Technology and Education​

September 25, 2019

Double Take with Ivan Silver

David Gratzer: We're joined now by Dr. Ivan Silver, who's a professor at the University of Toronto in the Department of Psychiatry, somebody who's had a life-long interest in professional development, and a former vice president of Education here at CAMH. Welcome, Dr. Silver.

Ivan Silver: Thank you for inviting me.

David Gratzer: Dr. Silver, we're talking about how education, particularly medical education, has been reshaped by technology. What are your thoughts?

Ivan Silver: Well, I think it's good to have a framework to think about – where technology actually fits into adult learning. And the most current way of thinking about what we'd like adults to be able to do, as doctors or students who are going to become doctors, is to really be able to efficiently learn on their own, or something we call self-determined learning. And this is covered by a new term, it's maybe not so new, but it was new to me a couple of years, ago called heutagogy, which is the 2019 version of what pedagogy was to adult educators 60 years ago. So it's really about the science of self-determined learning: being able to learn on your own; being self-directed; being creative; being able to recognize your own limits; being able to recognize when you don't know something, and be able to do something about it; be able to recognize the surprises that occur. I believe that technology is helping to enable that for students and practitioners to be effective learners, because with technology, there are so many new opportunities to learn that are not determined by your reliance on a teacher, or a face-to-face contact.

Ivan Silver: So putting it in that context right at the start helps me explain the details, because I think technology is really an enabler of adult learning as we see it today. We don't need to be face-to-face. We can be present with a facilitator, or teacher, or coach, synchronously or asynchronously. We can do it on our own time. We can engage learners around the world, both synchronously or asynchronously. All of these things we take for granted now. But in my lifetime, and my career in medical education, I've seen us go from almost zero to to the point we're at now. And it's quite it's quite incredible how we can prepare learners for face-to-face contact through things like the flipped classroom. Through all the technologies that are available from desktops to laptops to mobile technology. We've democratized education through technology. Take, for example, the MOOC, the sending education out to whoever needs to receive it, even if they can't pay for it, as a stepping stone for them to begin their education.

David Gratzer: Lots to think about what you've just said. But maybe we'll start here. You mentioned with your career, and your own education, going from zero. What was the first big change you think you noticed in education, in terms of use of technology?

Ivan Silver: Well, I noticed in my first year at McGill as a science student. I'd come from a little town in New Brunswick where everything might have been five to 10 years behind. But even so, I'd never seen video-based lectures before. I walked into the into the room with twelve hundred other people and a technician turns on a series of televisions and suddenly the lecture has begun. It goes on for an hour and a technician turns it off and we all leave. And for the entire semester I never saw the professor face-to-face. When it began it was the era of the theory of 'education as transmission.' All you had to do is turn on a video, leave the room, and of course good things would happen. Information would be transmitted into your brain and it would be just as good as being there, and being there to answer questions, which, of course, were absent. When video was first introduced in the university….

David Gratzer: Education happened to people.

Ivan Silver: That's right!

David Gratzer: They weren't active in any way, shape, or form.

Ivan Silver: Right. So I had the privilege, and many people of my vintage had the privilege, of engaging with Richard Tiberius, who was an education doctor assigned to the department of psychiatry. He wrote some very good papers about the shifting of education from the transmission theory to the person-engagement. The education as learning through relationships and through people. And I think technology, when it's used properly, can do that just as well. And, in fact, should be seen as a synergy with the face-to-face as each embellishing the other.

David Gratzer: You spoken enthusiastically about technology. What are some things that you see are really improving with better use of technology in terms of medical education?

