electronic health records at a time when they actually didn't exist. And now EHRs have not only become commonplace, but required for most of psychiatric care. And in the 1990s, you collaborated with Edward Tufte, also a professor at Yale, about the graphical display of information. And yesterday I heard Dr. Lewis say that EHRs used to, I mean, technology used to save him time, but now it consumes time. Yeah, and I believe there were studies that Epic actually adds something like, you know, an eighth more work to a clinician. So, Dr. Palsner, what is the ideal role of EHRs in psychiatry? And where do you think all this is going? Well, in a bad moment, my reaction is the most useful role for an EHR is to erase itself. But the problem that anyone who's read 1984 by Orwell will recognize is the terminology is deliberately misleading. The electronic health record is the name of it, but what it really is is a billing system and an administrative command and control system. If you look at the development of the EHR, you should start probably with Dr. Lawrence Weed back in the 60s. I highly recommend anybody who's really interested in the underlying question of what one writes in pursuit of treating patients and teaching trainees. You read one of his original works. The best version, I think, is in the Irish Medical Journal, but it's probably easier for you to get hold of the New England Journal of Medicine version, which I'm gonna say is published around 1969. It lays out a reason to write what you're writing and what the goal is. And there's nothing about billing in there. Diagnosis is not assumed to be something that you stick on the patient as soon as you've seen them. Rather, you put down a problem, which is hence the name problem list. The problem might start out as ill-defined in the case of medical folks as a cough or a fever. Hopefully, over the course of the admission, it gets refined to be pneumonia, and then finally, pneumonia with a diagnosis. and thus we go from problem to diagnosis nowhere in there. Do we worry about? Or did he worry about did you have a code that you could bill for? the next Development is that weed himself tries to make this electronic. He goes up to the University of Vermont had a large grant It was a disaster there were a number of other attempts and What they all ran into as best I could tell was I Doctors were not that interested in typing Administrators are not interested in hiring transcriptionists and It wasn't really clear that the writing did much anyway because although people paid homage to weed and said they were using problem-oriented charts They weren't actually thinking about what they were writing or what it did Let me stop at this point and toss in my favorite line on the subject of writing charts of any sort is That most health care is a relay race, it's very unusual for us to see a patient in any specialty Treat them and they're done. It's like that's a sprint. Occasionally it happens the emergency room folks get to do that more often Most of the time we are helping figure out what's going on now ordering some tests passing along the next case and so on And so it's a relay race. Hopefully getting the patient across the line alive Any of you have looked at relay races know you cannot win a relay race alone but you can lose it by yourself if you drop the baton and So the goal in my mind of writing something in a chart is don't drop the baton Now if you're interested in where you go from there There are handouts One sheet both sides and at the bottom of page one. I put a couple things you can read Which you might look at besides starting with Lawrence Weed and The first place I would start is the design of everyday things because once you've got some idea what you'd like it to do You should have some idea of What can we do with technology? Generally then start thinking about the record itself I think that there are other factors right as you said You know billing became part of it. I still remember that was the first thing my dad's office I was his tech support unpaid But anyway He was a he's a retired internist solo practice and The only computer he had like tons of paper charts, you know alphabetical He would scribble a few lines and put it back in but oh, they're only for him. There was no relay. It was just him It's the only thing he had was a billing system, you know in a scheduling system And I had to do all the troubleshooting backup all that kind of stuff I think now You know, obviously, you know here in the US are our legal medical record is really that it's real for legal purposes Not just billing but for malpractice And I think that you know other countries they write a heck of a lot less than than we do And I think now what I worry about is It's so easy To find information yet. We put so much my residents nowadays Copy forward tons of things in their notes Which I really don't understand because if you want what's something from before you just go find it But no, they're like so they always have like every med trial the patients on in a little summary And it just keeps going, you know from note to note and next thing, you know You know a 10-15 minute med check those notes like huge and yes You can hover an epic and figure out what's copy forward and what's not but after a while It just becomes more hassle and then it's really worth and I do worry that we're teaching our future generation And accurately how to document and make things Useful, I mean that documentation is more important than your face time, right? Speaking of which The ape and before. Oh, did you have a question go into the mic though? Yeah, go ahead Thank you, I wasn't I I have questions, but you all have questions, too, please. Please. Let's just have a conversation Yeah, let's just have a conversation. I'm a milder horn from Durham, North Carolina I Jarrow site for doing general psychiatry as well, and I heard about telepsychiatry in September of 2007 from size I eat and saw the possibilities and every time I see Dr. Lowe's name on something I try to come so here I am and the Electronic medical record system Apparently I was intrigued and Understand there was an award written were earned by the Oak Street Health Clinic for Having a medical record system that was written for doctors and I wondered if any of you had heard about that. I Haven't and you know, I think it's very interesting that Unfortunately, I would say the majority of the successful electronic health workers are not written by doctors. They're written by programmers David Lishner is a psychiatrist who's still around. I'm not promoting his product But one thing I've noticed is that at least for 12 years his electronic health record system is still Must be it still has a lower loyal user base because believe it was like a Word document initially that then some of the data was parsed out into kind of a structured database, but The point is that most most products I think are not designed by clinicians They're designed by programmers and I think you're right when when doctors get involved, which is something we always push for You know, then we we can sort of see how the best design things but like the chart health worker though