The 2019 coronavirus (COVID-19) pandemic has disrupted residency programs across the country, as rotations have shifted to meet healthcare needs and patient interactions have transitioned to virtual platforms.1,2 In psychiatry, some residents have found themselves working on the frontlines caring for patients with COVID-19, whereas others have learned to practice psychiatry remotely. The pandemic has also disrupted the transition from medical school to residency and residency to fellowship programs, as noted by the American Psychiatric Association.3
In a paper published in Psychiatric Services in Advance, Misty Richards, MD, MS, and Katrina DeBonis, MD, of the department of psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, presented some of the challenges and opportunities facing psychiatric residency programs during the pandemic.1 They noted that training directors have to balance “massive workflow adjustments across clinical settings” with resident wellbeing and “preserving educational momentum.”1
Dr Richards and Dr DeBonis highlighted that the shift to telepsychiatry and remote learning have been fairly rapid and successful, overcoming a prior reluctance to utilize telemedicine in educational settings. They also emphasized that the pandemic has presented learning opportunities for illness-related anxiety, psychological first aid, and coping with uncertainty amid crises.
Back to Internship Year
Some psychiatry residents pulled into COVID-19 units have noted that anxiety about their fitness and capability for frontline care is unfounded.4 After all, psychiatry residents handle cases in intensive care units during their internship year, and their essential medical knowledge makes them competent enough to work under an attending physician with more experience.
In fact, as 2 resident physicians in psychiatry at Massachusetts General Hospital in Boston recently noted, “Having a psychiatry resident instead of an internal medicine resident as your doctor may actually offer unique benefits.”4 Their training and perspective may help them cope with patients’ delirium, posttraumatic stress disorder, and psychological distress over the course of treatment.2,4
Shifting to Telepsychiatry
In their paper, Dr Richards and Dr DeBonis wrote that telepsychiatry may present unique challenges for inpatient units and partial hospital programs, with psychiatrists implementing partial telepsychiatric care, especially for family meetings.1 They stated, “Direct supervision of outpatient visits was the most cumbersome aspect to replicate virtually.”
As Dr Richards and Dr DeBonis noted, some members of the faculty experienced challenges with videoconferencing modalities that they had not previously used. To rapidly transition to telepsychiatry thus required “extensive training, flexibility, and ingenuity.” Similar to other areas of the workforce, the shift to practicing virtually has blurred the line between work and home life.
In a phone call, Ismatt Niazi, MD, a chief fellow in the University of California at Los Angeles Child and Adolescent Psychiatry Fellowship Program, stated that the shift to telepsychiatry made the transition from residency to fellowship difficult. In his program, which implemented an online orientation in addition to treating patients virtually, the lack of in-person interaction limited contact points and training opportunities for new members of the team. “For people who are starting training,” Dr Niazi noted, “a barrier is the lack of community.”
Psychiatry and Palliative Care
During the surge of COVID-19 cases in New York City in March and April of this year, psychiatric trainees at New York-Presbyterian Columbia University Irving Medical Center participated in a psychiatry-palliative care liaison team. This shift allowed advanced trainees to provide compassionate end-of-life care in the context of a strained healthcare system. Furthermore, by covering increased healthcare needs during the pandemic, these trainees facilitated the availability of palliative care specialists for challenging cases.
This model was explored in a paper published in the Journal of Pain and Symptom Management by Daniel Shalev, MD, and colleagues at New York-Presbyterian, Columbia University Irving Medical Center, and Weill Cornell Medicine in New York City. The paper followed the work of 16 trainees in the Adult Palliative Care Service. The study authors noted, “[P]sychiatrists are more likely to be available than other potential collaborators like emergency medicine physicians, hospitalists, or intensivists.”5
Trainees were supervised by consultation-liaison (CL) psychiatrists and palliative care teams and given written and online materials to prepare them for COVID-19. The care team dealt with up to 16 new consults per day, mainly focusing on goals of care, family distress, and psychosocial challenges, and were rotated on to the new service 1 to 3 days each week. In addition, training in communication skills and a biopsychosocial approach develops psychiatrists as suitable candidates for meeting palliative care needs during crises.
We spoke with Dr Shalev to learn a bit more about how his program coped with the disruption caused by the pandemic and how psychiatry trainees learned to adapt to current palliative care settings. This model of shifting personnel during a crisis may provide insights for other settings with different resources and needs.
What were the main challenges in providing instruction/guidance? How did instructors alter their approach to meet trainees’ needs?