Ivan Silver: I talked about the democratization. I think that's still in development. I think the MOOC is kind of a primitive form of that, and my sense is that MOOCs are dying. That it was very popular five or 10 years ago, and many of them have not, or cannot, be sustained even from a financial point of view. I think, on the other hand, when you're living fifteen hundred kilometers in Canada away from the source of information, or the opportunity to engage with other learners, and you have no opportunity, if you're a busy doctor in practice, to leave your practice, but you can engage online, that's a wonderful development. That's another example of democracy at work, just in time learning, so that 24/7 you can decide what you learn, how you learn. Whether people take advantage of it is another matter. Sometimes you can accommodate to the comfort of it just being there, but never using it. That's another issue. I think through technology use there are more opportunities for people who know things, who are trying to help enable others to know what they know, there's more opportunities for that to happen through technology – virtually, asynchronously, synchronously. Just the simple fact, in practice, when you're in a clinic, that your questions can be answered immediately if you're going to the right site. That's a pretty amazing thing compared to when I first went into practice.

David Gratzer: When you went to the library, perhaps, to ask the librarian for help?

Ivan Silver: Many, many hours in the library. And I still use the library, but now I've created my own digital library of evidence-based practice. I have, maybe, three hundred folders that this new information goes into. I actually read all the articles before I file them. I also have this wonderful digital file for access by the residents who train with me. In the olden days, I had five file cabinets full of these articles and many depressing days of trying to keep those up to date and throwing papers out, adding papers in, and then having to cart them around with me from job to job. And now it's all digital. It's all in folders. I can access it anywhere in the world. It's a wonderful feeling. It's almost like a transitional object that you can carry around with you all the time. So if you don't know the answer to something, you know it's pretty close to you, if you know where to look. I'm not sure we're there yet, in psychiatry, in having that kind of useful information to make it really "just for me learning." I think "just in time" is here, but "just for me" I don't think has arrived yet.

David Gratzer: In part because we don't have the real time data to build on. You've spoken enthusiastically about how medical education has changed with technology, and how it will change with technology, but what have we lost?

Ivan Silver: That's a difficult question because I'm not sure we have the evidence of whether we've lost anything. I think it very much is based on how technology is used. But there's the danger, of course, of losing the humanity in medicine if a technology is abused, or if it's not combined in some way with real person contact. Through technology you can engage others together in learning. You can, I think, have an even more intense relationship, practically speaking, with your facilitator or your teacher because of the tools that you have available to stay in touch. I just came from a medical education meeting in Vienna last week, and although I didn't have an opportunity to meet them before, what we created in a workshop has turned into a whole other kind of conversation leading to a couple of research projects with people I never met before from eight different countries. This never would have been possible – it just never would have happened – without technology.

David Gratzer: Thinking about tomorrow. What do you think are some future applications of technology in medical education?

Ivan Silver: When I mentioned that term heutagogy, I'm not sure we are doing the best job of preparing learners to use technology going forward. And we don't know what technologies are going to be available in the future, but even the ones that we have available now, I don't think we have determined what a lifelong learning curriculum looks like for students or residents. I think some work needs to be done to create that curriculum, to make it explicit that learning about learning is actually a part of all residency programs, no matter what the specialty. So the goal here is really to create capable learners. And I think technology has a huge part in this. In addition to being able to determine what competencies need to be updated, being able to identify new ones, being able to identify your gaps in learning, a lot of this can be aided through technology. I mentioned this already, but the "just for me" framework, I think needs needs work. So occasionally we get a pop-up to say that some medication we've prescribed distance doesn't fit with other medications. That we should think about that before we finish the prescription, but that's about it. What we don't get are pop-ups with suggestions around evidence based articles that go with this. And it's not just for the individual, it's for the whole health care team.

Ivan Silver: Another aspect that is just beginning to get some attention is the impact of technology on the future of the earth. In other words, the relationship of technology to greenhouse gases. So when I was over in Vienna, I was told that to get there from Toronto, I had used one and a half tons of greenhouse gases going and coming – just for me – and there were 4,000 learners at this conference. And nearly all of us had come on a long plane trip, some longer than mine. And is this going to be sustainable as a way of learning? So, where will technology fit into the future of conferences? Certainly, I don't think we can sustain air travel the way we have if we're going to reduce CO2 emissions. What I'm imagining might be more immersive than actually being there. Because what's worse than sitting in a room with 4,000 people, so far away you can't actually physically can't see the person, you're only seeing them on the video screen? So, I'm imagining something that actually might take us further. And I think the technology, from a cost point of view, wouldn't be as much as bringing all those people, and it wouldn't have the same impact on the Earth. And I think we're going to need to start to think like that.