Unfortunately, it's not just for doctors. It's also for the billers Nursing, etc. And so I think those are the challenges and the other part I was gonna add is I think Tech savviness, I think is something that's still New now, I mean, I hate to say this but my best friend and neighbor sometimes He'll say John I think something popped on my iPhone is is this this is what you call spam or not I'm like, all right. Hold on. Let me come over. So I go look. I'm like, oh, yeah, good job You spotted it, you know because he's been unfortunately ripped off a couple times So, I know there's some generational issues and I think it'd be interesting to see how in the future When my daughter, I don't know what she's gonna do when she she's already graduated She has she still figure out grad school, but you know When when I have grandkids at some point, they're gonna be way above my capability when it comes to technology To just underlie how visionary these two are See the the APA formally opposed the use of telepsychiatry Saying it was a poor way to conduct the doctor-patient relationship and then approximately 2012 the APA issued a statement that telepsychiatry had advanced and I guess the technology had advanced. So now it could be a great of great benefit As a historian what I what I see is that doctors used to make house calls and you know have the doctor's bag horse and buggy and in the 1900s and then figured that they could see more patients if the patients came to them and So that's why they're there are clinics now and With with that in mind with telepsychiatry, that's even more efficient So I just see it growing from a historical perspective, right? I would add to part of it is also the evolution of the hardware and software right because Bandwidth was really slow before like when I was using it now Everybody has you know broadband which is perfectly capable of doing video conferencing so I think part of the objection back then was the worry that The frame rates that you would get from really slow video as well as fidelity of it Which is sort of have you missed things like somebody who's looking quite depressed or possibly even manic? and so I think now and of course Probably the only positive thing of kovat was like everybody started using it and became rapidly adopted Without thinking and so and now it's become a preference of patients versus coming back in So I noticed the older patients who used to see me in person You know and saw me on video go back to in person But the younger patients who started with me on video, no, I don't really want to come in They just love the video part whether it's in the parking lot or hopefully not driving down the freeway at 55 miles an hour Which didn't happen to me once I remember doing some telepsychiatry in 2013 or 14 and there was a lag between the video and the sound and so to your point Maybe they were laughing at something and you don't know what and and then you know the psychotic statement comes in like a minute later but You you had a paper telepsychiatry in an overview for psychiatrists and this was published in 2002 But I want to ask the both of you. What are your thoughts about telepsychiatry today with the explosion dr. Posner what what are your thoughts about the use of telepsychiatry being so commonplace not just psychiatry but medicine also You work in emergency medicine as well It's with us it's not going anywhere it may the quality may improve from a historical standpoint I've even met analysts back in the 70s who had used telephone sessions at times So that concepts not really new I think it's mostly a question of whether people are comfortable working with it There are some things that still are hard to figure out. I've used it between emergency rooms where we would hopefully have a better connection movement disorders questions about tremor alcohol withdrawal in the emergency setting I've had to finish my interview and then call the emergency attending at the other end and say listen I think I know what's going on. But would you please check the following? It's got to be checked by somebody there Yeah, I think too that You know, not only has the technology gotten better but easier to use but I think that You know back early on I You know, there was a lot of studies Don Hilty worked on a few on like patient satisfaction I think the other part really is really that devices are used to be, you know, if you think about it a Computer for the doctor's office in 1990 was already three grand which is very expensive But now, you know Your iPhone or your smartphone is the expensive thing. It's about a Thousand for mostly, you know high-end one with enough storage But computers are just really I mean very inexpensive now, you know And so it's kind of funny that I think about it like if I had bought stocks or mutual funds instead of new computer Every year, I probably could have retired by now. Oh, well But but the reality is that you know, although there's still access issues, of course people that can't afford Computers or smartphones or the sort of last-mile issue of you know, do they have broadband access in their neighborhood? I know that you know, the big carriers are trying to get rid of that because that just it's expensive for them to be the last, you know landline connection in some of these remote areas And satellite just isn't that good to be honest. I was at Carl Chan's Summer Institute In Door County, and I remember there was a thunderstorm and I was supposed to be moderating the Grand Rounds session and I just had to Text somebody and say hey, can you take over because my video was going in and out so technology is not always perfect but but I do think that You know today's generation. It's gonna be very interesting because I think There's more and more power in our pocket Then then there will be actually on your desktop. It sounds like a Mae West line. Yeah Yes, I I found the this it's a med-tech breakthrough awards best overall med-tech software in 2021 it Oak Street Health won the EHR Innovation Award and then two thousand and twenty two at one yet another and they are apparently using machine learning it's it I I Would love for you all to look at it at some point Because I wonder if it really is as good as it's hyped up to be they were trying to do I think it's when work with Medicare. I Don't remember the term but essentially keep their patients out of the hospital So they had buses picking people up within ten mile radius. They had Line dancing and other things in their waiting room area of trying to make it sort of a meeting Socializing place and they were bought by CVS, but they're still independent So there but of course that they started about the time time kovat came and that it's amazing They made it through because of course people were going to be hospitalized But if they have something that's good, it'd be nice to know and it's called canopy Apparently is the name of it. Thank you. Thank you There are a couple of technologies on the horizon I'd like to ask your opinion about The first of course is artificial intelligence how you see that changing psychiatry and and then also I was in an Apple store recently and And the vision pro came out and because I live