Psychiatric Training During a Global Pandemic: How COVID-19 Has Affected Clinical Care, Teaching, and Trainee Well-Being

In the span of just a few weeks, individuals around the world were challenged to join forces and fight one of the deadliest global pandemics modern society has ever seen. Coronavirus disease 2019 (COVID-19) has affected virtually all aspects of our daily lives, reminding us of the liberties we once took for granted, including in-person contact with our friends, families, and patients. As we have strived to “flatten the curve,” we have been left to consider multiple systems that must accommodate and continue operating under new restrictions. As training directors of psychiatry residency and fellowship programs, our response to this pandemic has included massive workflow adjustments across clinical settings while preserving educational momentum and protecting the mental and general medical health of trainees. To do so, training directors must provide strong leadership by approaching problems systematically, communicating updates and policy changes clearly, and promoting well-being whenever possible.

Consolidating COVID-19–Related Information

Training future psychiatrists involves understanding and implementing the policies of multiple governing bodies. In the United States, training directors rely on the Accreditation Council for Graduate Medical Education (ACGME) to set the national standard for graduate medical education (GME), which is then upheld by institutional GME offices and implemented within specific departments and programs. With COVID-19, this process has been pressurized, with policy changes that would normally involve months of discussion being implemented in just days. Training directors must filter through the tidal wave of daily e-mails sent from various national and institutional bodies to consolidate information into a uniform message for trainees (1). Providing this trusted source of information enables trainees to understand exactly how COVID-19 may affect their training and helps them feel a sense of control during an uncertain time (2). Furthermore, inviting resident and fellow representatives to high-level meetings where discussions were held around surge planning, personal protective equipment (PPE) guidelines, COVID-19 testing, and workflow adjustments helped engage trainees in the process and facilitated peer-to-peer dissemination of information. It has been helpful to see ACGME and GME policies allow flexibility around standard requirements without compromising educational priorities. Trainees who were pulled from their rotations to cover for colleagues or meet clinical needs within or outside their departments were assured that they would not be penalized by having to extend their time in training or repeat rotations.

Telepsychiatry

COVID-19 catalyzed the previously reluctant movement of health care to telemedicine (3, 4). Telepsychiatry, a subset of telemedicine, involves providing a range of services to patients, including psychiatric evaluation, follow-up care involving therapy and medication management, and psychoeducation (5, 6). In efforts to decrease community transmission of COVID-19 infection, many institutions across the country have moved to telepsychiatry for all outpatient appointments. In more acute settings, such as inpatient units, partial hospitalization programs, and intensive outpatient programs, exclusive telepsychiatric care may not be available or adequate. As such, additional precautions have been created to protect both trainees and patients, including testing patients for COVID-19 prior to admission, transitioning all family meetings and visits to videoconferencing, and identifying safe drop-off locations for pediatric patients. Additionally, physical distancing of at least 6 feet between all individuals has been prioritized, including during group activities and meals. It has been impressive to see major changes such as these implemented throughout our country within a matter of weeks, reflecting the dedication of many individuals, including medical school deans, chairs, faculty, trainees, staff, and the administrative leaders who often engineer these initiatives.

This rapid transformation to telepsychiatry involves extensive training, flexibility, and ingenuity. Direct supervision of outpatient visits was the most cumbersome aspect to replicate virtually, requiring attending physicians with varying levels of comfort with technology to join virtual patient encounters, quickly discuss cases with trainees (either in private chat rooms without the patient present or over the phone), and create a collective treatment plan, all while observing patients via two-dimensional screens. A pleasant surprise in this process has been the collective realization of the benefits of providing telepsychiatry to our patients. Through videoconferencing, we are able to improve access to mental health care, reduce delays in care, diminish emergency room burden, improve continuity of care, and further reduce the barrier of stigma (7, 8). Additionally, through much-needed flexibility from insurance companies and appropriate softening of HIPAA regulations when using videoconferencing modalities, the logistics involved in providing care to patients have not been a significant barrier. Still, it must be acknowledged that many providers and patients miss the human connection involved with in-person contact. We encourage our trainees to temper the weight of this loss with gratitude, when possible, for being part of a medical specialty that places great importance on the connection between patient and provider.

