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Revista Portuguesa de Medicina Geral e Familiar

versão impressa ISSN 2182-5173

Rev Port Med Geral Fam vol.28 no.3 Lisboa maio 2012

 

EDITORIAL

Electronic counselling: Taking e-mail communication with patients one step further

John Yaphe*

*MD Associate Professor, Community Health, School of Health Sciences, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

Electronic communication with patients is a developing phenomenon in general practice in Portugal. In this journal, we have published three original studies1,2,3 an editorial4 and a case report5 on the use of e-mail in practice. International experience with e-counselling is also growing. It is time to take a closer look at this to assess what needs to change to promote it.

Since arriving in Portugal, my clinical practice has been entirely on-line, counselling patients in Canada. My experience treating over one thousand patients during the past eight years has been favourable. There is a growing body of literature on the safety and effectiveness of e-counselling to support this. Textbook articles describe the technique in both patient care6 and clinical supervision.7

Many social factors have promoted the growth of e-counselling. Widespread use of the internet for social communication has created the necessary infrastructure. In Portugal there was internet access in half the homes in the country by 2010.8 Pressures on the health care system have made access to care difficult in some places. Both rural isolation and urban crowding with increased demand for services are at work here. Family doctors are becoming increasingly sophisticated in their use of electronic media for patient records, information retrieval, professional communication with peers and communication with patients. Smart phones are in the pockets and purses of many doctors and patients and they are filling up with useful medical applications. Finally, developments in communication and therapeutic skills in general practice are being translated to the electronic forum and doctors have discovered their power in caring for their patients.

The recent Portuguese publications quoted show how doctors help patients with appointment times, test results and practical advice on-line. Evidence from other settings has shown how this can be extended to the assessment and resolution of medical issues on-line. While this will never completely replace the face to face medical encounter, it can be a useful adjunct to traditional services.

My practice is part of an employee assistance program. Workers in many companies have free access to on-line counselling services in addition to face-to-face and telephone counselling. Their counsellor is as close as their computer. They enjoy access at any time of day or night, with a reply in a day or two. Writing down issues is therapeutic in itself. Patients enjoy privacy and anonymity especially for topics they consider to be embarrassing. E-counselling provides words to hang on to. Exchanges may be printed for reading at a later time. Patients with agoraphobia or speech fluency disorders may especially enjoy e-counselling. I have reported on the use of family oriented e-counselling for a child with chronic abdominal pain related to unresolved grief of the child’s mother. This resolved after a number of on-line exchanges.9

Other advantages of e-counselling are related to the techniques used rather than the medium. A model called the CARE model draws on the spirit of humanistic psychology and the methods of cognitive behavioural therapy. The letters stand for connect and contain, assess and affirm, reorient and reaffirm, and encourage and empower. In three or four e-mail exchanges these four steps can be covered.

Many issues have been successfully managed by e-counselling. I have treated hundreds of patients with anxiety, depression, marital conflicts and parenting problems. A significant number have work-related issues, as expected in an employee assistance program. Some patients deal with grief and mourning in the on-line forum as we have demonstrated in another case report.10 As the only medical doctor in the current team of 50 counsellors (others have graduate degrees in social work and psychology), I tend to be assigned clients facing issues with a medical flavour. Many patients in recent years have discussed coping with cancer or the effects of cancer on their families. Other clients have focussed on heart disease, diabetes, chronic neurological disorders and dementia in loved ones. Each story is unique but the principles of patient-centered care with a family orientation can be applied as they are in the office visit for similar issues.

Some problems are less appropriate for e-counselling. There are concerns about missing non-verbal cues, or failing to identify the patient in danger. There are safeguards in place on-line although these don’t always work in the in-person encounter either. Patients requesting e-counselling are screened for suicidal risk, risk of harm from others, addictions or formal thought disorders. There is a low threshold for referral to traditional services although the numbers of patients denied access to e-counselling for these reasons is small. Some patients facing toxic issues arising during e-counselling have been helped successfully to overcome them with a transition to traditional helping services.

A pilot e-counselling project has started in Portugal in the health care region of West Porto. Pioneering clinical psychologists have started to provide on-line written counselling services to employees in this region. Initial evaluation of the service has been positive. This will remain a tool in the range of services available for employee assistance here.

For this technique to develop further, family doctors need additional training in counselling skills in the office setting. Specific writing and on-line skills need to be developed to translate counselling skills to the electronic medium. Legal, insurance and data security issues need to be addressed so that doctors and patients can enter into a therapeutic on-line relationship with confidence.

Electronic counselling has shown itself to be a viable therapeutic option in many settings around the world. Portugal possesses the human resources and technical infrastructure to make this happen too. This journal would be pleased to promote this development by publishing the results of case studies, educational programs and research trials of this exciting new treatment method.

 

REFERENCES

1. Pinhão R, Calisto M, Pimentel MA, Fernandes R. Implementação da comunicação médico-doente via endereço electrónico na consulta de MGF. Rev Port Clin Geral 2009 Nov-Dez; 25 (6): 634-8.         [ Links ]

2. Granja M. O uso de e-mail na comunicação com o médico de família: catorze meses de experiência. Rev Port Clin Geral 2009 Nov-Dez; 25 (6): 639-46.         [ Links ]

3. Ponte C. A utilização do correio electrónico na comunicação com os utentes da USF Porta do Sol. Rev Port Clin Geral 2011 Mai-Jun; 27 (3): 274-80.         [ Links ]

4. Santos I. As consultas por correio electrónico e as mudanças organizativas na Medicina Geral e Familiar. Rev Port Clin Geral 2009 Nov-Dez; 25 (6): 626-7.         [ Links ]

5. Botas P, Santiago LM, Constantino L, Miranda P. consulta@mgf.pt: um caso de comunicação médico-utente via correio electronic. Rev Port Med Geral Fam 2012 Jan-Fev; 28 (1): 50-6.         [ Links ]

6. Yaphe J, Speyer C. Text based online counselling: E-mail. In: Kraus R, Stricker G, Speyer C, editors. Online Counselling: a handbook for mental health professionals. 2nd ed. Amsterdam: Elsevier; 2010. p. 147-168.         [ Links ]

7. Yaphe J, Speyer C. Using email to enrich counselor training and supervision. In: Anthony K, Nagel DA, Goss S, editors. The use of technology in mental health: applications, ethics and practice. Springfield, IL: Charles C Thomas 2010. p. 194-205.         [ Links ]

8. Taborda MJ. A Utilização de Internet em Portugal 2010. Lisboa: Lisbon Internet and Networks Institute; 2010.         [ Links ]

9. Yaphe J. The healing power of the written word. Forum J Irish Col Gen Pract 2009; 26: 17-20.         [ Links ]

10. Speyer C, da Silva E. Composing oneself in e-counselling: a case study. TILT Magazine 2012; 9: 25-32.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

I have been an e-counsellor with Shepell ·fgi since 2004 but I have no financial interest in the publication of this editorial.

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