in Palo Alto Drive past what used to be Facebook and now it's meta which is basically virtual reality how do you see virtual reality and AI these two new technologies that Are just bubbling right now, but in two years, they're gonna be really commonplace. How do you see that affecting psychiatry? Well, I was actually on a workshop with skip Rizzo and Ida Melovich In actually this room a couple days ago and I think that USC and he's been Doing virtual reality research. Yeah, many for many years many years Tell me about the second the other person you mentioned Ida Mahalo. It's is a psychiatrist over at University, Illinois, Chicago Who's sort of incorporating? VR in our practice and I think you know, I think back to how many of you remember second life. Do you remember that? Yeah, I remember those people were buying islands on second life because they thought you know This is a big I'm really the next hot commodity and mixing, you know Right, and all that just disappeared again, I think VR stuff, you know used to be again the the domain of large corporations or Companies that were designed for like virtually better, you know again you had to have the programmers to create the virtual environments Nowadays you could actually probably download some open-sourced Game code and you know modify it although that takes a lot of effort It's not that easy to to create mods for health care from a game that's used for battle But but I think people are doing that now and I think With companies like Amelia and some other ones these headsets are not as expensive They're like three four hundred dollars the Apple Vision Pro is like three five hundred. I think it's already sold out But I think I go back to things like augmented reality you think about it the Google Glass was the hot thing and I remember so oh, yeah, all of us are gonna have the EHR right there, you know and kind of look like cyborgs I did wonder a little bit about patients You know, you're trying to make eye contact with them, but you're looking up something off to the side Whether that's the psychotic patients go. I don't think I'm gonna trust you. You're that weird twitch anyway, but then I don't know. Does anybody know what happened to the Google Glass? There was like a new version and then I've heard nothing So I think not to say that AI is headed that way or VR is but I think VR is becoming more You know something that any clinician can basically buy a headset Subscribe to certain platforms to provide different clinical environments and it'll be part of your arsenal just like if you wanted to prescribe an app or For exposure therapy. It's much easier to do now than it was before And who knows maybe I'm sure there's another company that's already working on the AI chatbot in a VR environment, you know that you could do remotely Well To paraphrase an old bad joke about psychiatrists. How many psychiatric apps does it take to treat a patient? Just one but the patient has to really believe it works Excellent and I think Those who've gone into the social anthropologic background of therapy and medicine generally There's Been a long history of making comparisons between the shaman of ancients tribal societies and doctors and how the most important thing the Aspect of it that translates across time space and culture is That the person believes this will deal with the problem they have If you believe the problem is your neighbor has cast a spell which is causing all your root Vegetables to move underground over to his garden you laugh, but this happens My neighbor has been up to something Then you need to go to somebody who's cast really effective counter spells If you believe the problem is that you've got calcium in your coronary artery Which you've probably seen about as often as you've seen the the carrots move underground You need to go to somebody who's got a really good piece of equipment that allows you to visualize it If you believe the problem is something about the way your brain makes Connections and was trained and may be adversely affected by experience Maybe you believe that what you need is a pair of really good glasses and a really good piece of software to help reprogram The question is do you believe it? Whether or not it works will follow I Believe the first computerized treatment for a psychiatric problem was in the 1980s John Grist had telephone based exposure therapy for OCD and the the research is that it works and And But but people were not interested in it And I I see the problem as being like going to the gym you buy a gym membership You know it works, but you just you know you still don't go So to your point yeah, that that's I think the problem. I guess it's med compliance and adherence versus app or stickiness right we know that some apps for The military is developed for treating PTSD or OCD are excellent, but you know there's studies that show that app use tails off dramatically after what three to four months to practically nothing and so There's got to be something about it that keeps people engaged And I'm you know I think we'll have to look at younger generations, so like I still don't understand discord And we get something recorded, but anyway, you know I don't understand the value of it but there's just Patients now that are just like oh, no no discords the only way to have like real conversations of real real people Sorry so discord I think Start off as a kind of a chat system you could use when you're playing other video games that don't have a chat feature built in or you actually prefer discord And it has become like the place you can host your own server Or you can go you can connect to different people's servers, and you could have like conversations with anybody on any topic It's kind of like reddit. I guess in a way on a kind of chat forum Basis with hashtags all that kind of stuff. I have patients now that I supervise residents who are saying or like Just that's they don't talk to anybody in person. They just have chats with people on discord all the time good You're invited so you you're better than Really, really excellent question, and I just wanted to hang on to that. In the 1990s, I got a grant from the APA to bring Dr. Pausner to the University of New Mexico for a visiting professorship, and I have memories of us driving through the desert, you with your laptop, with a little antenna off of it for a, that was 2G at the time, so that you could get Wi-Fi in the desert, and it was only 2G, right now we're at 5G. And then one thing you said in the talk that you gave was, in the future, what if an ad pops up, and how will you know, did they target you because they've read your, they know about you? And Dr. Guo, you also have talked about privacy, and just the hazards of doing your web searches on Google, and how that's not protected, and you're mentioning EHRs, yeah, so let's, we'll have a little time about the dangers to all this, and what we should all be concerned about. I think it reminds me of the old adage, anything on the internet is there forever, and I think that's pretty much true, you really can never scrub anything, right, there's the Wayback Machine, which is a way to archive the internet, because obviously