Quick Takes with CAMH Education is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at PorticoNetwork.ca/web/podcasts. If you like what we're doing here, please subscribe. Until next time.

September 25, 2019

Double Take with Peter Selby

David Gratzer: We're now speaking with Dr. Peter Selby, who's a physician here at the Centre for Addiction and Mental Health in Toronto, and he's also Chief of Medicine in psychiatry. Welcome, Dr. Selby.

Peter Selby: Thank you.

David Gratzer: Dr. Selby. I know you've a keen interest in education. Can you comment on the current state in terms of technology and education?

Peter Selby: Technology has helped us really make education much more accessible to providers, especially busy providers at the frontline, so I think it's a great advance that people don't have to come into a geographic classroom to learn and gain knowledge.

David Gratzer: What are some examples of the way that access gap has been bridged?

Peter Selby: So we've see a plethora of online self-study modules and webinars that provide traditional models of teaching, like lecture style, but they are accessible online. That allows people to access them when it's convenient to them rather than breaking up their clinical day. They can actually access this wherever – they can attend grand rounds et cetera. So that you're seeing as a use of technology. Then you're seeing more in-depth self-study modules where there's more instructional design and you're having people actually take some time to design interactive learning objects and people can use that as self-study to really get some more sort of learning. You can have video, you don't have to have just written material. And then you have, of course, online courses where people register and they form an online community and learn together over a period of time. So there are variety of things that technology has enabled. That really speaks to this issue of synchronous learning versus asynchronous learning, and that's where we are currently.

David Gratzer: I'm working with a resident who had a question about the titration of a medication, so she went to UpToDate, learning on the fly. What are other examples of just in time learning that excites you?

Peter Selby: Just in time learning. In fact, just yesterday I was talking about this because the amount of information coming at us is doubling and tripling within short order, in medicine, it's impossible for us to know everything. And so I think the future might be some sort of app or jackpot that's in our pocket that when we put in someone's symptoms, it, on the fly, teaches us about those things. And then it stimulates us to then go back and learn about it. If it's relevant to our work, we're going to see those cases again. So I think using the handheld smartphone as a way to actually put technology and education in our hands and, in a way, are external brains, because our brains aren't big enough to hold all the information being generated.

David Gratzer: Dr. Selby, education's really changed in recent years. Why don't we talk about a few of these developments and get you to comment. VR.

Peter Selby: I think VR is a great opportunity in its variations to create immersive experiences for learners so that they can actually learn skills and, potentially, attitudes. Because now you're going to activate more affective learning styles as opposed to just cognitive information that's dry. With VR there's potential for body learning. So, in a way, the (psycho mode of learning) may help us learn in different ways, and for different types of learners who prefer to learn different ways. But you'd get different modalities to get the information into the person and incorporate it.

David Gratzer: Simulation.

Peter Selby: Simulations are great ways to build skills. And we've been using it to help people understand and deal with things like prescribing opiate agonist therapy or methadone to patients. And in the simulations, they actually get to see what it's like to be a patient. They actually get to talk to a patient and they have to really practice translating the guidelines into simple language that the patient can understand. And so they really can simulate a lot of skills, of communication skills or practice skills, and we can observe and give them real time feedback as they're doing this in a safe place.

David Gratzer: What is something that we might worry about in the current state of using technology in education?

Peter Selby: The biggest risk is self study without actual demonstration of performance. And I think that's the challenge. The bulk of things I see online do not actually test the person for performance, but that's the same for in-person classes as well. I think that's a problem in education, continuing education specifically. We just do it, and people like the food and the interactions, but then we don't spend the time to actually see whether they got what they said they needed to get at the end of the course and did they actually put into practice. So I think that's the risk with technology: that you can create it, but if you don't evaluate it, there will be a problem.

