Consultation-Liaison Psychiatry in the Age of COVID-19: Reaffirming Ourselves and Our Worth

To the Editor:

The SARS-CoV-2 (COVID-19) pandemic has brought unprecedented challenges to our society. It has compelled clinicians to reexamine our roles as physicians, educators, family members, and citizens. Consultation-liaison (C-L) psychiatrists stand at the convergence of psychiatry and the rest of medicine. Similar to most medical specialties, C-L psychiatry is forced to adapt during the pandemic, possibly bringing permanent changes to our profession.

Owing to an almost universal lack of adequate personal protective equipment in the health care facilities of this country, as well as inadequate testing for COVID-19, many C-L psychiatry services have implemented telepsychiatry options, usually reserved for underresourced areas. Although the gold standard of consultation involves in-person evaluation of the patient, it is clear that this crisis calls for the use of technology to decrease viral transmission. Guidelines from the Centers for Disease Control and Prevention recommend the use of telemedicine when possible, limit on the number of staff providing care to COVID-19+ patients, and use dedicated health care providers who care only for COVID+ patients during a shift.¹ It would be simple to reflexively respond to this challenge by insisting that our service, in its fully staffed form, is an indispensable entity in the hospital. After all, we care for extraordinarily sick patients, we rely on physical examination findings including a thorough neurological examination, and we manage conditions, such as hyperactive delirium, catatonia, and severe alcohol withdrawal, which require frequent visual assessments.

As of April 9, 2020, over 9000 health care workers in the United States have been confirmed to have COVID-19, with at least 27 confirmed deaths.² Owing to lack of testing or inadequate reporting, these numbers are likely to increase.

As staff are increasingly lost to illness or quarantine, it becomes apparent that for the sake of personnel safety, we must adjust how we work. Ideally, we shift to a hybrid model, working remotely when possible and reserving face-to-face contact for circumstances where virtual care might pose more risk than benefit. “Seeing” a consult patient remotely is not shirking of the Hippocratic Oath, rather a wise adaptation in the face of a dangerous pathogen. Workforce preservation becomes essential to not only maintain a healthy number of clinicians but also to ensure psychological health. We must protect our greatest resource, each other.

Besides the obvious practical advantages of conserving personal protective equipment, minimizing infection risk for providers and patients, and maximizing workforce, transitioning to a hybrid model, where a proportion of consults are performed virtually, may have training advantages. One of the most challenging skills for trainees to master is determining the extent of involvement required for a specific consult. Trainees must learn to be thorough, avoid premature closure, and resist tunnel-vision focused on the specific consult question. They must recognize that not every consultation requires a soup-to-nuts evaluation, understanding the value in a brief, focused assessment. A hybrid approach to patient care on the C-L service, with some evaluations completed by chart review, telephone encounter, or video, creates an opportunity for trainees to learn valuable lessons about triage.

C-L psychiatry is often the most visible provider of psychiatric care within the hospital. As such, medical center leadership will look to us as experts in mental health care delivery systems. Most of the care that we provide as psychiatrists, across all settings, remains poorly understood by hospital administration. It is therefore essential to recognize that the tone set by C-L psychiatry, as the “face” of mental health, may inform the facility's entire approach to mental health care delivery during crisis. C-L psychiatry teams must gracefully step into this unofficial leadership role deliberately modeling a well-informed, flexible, and balanced approach. Whatever is “lost” (pride, sense of “patient ownership”, and so on) by stepping down from face-to-face clinical interaction can be gained through the demonstration of courageous leadership.

This modeling extends into our core liaison role in this time where fear and anxiety are normal adaptive responses to a life-threatening pandemic. Our training and experience allow us to reach into the most uncomfortable psychic places within ourselves, and to assist others in the same, without shame. Clinicians are combatting the ultimate in moral injury, unable to provide the high-quality health care they were trained to do, sometimes fighting within health care systems that were disadvantaged from the start. Never has the C-L psychiatry role been so important to support and hold the therapeutic container for the caregivers of medicine. What we may or may not prove now in face-to-face respiratory management of a complex COVID-19 ventilator weaning, we will prove with a nuanced approach to the intricacies of the health care system and the people within.