some companies are defunct, and so if there's some bad information about you up there, that'll eventually, someone can find it, and I think, especially with better web search engines nowadays. So you're right, privacy is really an important issue that I think that convenience unfortunately has trumped too much, and I think that goes to our patients too, I mean, the other day, this is hard to say, but I was actually, you know, supervising one of my residents, I come into a video visit, and then it dawned upon me, where was my patient? The patient was in the women's restroom in one of the stalls, having her video visit, and I was thinking to myself, because I heard this flushing sound in the background, and I was thinking, whoa, now of course that was her choice, we didn't push her there, but I thought, wow, where are we now, where, you know, I mean, so I do think, I do talk a lot about how information online can affect, you know, not only your privacy, not just in the dark web where they can steal your social security number, et cetera, but nowadays, right, the scammers know your cell phone, you know, part of it they can just generate numbers, and I'm sure it's somewhat random, but it, it's a whole industry out there. I was asking more about medically, very relevant type of information, like, I'm coming from a very crimson state, and for instance, transgender health care, abortion issues, how do you navigate those with an HR that most of the times is open, and government has no problem in helping you? Well, I, go ahead, Chris, I was, well, if you've got one of those EHRs that has interconnect, so that you not only have your records, but you can see the patient's visit to other hospitals, and of course, vice versa, and clinics, and so on, then you find yourself very quickly in the world that Scott McNeely said we were in back in the late 80s, he said there is no privacy, get over it, and that got a whole bunch of people dumping on him, but nobody actually challenged the reality he was describing, and which you're hinting at, and which I'm sure exists, namely that the protection is not in the computer. The protection at this point has to be in the people using the machine, and in the governmental agencies, and so you find yourself in this country, unlike Europe, where they've gotten used to a whole bunch of people living together in a smaller space, they've got more focus on human control of information sharing. Here we tend to leave it to the machines, and that, of course, will fail. Just a little background on privacy from what I understand, and then I'll go to you. So it's in the Hippocratic Oath in ancient times, it was acknowledged how important privacy is in the doctor-patient relationship, because if you don't have privacy, the patient may not be telling you the actual, the patient is thinking about privacy and not telling you the actual story, maybe. And then we had HIPAA, which stands for Health Insurance Portability and Accountability Act, which the origin was that Hillary Clinton was trying to have universal health care that was portable. She did not succeed, but out of that came HIPAA, which is why it has that strange name. What HIPAA actually does is it makes, there's actually less protection, in my opinion, in that health information can be shared with insurance companies and with anybody, with other health care providers, and insurance companies, the people who have access to there are not bound by any kind of medical code of ethics. So we're talking staff, and they all have access to this. So actually, I think HIPAA means that there's less privacy. So yeah, what do we do with this? Let me ask, Dr. Balfe, are you concerned about the possibility that in a state where there is both sharing of electronic medical records is controlled as such as it is, and there are laws which allow private citizens to pursue other citizens who've sought abortion or something else, how will HIPAA or anything like it be enforced? Is that what you're wondering about? Or privacy? I keep some things out of the record. Yeah, and I think the other thing we can use is not just paper shadow charts, but encryption, you know. I have a notebook of, actually it's funny, when I see patients, I don't type, I take it in my notebook, which I can't even read sometimes, to be honest. In psychiatry we have that tradition. Right. Shadow notes. Right, and so I keep some private information there that I don't put in the electronic health record. There are some things, obviously, that only psychiatrists can see, so that's sort of useful, but I'm also intentionally vague there. I don't put details in there, but you're right. I think it is a personal responsibility, and I think sometimes the technology, unfortunately, as Dora was mentioning, does enable easy sharing oftentimes. I do think that it may be our responsibility if possible, obviously, if the patient's trying to receive gender-affirming care, then you can't quite block that, but there's the ways, if there was an event that they don't want to be disclosed, you can keep that kind of, I put notes to myself that remind me of it, but I don't describe it explicitly, so that way, you know. You can advocate for it, but from a technical standpoint, it won't happen. You don't think blockchain might be part of that? We can pick up the telephone still. Blockchain is actually less secure, and if you get into the technology, you'll discover that people have already figured out how to crack the original blockchain, the Bitcoin stuff, to figure out who's actually using it. Oh, really? So that's been cracked, and it's a fundamental flaw in the implementation. It's not the actual design of it. Picking up the telephone brings us back to the relay problem. It'll work in a small practice environment, maybe, so let's go back to gender-affirming care, because this has come up for me when a patient says, I don't want the following in my record. Actually, what they said was they didn't like the way I put it in their record. If it's just the use of the pronoun, I usually don't care, and I'll say, yeah, sure, we'll fix it. But one wanted a change, and it was a complicated case. Hormones were being administered, and I said, no, this is a complicated case. People will have too much trouble understanding what's going on medically and endocrinologically if I make these changes, and I'm not doing it. And that was that. Nobody said anything further. But I point that out not so much as me vis-a-vis the patient as the situation is really very complicated. And so, no, I can't get on the phone with just one treater. There are a bunch of people treating this patient, and technology tends to move like an epidemic, you know, the expression, it went viral. That's for real. Once this technology gets going, and it already has with care everywhere, sharing, the majority of folks don't want to back away from it. So McNeely was right, and we're just going to have to figure out how to deal with that on a human basis. Hi, I'm Mark Hauser from Boston, Massachusetts. On the screen, everyone can see that it talks about Robert Kennedy, the executive director of the AATP. And I thought that you guys might want to share more with the audience