What to Do When Being There Means Being Vulnerable
In the early days of the pandemic, there was debate about whether clinical services for patients with psychiatric illness were “essential.” The evolution of psychiatric consultation-liaison services to medically hospitalized patients was no less complex.
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FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY
In the early days of the shelter-in-place edict that was established in the San Francisco Bay Area in response to the COVID-19 pandemic, there was some debate about whether clinical services for patients with psychiatric illness were “essential.” The department of psychiatry at my home institution installed a COVID-19 Task Force for patient care, appointed by departmental leadership and composed of clinicians, researchers, and administrative staff. A remarkable number of departmental meetings were held to eventually conclude that patients with psychiatric symptoms could still receive care from behavioral health clinicians, psychiatrists included, who were now expected to be working from home, even though it has been argued that psychiatry is an essential medical service and should be delivered in person if and when necessary.1 The strategy adopted for accomplishing this goal in the outpatient setting was conversion of all office-based appointments to telehealth visits on a secure internet platform.
The deliberation was more complicated and the decisions more controversial (and less universally adopted) in the hospital setting, for patients, both children and adults, who were psychiatrically hospitalized, or who were receiving care in general medical (non-psychiatric) hospitals and had psychiatric symptoms and/or comorbid psychiatric illness that required consultation-liaison psychiatric care. Directives from departmental leadership were rapidly evolving in the first few weeks of shelter-in-place, and included such decisions as not psychiatrically hospitalizing any patient aged 60 years or older or not having psychiatry residents interact directly with patients in emergency rooms. Fortunately, directives such as these were quickly revised, presumably through an iterative process between clinicians and leadership.
What took longer to establish were the policies for providing psychiatric consultation-liaison (C/L) service to medically hospitalized patients. These policies were hospital-specific and ultimately diverged on the basis of the philosophies held by the leaders of the respective C/L services. Each university-affiliated hospital was tasked with developing the protocols that would allow for consultations to be provided while taking into account the patient’s COVID-19 status. The solution that was adopted by the psychiatry C/L services of the 2 hospitals where I attend (a university-affiliated tertiary care center and a public safety net hospital) was a version of remote consultation via telehealth.
Most medical specialists who were still providing care and meeting the expectation of social distancing and infection control protocols in these hospitals embraced this technologic solution. Arguments in favor of this version of consultation were made to suggest that the quality of remote consultation would be adequate for the care provided. That may be true for straightforward cases. However, more often than not, there are cases that are far from straightforward, which flummox clinician efforts to use communication-enabling technology.
The university hospital where I am an attending on the adult C/L service had years of experience with remote psychiatric consultation long before the COVID-19 pandemic. Our team provides consultation to multiple affiliated hospitals within the university health network but is headquartered in just one of them. From where we are stationed, our efforts to provide psychiatric consults via technology have been and remain fraught with challenges, both technologic and patient-based. This experience demonstrated the shortcomings of being far afield from patients.
We are dependent on: the hardware and software functioning adequately; the hospital staff designated as “resource nurses,” who serve as our bridge to the patient by wheeling in the computer cart on which the technology runs and being present with the patient while our team engages with them; and our clinical acumen to detect subtle changes in facial expression, affect, and engagement on a small screen. These technologic factors are moot when patients refuse to interact with their consultant over the computer or to even consent to such an intervention. Even when patients consent to a virtual visit, there may be circumstances when their level of disorganization, paranoia, distractibility, agitation, or distress prevents them from interacting in a meaningful way with their consultant.
The experiences of the adult psychiatry C/L service described above informed the child and adolescent psychiatrists (CAPs) providing consultation to our different pediatrics units, but in different ways. At one site, the patients in the children’s hospital were evaluated through remote consultation unless strict clinical criteria (altered mental status or suicidality if not COVID-19 positive) were met to justify in-person (in-room) consultation (COVID-19 positive patients were not offered in-person psychiatric consultation). This algorithm required the primary pediatrics teams to engage with COVID-19 positive patients or their caregivers as a proxy for the CAPs (in the case of behavioral dysregulation or other symptoms that precluded the use of the telehealth device that the CAP C/L team relied on). Furthermore, the protocol did not accommodate patient preference. The COVID-19-negative patient confronting her cancer diagnosis had to engage with the team psychologist through a device and had to forego the opportunity for human contact.
The justification for remote consultation was the effort to minimize the number of staff exposed to COVID-19 and thus the likelihood of further contagion (presuming staff acted as vectors). However, the technology still needed human agents to manipulate it. Those humans were the same front-line staff who were expected to do the other tasks of patient care. Not only did this expectation suggest that their workload could be increased for the sake of supporting the CAP C/L team, but also that the safety of front-line staff could be forfeited for the safety of the consultants.
