Being Essential in the Time of COVID-19

The place of psychiatry within the field of medicine is ever evolving. The current COVID-19 pandemic has raised a number of issues related to the role and importance of psychiatrists compared with medical colleagues at this time of widespread illness and massive changes. Psychiatrists have long existed in a medical system that at times undervalues our work, and distances us from mainstream medicine. Both public and private insurance in the US limit payments for mental health treatment in spite of the law mandating parity.¹ We live in a society that gave five Academy Awards and a Golden Globe to a film portraying a psychiatrist as a cannibal.

Our medical colleagues are struggling on the front lines of this pandemic providing direct treatment to patients infected with COVID-19, while feeling anxious about their own exposure to COVID, and lack of access to appropriate personal protective equipment. Does this crisis require psychiatrists to reevaluate their role in the overall system of medical care?

We have heard some of our psychiatric colleagues expressing guilt about the ability to see patients via telehealth while inpatient and emergency room physicians continue to see patients in person.

Others wonder if adjustments in schedules and patient flow will indicate to administrators that a smaller number of psychiatrists than are currently hired are needed to perform the clinical work. Other psychiatry colleagues wonder if the current pandemic has led to a reemergence or continuation of the belief that psychiatry is considered a “luxury” or “non-essential” field. Many hospitals have announced that non-essential staff can stay home, but have not specified who is essential, leaving us each to answer that question for ourselves.

The mode in which psychiatrists practice may be more flexible than that in other specialties; however, it is our firm belief that now, more than ever, our services are both essential and invaluable. We are tasked with treating patients who are struggling with fear and uncertainty related to this pandemic, even if they are not infected with the virus.

These patients may be established outpatients, they may be patients presenting to emergency rooms with primary psychiatric symptoms, they may be medical inpatients wondering about their diagnosis, or they may be psychiatric inpatients unsettled by the current climate. Patients not physically ill but quarantined at home are struggling with social isolation and how to effectively manage anxiety related to the pandemic as well as their ongoing baseline psychiatric conditions.

Medical staff burdened with longer hours, insufficient personal protective equipment, separation from their families, increased rates of patient loss, and in some cases the need to triage access to ventilators will inevitably struggle with the impact of this crisis for the foreseeable future. Psychiatrists will have a unique role to support our colleagues who have anxiety and depression as well as those who feel guilty or inadequate.

Consultation-liaison psychiatry in particular will have to adjust and reassess the best approach in this situation. Consultation-liaison psychiatrists generally have the closest relationships with medical/surgical teams and the most experience regarding these colleagues’ struggles. Consultation-liaison psychiatrists also travel throughout the hospital system, which we must now avoid because we can be vectors of disease throughout the various patient units.

At our large, urban, academic medical center we have therefore, along with the outpatient services at our hospital, been adopting telehealth to the greatest extent reasonable for consultations. We have adjusted our usual face-to-face encounters to align with best practices to minimize exposure of both clinicians and patients. In doing so, we are not, as some may fear, undermining the importance of our work. We are demonstrating that psychiatry can be a flexible, adaptable, and practical specialty responding in a medically appropriate manner to this public health crisis while continuing to provide excellent clinical care to our patients.

We have found so far that our consultee services have appreciated that we are available but are not using personal protective equipment that may be needed for urgent medical crises during this pandemic. Patients have expressed appreciation that by using telehealth they can see our faces and we can see theirs, which they find more comfortable than having a very personal conversation with face masks in place.

Younger patients have requested that they continue to be permitted to see us via telehealth even when the risks are over, because this is a very comfortable medium for many of them. We have found using telehealth to be much less of an ethical compromise than abbreviating the duration of evaluation, reducing the number of visits we can give a patient, using up the limited commodities of personal protective equipment, or risking exposing our patients to our own germs.

In encouraging others in our field to consider adopting telehealth as the preferred modality during this pandemic, we are thinking about public health first and foremost, and endeavoring to provide excellent care for patients in a flexible way that doesn’t put anyone at unnecessary risk. None of that means psychiatry is optional or expendable-it means we are medical doctors who are part of the solution, not the problem. The effects of this pandemic will be enduring and grim, and we, along with our psychiatric colleagues, will play a vital role in recovery.

Disclosures:

Dr Allen is Assistant Professor of Psychiatry, Division of Consultation-Liaison Psychiatry, Columbia University Medical Center, New York, NY; Dr Mishkin is Assistant Professor of Psychiatry, Division of Consultation-Liaison Psychiatry, Columbia University Medical Center, and Psychiatric Consultant, Blood and Marrow Transplantation and Cell Therapy Program, Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Appelbaum, P, Parks. Holding insurers accountable for parity in coverage of mental health treatment. Law Psychiatry. November 14, 2019; Epub.