about how vibrant our annual meetings were at the APA for at least 10 or 15 years. When we would meet for a full day on the Saturday before APA started on Sunday, and we would invite luminaries, and we learned that no matter how much any one of us knew about a topic of the technology interface with psychiatry, there were other people who had a depth of knowledge of a different part of technology in psychiatry. And even like 20 years ago, when the fellow you mentioned, Rizzo, came and gave a talk on the virtual reality of soldiers with PTSD, and he showed us how you could lose your seatmate to a bullet through the window. I mean, it was amazing. So I thought you might, because we did that for so many years, and we can't do it anymore, but it was relevant. The other problem with the privacy is no matter how much you respect your patient's privacy, their pharmacy records are held by the pharmaceutical industry and the government and the insurance industry. And if they're on hormones, even if you don't write it down in the record, whoever wants to know to violate their privacy already knows from the pharmacy records. Well, thank you, Mark, for that. I was going to say, I still remember, it started off with a small group of people who were very interested in technology called the Psychiatric Society for Informatics. And I remember as a resident coming and like, oh, like-minded people, this is kind of cool. Because I remember also when I told my training director that I was interested in medical informatics, he looked at me and said, what? What is that? Oh, you know, interface of technology and medicine. And I think I was going to do a medical informatics fellowship. And he looked at me again and he goes, what? And so I think it was really nice to find a group of like-minded individuals who really became not only my teachers, but really peers and mentors to help my career develop in the field. And I think that, as Mark just said, we all just meet earlier and talk. And actually, you think about it, part of it, I think, was because APA at the time didn't have a technology-focused workshop. We had things like the Office of the Future, which is to show, oh, look, here's a word processor. This could potentially write your notes. This is like, mind you, in the 1990s. And I think that if you flash forward to today, not to say that AATP shouldn't be resurrected in some way, but it's become mainstream now. Technology is now mainstream. And so APA has a technology track where you use your app and you can click on the top right. You can select technology. You see all the things that have, all the sessions that have technology listed on there. And, in fact, there's, I think, over 46. In 2016, there was one. Yeah. Anybody was at that meeting. Right. And so this is something I've been fighting for for years. I'd always submit a technology workshop and it would always be under administration or something crazy like that. So we've come a long way in the organization to where technology is kind of part of the bread and butter of the scientific program. The technology subcommittee has actually only been around a couple of years. And so I think that's going to continue. And, honestly, if I am being recorded, this is trouble because then I have to keep this promise. But, you know, I think at some point that we have, the organization has awards for pioneers or people that have contributed to the field in geriatric psychiatry, research, child, forensics, et cetera. So, you know what? Maybe we should get the ATP band together and create a technology award in psychiatry because we're, our field, our group is still, you know, vibrant and contribute a lot to our field. Yes, we'll do that. We'll give it posthumously to Graham Bell, Alexander Graham Bell, founder of Telepsychiatry. Yes. Yeah, call up to the mic, please. Absolutely. Good morning. Good morning. Good morning to everyone in the room. I'm enjoying all the conversation, hearing some of the history. My name is Mark Thomas. I'm a pharmacist by training and have a great affinity for technology and healthcare and some of my background. I'm certainly interested to hear the thoughts and opinions of the role of digital therapeutics, particularly in psychiatry. Digital therapeutics, as defined by Digital Therapeutics Alliance, are software-based interventions that can treat, manage, or alleviate slash prevent a particular disease state. So, you know, talking about innovation and apps, and I think you made such a funny joke earlier, which is that you, going back to the one patient and like the patient has to believe it, that's the app that'll work. So I'll hand it back over to you all just to get your thoughts on digital therapeutics. Oh, I, oh boy. Unfortunately, I meant exactly what I said. I do not believe, from my perspective, that it matters what's in the app at all. I used Eliza. I showed it to my grandmother back in 1970. That was amusing. Her response to the whole thing was, so where is the person hiding in that machine? And there was no point going any further. The flip side of that was she believed there was a person in there. And if she believed, which she didn't, that talking to a person was useful for treating whatever was bothering you, that would have been fine. At the other extreme, I can imagine a device so simple that it doesn't really require software, something to remind you to stop keyboarding, raise your hands up, lower them down, and go back to keyboarding every five minutes, which could just be a little vibration-type device with no smarts in it. That would, in fact, make a difference, and especially it would make a difference if people believed it would make a difference. And I understand this sounds kind of nihilistic, but the reason it's nihilistic is because it then says that what we're doing with people, vis-a-vis therapy and so on, is more dependent on the person believing it will be helpful and subscribing to that, as it were, frame of mind or understanding of mind than it is us personally. And that's a difficult point of view. I think I would add to that, just like you know that one medication doesn't treat everybody's depression, certainly one prescribed digital therapeutic is not going to be the end-all, be-all. So whether it's the individual believing that it works or there's something in it, I think one of the things I'm really concerned about, to be honest, is the erosion of the long-term relationship with the patient. I think I'm seeing now, as a training director, that most of my residents graduating, they're choosing tele-psych jobs, but not only tele-psychiatry jobs in a large group, some of the ones that are recruiting here, and I do think they're underserved, but in the prison system. And so, to me, it's like, wow, you're just going to see patients, it's kind of like a video game, you turn it on, you see your patients, may not be the same one you see the next time or five years from now or 20 years from now, partially hopefully because they've served their sentence or something to that effect, but I do worry that future generations of psychiatrists are really not as engaged about that. One of the therapeutic things is really the relationship between the provider