Another benefit that was touted was improved communication and/or collaboration between psychiatry consultants and primary teams. For those of us doing proactive consults, and those who are fortunate enough to be integrated into inpatient teams, conversion to telehealth would have meant “retreating” from the frontlines and from our role as teammates. Instead, at the hospital where I am the CAP consultant to the inpatient Pediatrics unit, we developed a protocol (Figure) for conducting remote consultations for patients who were COVID-19 positive but not suicidal or homicidal to minimize interactions with the patient. We continued in-person consultations for everyone who was COVID-19 negative and “persons under investigation” (ie, patients whose test results were pending) or who were suicidal or homicidal (regardless of COVID-19 status). The difference between these circumstances would be the personal protective equipment (PPE) we would don (surgical masks and face-shields for COVID-19-negative patients; N95 respirators, face-shields, gowns, and gloves for COVID-19-positive patients). Of course, this protocol required the consumption of PPE.
Resources have been scarce, but hospitalized psychiatric patients are just as entitled to medical care as any other hospitalized patient, and those psychiatrists providing care need to be protected in the same way as other medical specialists. Physicians have always recognized that there are risks inherent in treating patients with medical illness, and we have accepted this risk as a hallmark of our professional duties.
The protocol that we developed recognized the importance of being present for the inpatient teams and the challenges that telepsychiatry can pose for our patients who are acutely (psychiatrically) symptomatic. The first patient I evaluated using this protocol was an adolescent manifesting symptoms of excited catatonia; she paced throughout her room during the entirety of the interview and could barely attend to me while in the room with her. It is highly unlikely that I could have engaged her and redirected her over a video monitor.
It came as no surprise that in response to the COVID-19 pandemic a number of remarkable policy changes occurred, perhaps more quickly than they otherwise would have. Several innovative programs arose at my home institution to meet the mental health needs of medical center staff: resilience and emotional well-being videos and webinars; self-care apps; family support programs; and direct assessment and treatment for faculty, staff, and trainees. What seemed to be missing from these efforts was comparable attention to the emotional and functional well-being of our patients with psychiatric illness.
It is becoming all the more clear that additional support for the increasing mental health needs of patients, especially those with pre-existing psychiatric illness, will be necessary.2 So far, such support has been surprisingly limited. One program, our autism clinic, pivoted by establishing a virtual “coffee chat” support group function for the parents of patients with autism.
More data seem to be collected about the clinicians’ experiences of transitioning their services to telehealth platforms than the patients’ experiences of not being seen in person. Professional service organization listservs have become repositories for institutional strategies for converting (in-person) inpatient C/L services to telehealth. Ambitious members of these organizations have constructed methods papers about these strategies.
Attention is slowly beginning to shift from the process of providing telehealth to its consequences, especially in the area of patient satisfaction3 and mental health care delivery.4 The consequences of these policy changes on the patients’ well-being are likely to be profound, and so far the impact of these changes on the needs of this vulnerable population has not been adequately explored. It makes no sense to deprive patients of the valuable service of in-person consultation if there are no clinical imperatives to do so. It can, of course, be a reasonable alternative to no care at all for patients who cannot access psychiatry through conventional means.
Technology is a fickle ally. It promises support but it falls short of authentic connection. In our effort to open new vistas for consulting on medically hospitalized patients with psychiatric symptoms, we should not lose sight of what our duty to them was meant to be.
Dedicating ourselves to the principles of social distancing may have resulted in the perceived abandonment of our patients. As our subspecialty comes to terms with the new normal of life in the post-COVID-19 era, it will be important to ensure that the emotional well-being of our patients is given at least as much attention as the mental health needs of our colleagues. Access to genuine care should not be relegated to virtual visits.
Dr Ihle is Health Sciences Clinical Professor in the Departments of Psychiatry & Behavioral Sciences and Pediatrics, Langley Porter Psychiatric Hospital and Clinics, UCSF Weill Institute for Neurosciences, University of California San Francisco, and Zuckerberg San Francisco General Hospital, San Francisco, CA. Dr Ihle has no disclosures regarding the subject of this article.
Acknowledgements—Thank you to James Alan Bourgeois, OD, MD, for his support and mentorship, and to all of the physicians on the front lines providing medical care for patients during the COVID-19 pandemic.
References
1. Ihle EC. Psychiatry is an essential medical service during the COVID-19 pandemic. J Psychiatry Reform. 2020;8:1-4.
2. Wan W. The coronavirus pandemic is pushing America into a mental health crisis. The Washington Post. May 4, 2020. Accessed September 15, 2020. https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus
3. Siwicki B. Survey: Americans’ perceptions of telehealth in the COVID-19 era. Heathcare IT News. April 3, 2020. Accessed September 15, 2020. https://www.healthcareitnews.com/news/survey-americans-perceptions-telehealth-covid-19-era
4. Ojha R and Syed S. Challenges faced by mental health providers and patients during the coronavirus 2019 pandemic due to technological barriers. Internet Interv. 2020 Sep;21:100330. ❒