First of all, in terms of instruction, I think there was a shift from a formalized didactic curriculum toward something much more driven by learners’ just-in-time needs. As trainees were shifted from their regular roles to new and oftentimes novel roles, teaching needed to adjust to address the trainees’ ability to successfully fill those roles. I think trainees actually took ownership of guiding instructors to address those topics that they felt they needed immediate instruction in, whether that be palliative care, ICU basics, or the psychiatric aspects of COVID-19.
The other major change I noticed from my perspective was a shift toward a more explicit stance about trainee wellbeing. I think that in the past, learning and wellbeing were implicitly categorized as separate domains of medical training. During COVID-19, I got the sense that successful teaching coupled emotional and social support with the transmission of information.
Which aspects of normal training are you most worried about psychiatry residents missing out on during the pandemic?
I think that psychiatry trainees being redeployed into medical settings — whether they be palliative care, or even medical wards or ICUs — need guidance and coaching about managing their dual identities and skillsets. On one hand, psychiatry trainees working in these settings need to utilize appropriate medical skills as needed. On the other hand, psychiatrists can bring unique skills and perspectives to these roles in terms of their ability to support patients and peers, recognize neuropsychiatric illness in medical settings, and utilize their communication skills.
But this isn’t something that folks are inherently trained to do. Trainees need guidance into how to successfully navigate these dual identities and to translate their “psychiatry skills” into the world of COVID-19. I am concerned that trainees did not have access to that sort of instruction.
What learning opportunities did this unique experience present, and how were they incorporated into your training program?
The concerns I noted notwithstanding, I think COVID-19 has given psychiatry trainees an opportunity to practice their skills and bring their knowledge to completely novel settings. Having the opportunity to reflect on what you as a budding psychiatrist can bring to an ICU team or a palliative care team is an incredible way to consolidate skills and identity, to develop novel problem-solving, and to learn more about your specialty and skills in the most intense setting imaginable. With the appropriate instruction and support, this is an amazing opportunity. I felt that our rotators on palliative care were learning the basics of serious illness communication on the fly, and also using their psychiatric skills at the very highest levels to manage a completely novel situation.
What concerns should training directors be thinking about moving forward as new waves of COVID-19 emerge, or as cases recede and programs can return to prior schedules in some form?
I think working with the larger institution to operationalize rational redeployment is so important. During the first wave, we were really caught off guard. People were sent wherever they were needed without much planning about where their skills would be most useful. If we should experience new waves of the pandemic, I think it’s an opportunity to figure out how to assign trainees to high-needs areas that are most complementary of their skills.
For instance, I felt that the use of our psychiatry trainees in the palliative care setting was a great solution. Our trainees’ communication abilities gave them a huge leg up in developing palliative care skills rapidly, and they were able to work at a high level quickly, while also feeling like they were using a range of skills familiar to them from their primary specialty.
What lasting impacts might COVID-19, as well as the corresponding shifts programs made, have on residency training in psychiatry in the long term?
I think it’s too early to say. My hope is that this will spur psychiatry to continue to integrate more fully into the medical community at large. Our skills are so important in the hospital, and I think expanding the traditional CL model to thinking about ways of integrating psychiatric expertise across a range of settings, including palliative care, will expand the impact we make on patients’ lives, enrich the roles and options available to psychiatrists, and make our field as a whole stronger.
- Richards M, DeBonis K. Psychiatric training during a global pandemic: how COVID-19 has affected clinical care, teaching, and trainee well-being [published online June 30, 2020]. Psychiatr Services. doi:10.1176/appi.ps.202000277
- Stone W. Doctors in training learn hard lessons during the pandemic. https://www.npr.org/sections/health-shots/2020/05/18/858224183/doctors-in-training-learn-hard-lessons-during-the-pandemic. May 18, 2020. Accessed August 15, 2020.
- Ernst C, Kerlek A, Thomas L. Transitioning to residency during COVID-19. American Psychiatric Association. https://www.psychiatry.org/residents-medical-students/medical-students/apply-for-psychiatric-residency/transitioning-to-residency-during-covid-19. Accessed August 15, 2020.
- Turban J, Anderson C. We’re psychiatry residents. We will take good care of you if you get Covid-19. STAT News. https://www.statnews.com/2020/05/13/psychiatry-residents-provide-good-medical-care-covid-19/. May 13, 2020. Accessed August 17, 2020.
- Shalev D, Nakagawa S, Stroeh OM, et al. The creation of a psychiatry-palliative care liaison team: using psychiatrists to extend palliative care delivery and access during the COVID-19 crisis [published online June 13, 2020]. J Pain Symptom Manag. doi.org/10.1016/j.jpainsymman.2020.06.009