and the patient, and I think where technology has sort of enabled things, you have more access, but we're still not there where when you're in the ER and the patient comes in, you can tell, oh, they haven't washed in a while, so okay, that's first interventional. Either they are super depressed or they're possibly quite psychotic, but you can't tell that on video. Although I know that Skip Rizzo mentioned there are small pods you can use to do these sort of micro-dose kind of like smells to enhance virtual reality environments, but I don't think we're quite there yet for you in assessing the patient. There's really going to be something missing, and I think what's really missing, what I worry about is the sense that someone actually out there cares and is willing to go to bat for you, because I still remember I have patients that have written back to me or someone in their family that one patient of mine with depression had to go to his home state to get liver cancer treatment, and I remember getting an email back from a friend to let me know that my patient had passed on, but the comment was made was, you know, you love the fact that you're always there thinking, oh, the next thing to treat is depression, and so that was valuable to him, and I see my residents who really just want to clock out at 5 o'clock. They believe that they shouldn't do any extra work after hours. It's the law now. It's the law, yeah, ACG rules, but I worry what I went to psychiatry for was that patient interaction and that connection, and I think I'm not saying this is technology's fault necessarily, but it is on some level because it does create a little bit of a gap. You know, there's a different feel. There are just, we have mirror neurons. It's the monkey see monkey do neurons that we imitate others, and we internalize others, other people, which is kind of a foundation of therapy, attachment theory, human development. Here's an example right here. Seth was my professor, and here we are in blue blazers. So many years later, but, and then in terms of therapeutics, I want to ask you about digital therapeutics because you actually are an expert in the primary therapeutics we use now, which is medications, and we have, and now it's acknowledged that placebo is a huge part of why they work, and I remember my classmate Ian Cook at UCLA studying antidepressants and realizing that placebo was such a big, that, well, so in his double-blind placebo-controlled studies, the placebo had such a huge effect that he 180'd and started studying placebos, but in any case, the pills are prescribed by psychiatrists, and there is literature about when a patient takes a pill, they're actually internalizing the psychiatrist in some way. Maybe that accounts for the placebo effect, but what are your thoughts about digital therapeutics that you brought up? Yeah, thank you for asking. Can you come to the mic? Sorry. Thank you for asking that. Excellent points. I think digital therapeutics are a very fascinating pillar, if I may, certainly not the end-all, be-all, perhaps, but digital therapeutics can be used as monotherapy or adjunct therapy to clinician care. So in the example of depression, if a patient perhaps isn't getting the results that they're hoping for, the clinician isn't seeing the results, and the patient doesn't want to add on another medication, digital therapeutics can be an excellent alternative for that. And as a pharmacist, one example that is near and dear to my heart that I think just talks so much about the value of digital therapeutics and technology in general is when we go on vacation, it's all too often that we may forget our medications at home, and we know what that patient's journey is when they're on vacation. It burdens the office. They've got to find a pharmacy to call into, et cetera. But I don't know anyone who's ever forgot their smartphone for vacation, perhaps on an errand. I understand. But what I mean is in that sense, you would always have your treatment with you. And to me, that's such an empowering thing for folks is that we now are able to just have our treatment in the morning, the evening, all the way across the world. I just think that's incredibly empowering. So thank you all for your feedback. Thank you for your comments. I was going to add that although I still think the best vacation I had was in 2008 when I went on an Alaskan cruise, and I realized there was no cell tower. So I put my phone in my cabin, and I didn't use it for 10 days. That was the best vacation I've had. So a little counterpoint, but anyway. Oh, questions, please come up to the mic. So take turns. And you in the beautiful blue. Hello. Thank you so much for putting this talk on for all of us. My name is Dulce De McCoy. I'm a resident. In thinking about what Dr. Palsner was talking about, belief, I think a really big piece of it, especially here in the United States, is marketing. If we market to the right people, the right product, maybe we can gain that belief. And being in training, I've often thought a lot about my own personal marketing as a psychiatrist. Is that something that maybe being young, you know, getting ready to enter the field, would that be something that you would emphasize to your residents? Maybe it is time to think about your own marketing and your own platform on these social media sites in order to get that buy-in. Well, actually, residents are doing it already. In fact, I'll mention this. One of my new incoming interns actually is probably more famous than I am, believe it or not, because I was hanging out with him. And he does a lot of TikTok videos on mental health topics. And people were coming over to the left and right and saying, oh, hey, you're the guy that got that TikTok on. Oh, I love it stuff. And then, you know, they're sharing contact information. Narcissism never lets you down. Yes. Anyway, but I thought, wow, this is the next thing, really. And I think that many residents, you know, have started creating their kind of social media presence. I think the problem we have is we as the faculty, can we teach them the appropriate guardrails or are there none? I don't know. In terms of professional use of social media for marketing and creating your presence online. It's interesting. There used to be ethical guidelines against physicians advertising as being contrary to the goals of the profession. Those are gone, I think. Those are gone. Those are gone. And I appreciated Nishi Bhopal's talk last year about how psychiatrists can actually do a great service to patients by putting information online and making it more accessible and transparent. But things are changing. I have a very different angle on this. I hope it isn't too much of a downer. At this point in your career, I would emphasize your textbooks, and I mean textbooks. You will not have the time you have now, and it's not very much now, to sit, absorb, think, and start to understand how the pharmacologic, therapeutic, and other tools available to you can be used to help your patients, what diagnoses make sense, which ones are a little hmm. So I strongly recommend you take this time now. As time goes on, there will be more and more demands, professional, social, family. If