David Gratzer: You've been involved in many education projects over the years and have had education leadership positions as well. What's an education project you're particularly proud of?

Peter Selby: So the TEACH project was essentially started to create capacity for different healthcare providers to deal with the number one addiction in Canada, which is tobacco addiction. There was a gap, so we identified the gap. We identified the need and we created this course that had a core course that lasted 18 hours, so to speak. And then we added additional hours to create a certificate for 40 hours. And that has been so attractive to the variety of health care practitioners across the province.

David Gratzer: What are some of the metrics around this program?

Peter Selby: The metrics are: we do a baseline assessment and we look at outcomes immediately after and then three and six months later. And so we are seeing practice change, self reported practice change, at six months.

David Gratzer: How many people have gone through the course?

Peter Selby: Fifty-five hundred.

David Gratzer: Fifty-five hundred. Right across the province?

Peter Selby: Across the province. And because it's now online, it's an online course, we're getting people from different parts of the country. So this ecosystem that has developed around the course has been a really interesting way to move the needle forward.

David Gratzer: What's an example of the impact TEACH has had?

Peter Selby: We went from dissemination, capacity building and education, and now we have a technology enabled platform called Stop. And we've been able to implement that, with these practitioners, in over 85 percent of all family health teams in Ontario, 75 percent of CHC (community health centres), 75 percent of nurse practitioner-led clinics, about 40 percent of all the addiction agencies, and about over 50 percent of all the Aboriginal Health Access Centres. This would not have been possible if we didn't have TEACH as an enabler to prepare the soil for implementation.

David Gratzer: Can you give a story about how TEACH has been successful?

Peter Selby: When the Syrian refugees arrived in Toronto nobody realized that they smoked. Much of their money was going towards cigarettes and there was no assistance to help them quit smoking. The problem was they mostly spoke Arabic and there wasn't a lot of support. So through this community of practice we created an Arabic resource that was then enabled and now can be used anywhere in the province when anybody is doing smoking cessation with Arabic-speaking refugees, even if they are not native Arabic speakers. Because with this mechanism, we were able to engage an Arabic-speaking physician to create the content and the technology has allowed us to move. That's the impact of this. It is really an important way for us to look at – that our education is speaking to the issues of disparity of how this tobacco addiction epidemic has affected our populations. And and part of this is, you design for the most vulnerable, you'll end up designing for everybody.

Quick Takes with CAMH Education is a production of the Centre for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at PorticoNetwork.ca/web/podcasts. If you like what we're doing here, please subscribe.
Until next time.

September 25, 2019

Double Take with Sanjeev Sockalingam

David Gratzer: Joining us now on Quick Takes is Sanjeev Sockalingam who is a psychiatrist, Vice President of Education here at CAMH, and recently he became a full professor at the University of Toronto. Doctor, we're talking about technology in medical education. How are things likely to change moving forward?

Sanjeev Sockalingam: Well, David, I think it's an interesting question, because I think change has been some of the challenge in technology in medical education. As I think of some of your earlier podcasts, you've talked about technology and its use in clinical practice. And I think in health professions, and specifically medical education, there's a need for us to consider how we prepare the current and future clinicians to be able to use, adapt to, and incorporate technology into our clinical care. And then with that, how can we use these same technologies that are currently in practice, and as they advance, to better create more accessible, interactive, practice-based types of training opportunities so that we can measure our outcomes better in terms of changes in provider practice, and quality improvement, and better patient care overall.

David Gratzer: Let's talk about your first point. Patients are doing therapy differently. They're learning about care differently. How should education adjust?

Sanjeev Sockalingam: I think we probably don't do a great job in our medical school training, for example, or residency training with our psychiatry trainees. But, more broadly, in postgraduate education and for our existing providers who are seeing patients in their practice. Preparing these students and physicians for how you might have discussions with your patients and how you might handle these challenging encounters. And they're challenging because they're unknown and they may not have experience with apps or wearables (people monitoring themselves), or even basic things like Googling with advanced search engines, websites, blogs, et cetera. So I think as people are starting to gravitate, due to access issues, due to availability for some of these things, that we need to start training our providers on how to have these conversations, be familiar about these conversations. How do they incorporate them into our practice? Are they part of our treatment plans in some way? And how can you do that in an evidence base way, but also be informed – specifically in privacy and ethical issues that might emerge.