Remote Teaching

Along with the massive clinical adjustments to attenuate COVID-19 spread, a majority of psychiatry training programs have transitioned to remote teaching. Preserving and maintaining high-quality teaching are essential to not only satisfy ACGME milestone requirements but also to ensure that trainees develop the rich knowledge base necessary to practice psychiatry (9). To initiate these changes, a major investment was made to educate core teaching faculty about how to utilize common videoconferencing platforms (e.g., Zoom). Once competency was established and unexpected difficulties were managed, faculty and trainees alike were encouraged to approach this rapid change with a growth mindset. Furthermore, for faculty who had trouble teaching remotely, training directors supplemented videoconferencing lessons with vetted, online modules to ensure that there was minimal disruption to trainee education. Specifically, the National Neuroscience Curriculum Initiative produced a “quarantine curriculum” (10), which has been well-received by trainees, that includes lecture series ranging from complex trauma and borderline personality disorder to child psychiatry and psychosis. Importantly, the creators of this curriculum demonstrated that desirable active learning principles can be introduced remotely while deepening a learner’s knowledge base within essential topics of psychiatry. Videoconferencing has been successfully utilized to preserve areas of education in addition to didactics, including supervision for psychotherapy and medication management as well as process groups.

Well-Being

During the first few weeks of the pandemic, programs focused on creating new workflows for hospital and clinic-based services to minimize in-person exposure while preserving access and high-quality treatment for patients. At the same time, trainees were worried about their own safety and the health of their families. Some felt anxiety about the potential necessity for psychiatrists to serve in medical services outside their core specialty, as was seen in New York and Italy. Keeping Maslow’s hierarchy of needs in mind, we focused our initial efforts on trainees’ basic needs and safety, before addressing higher-level needs (11, 12). This approach included education about good hygiene habits to prevent cross-contamination, access to PPE, accurate and clear information regarding the frequently changing workflows, surge planning throughout the health system, childcare, and housing in case of sickness or quarantine (13). Particularly during the early stages, our work included advocating for consistency in guidelines across training sites, amplifying trainees’ concerns about inadequate supplies or insufficient protection (i.e., reusing a surgical mask for 1 week) to health system leadership, and even pulling trainees from sites until adequate protections were in place. Furthermore, we increased the frequency of our program evaluation committee meetings; expanded resident and fellow participation in departmental, GME, and health system–wide meetings; and conducted frequent check-ins with trainees over videoconferencing. The most helpful interventions to address fears of redeployment included specific details as opposed to general reassurances. Sharing institutional dashboards relating the number of occupied beds in the intensive care unit, number of COVID-related admissions, and detailed contingency plans helped trainees feel informed. Once some of those basic needs were addressed, we targeted the higher-level needs through activities such as mindfulness exercises, remote process groups, virtual game and movie nights, and other community-oriented activities. As we settle into our new training environment with COVID-19, we are reminded more than ever of the value of human connection to preserve morale, including by recognizing individual trainees in departmental communications for their hard work, flexibility, and dedication.

The Future

In our role as training directors, we must consider the immediate and long-term consequences of the COVID-19 pandemic on trainee well-being, professional identity, and clinical experience while making timely modifications to the educational curriculum in preparation for the challenges ahead. This crisis offers an opportunity to provide emergent learning around relevant topics, such as psychological first aid, refinement of high-quality telepsychiatry visits, and treatment of illness-related anxiety. Perhaps even more important is the hidden curriculum we are providing to our trainees. By role-modeling the ability to cope with uncertainty and to make difficult decisions amid heightened anxiety and incomplete information, we are providing lessons that will shape trainees’ leadership styles. Similarly, when we show how we support one another through these trying times, including our interdisciplinary team members, we are teaching our trainees how to maintain solidarity during a crisis. We are teaching burnout prevention when we discuss our own self-care and how we balance it with caring for our patients and our children (14, 15). As we move forward to the next stages of this crisis, we face additional uncertainty as we consider questions such as, Which patients benefit most from in-person appointments? How does one decide between in-person and remote learning? and How do we use what this crisis has taught us about the human condition to become better psychiatrists? Although the answers may not have crystallized just yet, perhaps it is enough for our training community to ask these questions together in earnest and to remain hopeful as we continue to rise to the needs of our patients and communities.