you don't do that now, you'll never get it. On the other hand, it's very easy with all the automation to let your Internet persona outrun you. And then you'll never catch up. That's not putting your patients first. The basic Hippocratic oath of I will enter the homes of patients for their benefit. And in there you can read so much, such as in the ethics about no sexual relations with patients actually comes out of that. And I would say in this case, putting your own persona in the media ahead of your patients, I think that's something that needs to be thought about, that basic ethic of putting your patients first, which I think is a basic human moral ethic that is in the medical profession, that is not in the larger business world. And we have to hold that dear. You had a question. My name is Vanessa Favaro. I'm a psychiatrist from Brazil. Oh, hello. I was born in Brazil. That's why I'm here. Nice to meet you. I have a question for you because patients are changing. When they arrive at the appointment with us, they have lots of information and lots of ideas because technology has changed the scenario for them. So what do you think about that? Because the patient-medical relationship has already changed because of technology. I think sometimes they are more empowered because they want to be better, they want to improve from their condition. I think that ultimately, I agree with you that the more informed patient could be good, but also there are some downsides because some of them said, I already read this, I want this medication specifically, and I think I have this diagnosis. And if you disagree, then that could be an issue, or really ultimately, well, I guess they'll go find another doctor. But I do think that I still remember patients would find information on the Internet about certain medications. I mean, nowadays they can download Apocrates or the PDR and read up everything, go on forums, et cetera, so they're just as informed. I think the thing that we offer is, yes, in the plethora of information on the Internet or in journals about your condition, here's what I believe will help you. And I think it gets back to what I've always said, which is it comes down to the patient-physician relationship. If you can show them that you're there and listening and understand their issues, then honestly it's not so much the medication or this or that one, it's really the fact that it's an engagement, a relationship that you will help them figure out what the right thing is, whether it's therapy or digital therapeutics or medications. I still remember, this was kind of amazing, one of my patients with severe depression on her own decided, you know what, Dr. Lo, I really want to get a vagal nerve stimulator. Okay. And so she found the neurosurgeon to put it in, and I'm like, and she goes, Dr. Lo, I want you to program. And I'm like, I've not been trained on this. I have zero idea how to use this thing. I never stopped you before. True. Anyway, but because the trust was there, the idea that, hey, you're the expert in me and what I need, she was totally fine with, I talked to a VNS rep about, okay, you got to query it. I still remember it was a pocket PC device. You got to query it, check the values, program it, and then query it again to make sure it was right. Ultimately, it didn't get her depression much better, and she went back to ECT. But, you know, I think it was a great story because it tells you that the power of the relationship was really mattered, not so much because I prescribed this or that. And how was the relationship after all this? Well, she ended up moving back to Wisconsin. That's a great segue for two cases which have no technology involved but I think highlight this problem. So back when I was in private practice in Chicago and I had a depressed techie type come in and he wanted to talk. It was fine. I was doing psychotherapy. It was all fine, and I listened to him for a while and concluded that he ought to be on an antidepressant, and I recommended that, and he said no. He wanted to keep talking. And so given that that was a hard stop for him, I said okay, and I was early in practice so I wanted to get paid, so I'm fine. So I kept this up. This went on for about a year, and maybe he got a little better, but I realized about a year in, this is going nowhere or this has gone about as far as it's going to go. He really needs an antidepressant, and was about to confront him on this, and then it turned out he had a new girlfriend and he was feeling better enough, and he said, you know, I'm feeling better enough. I'll terminate, and he was not that much better. I don't think his scores would have been very good. That and another case came together. This was while I was now an academic and answering an emergent call from another colleague who had a lab assistant and so on who was very depressed, and fine. So I'll stick around. I'll go to dinner late. Fine. Saw the patient. This was somebody with a lot of technical knowledge, and so after doing the rather involved history because I'm going to be treating this patient out sort of in the wild. I can't lock him up or anything. He was depressed. I said, yeah, I'd recommend an antidepressant. I'm guessing you have some knowledge about this because he's a pretty intelligent person working in a biochemistry lab, and sure enough he did, and so I said, fine. He mentioned a drug which one of his relatives had taken, so I said, fine, here's the PDR. Read up on it. I'll go find my prescription pad, and if this is the one you want, I'll prescribe it. And it was all fine. Where this goes next I was not expecting, so I wanted to hear from him a day later to make sure he was still okay because he was suicidal. I was going to handle this just out there, and if he'd done something he would be right there in the hospital. That wouldn't have been very good. So I was a little nervous about that, and finally I was able to see him on Friday lunchtime. So he comes in, and he's clearly better. He says he's better. Any problems with the medication? I never felt a prescription. Talking to you was so helpful. And what all these cases highlight is that there's a lot else going on besides your digital or drug intervention, and what you're pointing out is, thanks to the readily available information, it even front loads the problem. The patient walks in with a whole bunch more stuff, and I have no solution to that problem. Patients are, in that sense, more complex. What hasn't changed from the guy who simply came in and said, I don't want any drugs, he couldn't name them, he just didn't want them. Can you work with that and see where it goes? And the only problem is you may not respond as fast as the Internet does, so maybe the patient's got to go back. But, yeah, it's a real challenge. In this talk about reflections on technology and psychiatry, we are concluding with the importance of the doctor-patient relationship and the importance of relationships in psychiatry. Dr. Pauser has not been my clinician as a psychiatrist, but he's been my professor, and even to this day, 30 years later, whenever I see patients, I do say, well, what would Seth do? I mean, and what would Seth say