David Gratzer: New technologies and new challenges. But you've also touched on new opportunities about incorporating some of these technologies into MedEd itself.

Sanjeev Sockalingam: In medical education we have many of those traditional kind of methods of teaching where people come to conferences, come to classrooms, they have the sage on the stage who provides that wisdom. You know, we've moved the bar in terms of using more interactive evidence-based longitudinal kinds of programs and seminars. But I do think there's unique opportunities to bring education technology to the forefront across that learner continuum. So some specific examples are things that are currently available, like synchronous types of training where people come together in learning communities or in online videoconferencing. So this allows people in their breaks to dial into those networks and have an opportunity to share best practices, cases, and have that truly workplace-based kind of moment with their community of practice. Echo is one program like that that is being provincially launched here at CAMH. So that's an opportunity. There are things I remember in my own master's program – dialling into Blackboard, posting, getting some messages back. And there's more asynchronous ways that are evolving and I think the use of them in continuing professional development is still, I would say, early but evolving. And then I would say, more and more people have talked about simulation. I think in mental health, we're starting to catch up, but initially it was used more in surgery and more procedural type of specialties. As we think about simulation, and how it might not be feasible for everyone to come to a place and practice in a simulation lab, how we can make those more virtually available either through augmenting with virtual reality, or other kinds of digital spaces where we can start to experiment in more team based care. That's probably typical for mental health.

David Gratzer: What excites you?

Sanjeev Sockalingam: If I recall back, things like CD-ROMs and multimedia, were probably kind of the foray of technology in education and medical education. The we went to e-learning as the Holy Grail for medical education.

David Gratzer: Wait, we're not using CDs anymore?

Sanjeev Sockalingam: Well, some of us may be...

David Gratzer: No names?

Sanjeev Sockalingam: No names!

Sanjeev Sockalingam: I do think that what excites me is the possibility of using these technologies in a way that might make it more accessible for individuals. I do think things like virtual reality and online simulations, as they become more cost effective, more accessible, more open source, that there'll be more opportunities to be creative about it and use it in day-to-day education. Probably the other component, to me, is how academic organizations and hospitals use data and information that are collected in electronic health records. Or, dare I say the c-word, which is competency based education. That, as we think about implementation of these programs, there's a large amounts of data being collected about learners in their assessment contexts. With artificial intelligence and machine learning can we use that data to inform future learning? Learning improvements? Insight (give feedback) in a more readily available manner to our practicing clinicians and our trainees?

David Gratzer: One way of gauging how people are doing is exam writing. With the potential of A.I., could we be at a point where we identify learners deficiencies before the exams and address them in real time?

Sanjeev Sockalingam: That's the hope of competency based education in some of these new paradigms. I think technology would be well equipped to really accelerate how we use that in real time for our trainees. Although we may enter them online in the back end, we don't have that data sophistication to be more predictive and proactive.

David Gratzer: To tie back into what you're saying: more simulation, possibly more VR, more data, more A.I. What worries you?

Sanjeev Sockalingam: I guess what worries me is as we move to more technological kind of advances, there are concerns and risks for different professions. Maybe not so much in psychiatry and mental health, but that we will have to train our students to use technology, and that might replace some of the skills that we previously would have been teaching in that curriculum. And so I think that it's a risk that we may lose some skills, and augment some skills, with technology to make them more accessible. We may not focus, and not want to veer too much in technology so that we lose some of those core skills, so that we understand how technology works and can assess its effectiveness. But I also see it as an opportunity to continue to reinforce compassionate care, which is the mainstay of, I would say, of psychiatric care and more person-centric care. And so I do think it presents an opportunity on how we refocus – we just have to be mindful of that balance. I would say the other issue is being able to ensure that we don't fully swing the pendulum to the point where we're embracing these technologies without being critical about potential risks. I do think that without adequate preparation of risks around privacy, we might even see issues around funding, and the same thing as pharmaceutical companies – how device companies may influence continuing medical education as well. So I think we need to be cognizant of these transits as things emerge.