about this situation? And I think that that's, I just say that as a concrete example of how a relationship gets carried on into your everyday actions, I mean, decades later. And so, I mean, when we get, can a pill do that? Can an app do that? So it sounds like our reflections are ending with the importance of relationships. Well, thank you. Any other thoughts or questions? Dr. Takashita. Yeah, hi. I'm Junji Takashita from the University of Hawaii. The issue about telemedicine is really interesting. I've had some recent cases where it showed some of the deficiencies, and there were kind of really practical ones. One was at various nursing homes where the nursing assistant would just shove the iPad from the patient's face and completely confused, much worse than their usual, because they're increasingly confused, much worse than their baseline. So case two was another patient who had pretty severe depression, was an outpatient. The outpatient psychiatrist didn't realize how much weight the patient had lost because all you could see was the face. The patient was admitted to the hospital. BMI was 14. Wow. But you could see why it was this, because if you just look at the face, it wasn't too bad. So some just practical limitations. And if they're malodorous, they haven't bathed in weeks, you don't get that sense. There are some things that you still miss, and I think in terms of building that connection, you still need some connection. It's much harder to do through video unless you're incredibly skilled, and I think a lot of the people who are doing it are not incredibly skilled. So I think having that face-to-face interaction really makes it much better. On top of that, I was going to say there are actually residents graduating now in the COVID time who actually have never seen an outpatient in person. Wow. I know some graduates of local programs have done only their outpatient by telephone, not video, telephone. And I worry. I worry about, wow, that graduating resident is going to have a steep learning curve when they see patients in person because that's going to be an awkward experience for them. You hope they have a learning curve. I hope they have a learning curve, correct. Dr. Bouvalde. Thank you so much, panel, for doing this workshop and discussion on the reflections of technology and psychiatry these days. I'd love more to hear about it. But I had a concern. I think you know that I'm from Europe and Amsterdam, and we live in a small country, 16 million, 18 million people. In the Netherlands, right? In the Netherlands, right. And Microsoft is coming, and they said, okay, we need a hub for all this AI transmissions and doing all these technologies in Europe as well. And then the government said, well, you can come. And thereafter said, we cannot come because we have a burnout of our electricity system. So it costs a lot of electricity and a lot of energy. And we are now in the age, and I thought I would have heard more about it, the climate change issues we have in the world, and we have to overcome that. Can you reflect on this, how you think about this difficulty? How can we? Because the G5 and maybe the G6 and all the systems going to absorb more and more energy. So what are we doing if we do not have electricity at home? Doctor, are you giving us, as we would say here, a slow pitch that he's very worried if we don't quit burning up all this energy training on large language models, the Netherlands really will be underwater? I assume that's where you're headed with this. Well, then we will hire up the dykes. So that's not an issue because we have smart technicians, but I'm more worried about the United States because we have to get things, dykes, also in the United States. Oh, no, we don't. We have more land. We'll just move to the high ground and Dr. Balfe will find herself at the center of everything because it's far enough in and high enough. And the University of Utah will be number one. Unfortunately, although this sounds like a horrible joke, I'm afraid it's true. I mean, if I step back and look at things from my cultural understanding around the world, I do truly believe that the Dutch engineers, whom Phillips is a wonderful example, will do their damnedest to keep the dykes and the various techniques to hold the water back, but we're not sure. Are you guessing that Dutch engineers over the Italian ones? I'm not going there. I'm just not going there. Actually, I'm very worried about Venice. But seriously, I'm afraid the cultural attitude in the United States is kind of go west, and since we've made it all the way out to California, it'll be go Midwest. And I'm afraid that is exactly what we do. And I already had a conversation with a colleague back in New Haven who inherited property in Florida, and the question is, do you hang on to it? Do you sell it? Do you try to gauge when the demand, because the sun is still wonderful, will be countered by the rising water? I mean, this is lunch conversation here in the United States. So I'm not optimistic. I'm really not. I remember when one of the first MRI machines was at Yale, and they said that it used as much electricity as half the city of New Haven or something like that. Oh, sure. And now they're saying that about AI in Palo Alto, that five graduate students doing AI at Stanford are using as much electricity as half the city. And of course, we all know about the climate crisis. So it's a very good point. So maybe we should build some more windmills and all that kind of stuff. I was waiting for you to say that. This is an open door, so I thought I would step in. Yes, I assume that's where you were going with this, that you were going to set up wind power. By the way, I'm afraid she's brought up a really bad tradition of using however much power it takes, and who cares what happens to the environment in pursuit of technology. Well, then you're super cool. No, no, no. This is really grim. We joke about it now, but one of the first examples of this that was really huge is the Tennessee Valley Authority power going into the purification of uranium for the atomic bomb. And I believe it was Neil Bohr, Copenhagen, who when he got a chance to see this, somebody turned to him and said, you claim that it would take a country's economy to make a nuclear weapon. And he pointed to what was around him and said, looks like you've done that. And so we have a terrible tradition, which we're going to have to watch, of using however much power it takes to make the next technical advance, whether or not we like the long-term outcome. It's a real problem. On that upbeat note, have you got a good way to summarize? Well, I was going to say that it is 12 o'clock. I am impressed you all stayed. Thank you very much. I felt it's a last day session. I figured it would be like two people. Anyway, but I really want to thank you for coming and your questions. And I think this was a great session. Thank you.

Technology in Psychiatry

Electronic Health Records

Telepsychiatry

Digital Therapeutics

Artificial Intelligence

Virtual Reality

Doctor-Patient Relationships

Privacy

Therapeutic Relationships

Emerging Technologies

Environmental Impact

Patient Engagement

Psychiatric Practice