David Gratzer: You did your medical education at the University of Manitoba.

Sanjeev Sockalingam: That's correct.

David Gratzer: As did I. You recall there were big classrooms there, a lot of seater block. Will there be classrooms like that in the med schools of the future?

Sanjeev Sockalingam: So I can speak to the current state and where we might go. A good example would be the revisions and reform in our medical school here at the University of Toronto. With one iteration of advances in moving into online and videotaped lectures, we saw vacancy in those large seminar rooms. You and I can both reflect that there may have been a few vacancies in our time, but probably much more in proportion now as people are watching things at six times speed at home and being more efficient with their learning. But I do think we may move to virtual classrooms where people would dial in from their respective sites. It might keep students closer to the clinical spaces as opposed to having to come into a classroom or seminar room to to hear that sage transmit that information at the forefront and might allow us for more interactive collaborate spaces both virtually and in person in those hospital settings.

Quick Takes with CAMH Education is a production of the Centre for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at PorticoNetwork.ca/web/podcasts. If you like what we're doing here, please subscribe. Until next time.

September 25, 2019

Double Take with David Goldbloom

David Gratzer: We're joined now by Dr. David Goldbloom, who is a senior medical adviser here at CAMH. And he's been very much involved in education and technology through his career, which includes time as Physician in Chief here at CAMH. Dr. Goldbloom, welcome.

David Goldbloom: Thank you. Nice to be here.

David Gratzer: Dr. Goldbloom, we've had an animated discussion talking about the past, present and future of technology and medical education. Let's put you on the spot. What do you think are things we might see in the future? Let's be specific in our ask. What are five things?

David Goldbloom: I would offer five predictions, comfortable in the knowledge that I won't be around to be held accountable for them in a couple of decades. First is that millions more people will be reached in terms of mental health through the assistance of technology than we are currently able to do with our human complement. The second is that technology will reinvent the role of clinicians. Clinicians will not disappear, but how they work will change much as it is changing for dermatologists, radiologists, neurologists and other clinical brethren. The other thing that will change dramatically is how we do research. Because our current ways of evaluating things therapeutically, with the golden aura of the randomized controlled trial, will change dramatically with the impact of technology because technology changes far more rapidly than any form of psychotherapy and more rapidly than any medication. So we will have to come up with new research paradigms. The fourth will be that the human factor will not disappear in our lifetime. And indeed, the most recent article that I've found is about the therapeutic alliance in digital mental health interventions and how we can come up with ways of establishing that. And related to that, my fifth and final point would be as humans, we are relentless, anthropomorphizers. And it is no accident that Alexa and Siri have names so that we take these inanimate artificial things and we humanize them, much as we do with our pets. So I suspect that the technology will also morph to be more and more human-like. And then, of course, raise those big philosophical questions of what is it to be human.

David Gratzer: You see the field of psychiatry dramatically changing in coming years. What are the implications for medical education in light of that?

David Goldbloom: Well, I think medical education is playing catch up. And when I say playing catch up, certainly when I trained, a lot of our reading was based on writings done generations earlier.

David Gratzer: And so how should medical education change accordingly?

David Goldbloom: If you think of our various Can-Meds roles, one of our roles is ultimately to be an expert – and we need to have expertise in the new technologies. That means familiarity. I think that also means taking them for test drives, experiencing them wherever possible, so that we can make informed recommendations to our patients who turn to us for our expertise.

David Gratzer: John Torous has a paper recently published looking at patients who use a mental health clinic in the Boston area. And he talks about whether or not they download apps. Patients 26 and under, something like 100 percent of them, have downloaded a mental health app. It's a different world.

David Goldbloom: Totally. And as Torous has pointed out, there are now about 10,000 mental health apps out there. Doesn't mean they've all passed the smell test of evidence to support their efficacy, but this is mushrooming rapidly. And, yet, I find even among some of my younger colleagues and my trainees, they've never looked at any of these apps.

David Gratzer: But just as a generation ago, we might have helped our patients pick a book on cognitive behavioural therapy, we might turn around and help them pick an app on cognitive behavioural therapy.

David Goldbloom: Absolutely.

David Gratzer: Any therapies are interesting. I mean, some of our colleagues are very hesitant on this, and yet, I mean psychotherapy is about trying to form a connection, and that might be in person, but that might be over the Internet as well.

David Goldbloom: And look, I have seen with patients who I have recommended apps to, that they rapidly personalize those apps. And the app makers are very smart to have a little avatar or a figure, a funny looking robot, who nudges you and stuff. So it quickly humanizes.

David Gratzer: David Clarke makes a point, as you know he's the psychologists at Oxford who's been very involved in expanding psychological services in England, they're now experimenting with online therapies. And they've asked people if they feel more connected with an online therapist than an in-person therapist. And intuitively, you'd say: "Well, how can that be? Your in-person therapist you've shared space with. He passed you a tissue during an unsettling moment in your last session, and the online therapist just pops you an e-mail?" It turns out people feel more connected with the online therapist, at least with the people he's had contact with, on the grounds that the therapist is much more available than once a week. Send them an email on a Sunday, you get a response Monday morning. Tuesday, a response that afternoon, and so on.

David Goldbloom: Look, this is about challenging our own norms, values and expectations as clinicians. Because, generally, people are conservative and not in a big hurry to change what they do. They look for evidence that reinforces the value of what they've been doing for a long time. Many years ago, more than two decades ago, we did a study looking at therapeutic alliance for patients seen via televideo versus in-person in the office. And we found that it was no different. But people still say to me, you know, I don't think I would feel comfortable seeing a patient on a television monitor. It's just not the same for me as all the nuance that I observe when they're sitting in my office. Well, frankly, what counts is not your sense of the nuance, but how did the patient like it and did the patient get better? The rest is icing.

David Gratzer: You bring up televideo. You were actually involved in some of the early experiments here at CAMH, some of the earliest experiments in North America, no?

David Goldbloom: No. In fact, the first use of televideo that's documented in the peer-reviewed literature, I think goes back to Nebraska in 1957. And the latest evidence from Ontario, more than half a century later, is that about 7 percent of Ontario's psychiatrists do televideo work, despite half a century of evidence that this is a great way to overcome the geographic and distribution disparities that exist in almost every jurisdiction.

David Gratzer: Is that a failure of education? Is that a failure of doctor culture? We're using our phones for everything. You suggest not only do relatively few of Ontario's doctors use this technology, but demographically it tends to be older psychiatrists, not younger psychiatrists. What happened?

David Goldbloom: Are you suggesting I'm an older psychiatrist?

David Gratzer: This isn't about you (laughs).

David Goldbloom: Because I'm just prematurely grey (laughs). Yeah. I think it is a failure of education. I think it's a failure to inculcate new models into the curriculum sufficiently aggressively. And I also think we model behaviour as clinicians. So if we're not doing it, the students would say, well, why should I do it?

David Gratzer: What do you think is the downside? So technology continues to change society. Technologies continue to change medical education. What do you think is something we should be wary about?

David Goldbloom: Well, I think the first thing we need to be wary about, and I say this as somebody who's not involved with any social media of any kind, is that people are suddenly waking up to the privacy concerns that have existed since the creation of supposedly "free" social media platforms. And similarly, there have to be significant concerns about privacy in relation to technology. Now, I happen to believe these are not insoluble problems, but we can't be asleep to them. Frankly, before this technology, it was easy enough to have a paper chart faxed to the wrong address, or left in the backseat of your car that somebody could nick. So there have always been privacy concerns – whether it's a conversation in the elevator or something else. But they seem to be magnified by the technology. So the very thing that can increase access, can increase risk in terms of privacy. And I think that's one of the big challenges that needs to be addressed.

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