Training of psychiatry and mental health in a low- and middle-income country: Experience from Thailand before and after COVID-19 outbreak

Abstract

Since the start of COVID-19 pandemic in March 2020, training of psychiatry and mental health has been impacted considerably. We illustrated the change of academic and clinical psychiatric residency training procedure at Chulalongkorn University in Bangkok, Thailand, a developing country situated in South East Asia which is categorized in the low and middle income category of countries. The training setting has set up a task force responsible to set various strategies in response to the COVID-19 measure of social and physical distancing to maintain standard of care for psychiatric patients and educational experience for psychiatric residents. The strategies include online education, service team separation and avoidance of contact between teams, reduction of non-urgent clinical activities, and the use of telemedicine for psychiatric patients. Despite exposure to the difficulties of training during the pandemic, all senior residents were qualified and licensed at the national examination. Residents reported that pandemic did affect the academic activities and services and also the quality of living and satisfaction. Academic issues, including the inconvenience of studying online, were the most concerned problems among psychiatric residents at the time of pandemic.

Introduction

On March 11, 2020, when the number of cases of coronavirus disease 2019 (COVID-19) outside China increased 13-fold and there were more than 118,000 cases in 114 countries, the World Health Organization declared the pandemic status (World Health Organization, 2020). The cause of COVID-19 is from severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) resulting in 2.7 million deaths within just about 12 months after the pandemic (Worldometer, 2021). The main measure that has been used to control spreading of the virus is social or physical distancing (Chu et al., 2020), which - accompanying with other related factors- impacts mental health, economic and societal costs, as well as education of students and general population around the world (Chiesa, Antony, Wismar, & Rechel, 2021; Luo, Zhong, & Chiu, 2021; Pungpapong & Kalayasiri, 2021).

Educational training in surgical and medical specialties has been disrupted since the beginning of the pandemic, with challenges and innovative solutions being proposed worldwide (Dedeilia et al., 2020). Similarly, training in psychiatry, a specialty focusing on mental health, was severely impacted by the COVID-19 outbreak as well. The new design of training and clinical practice was needed to help trainees accomplishing the essential core of the science and clinical practice with competency, satisfaction, and especially with safety just in time of the beginning of COVID-19 pandemic. Such difficulties were more pronounced in developing countries including countries in the Asia Pacific region, as shown in the Philippines (Leochico, Espiritu, Ignacio, & Mojica, 2020), although some tele-education in psychiatry and psychotherapy was observed with satisfaction in Indonesia, Malaysia, and Thailand before the time of the outbreak (Alfonso, Michael, et al., 2018; Alfonso, Sutanto, et al., 2018).

In this paper we illustrate an example of the re-designed psychiatry training environment at the time of COVID-19 pandemic in a developing country in South East Asia. The work can be adapted, improved, and used in the future for preparedness of urgent crises that affect training and clinical practice in psychiatry in other regions with the same context.

Psychiatry residency training at the Faculty of Medicine, Chulalongkorn University (CHULA) before the COVID-19 outbreak

The Department of Psychiatry at CHULA, affiliated with the King Chulalongkorn Memorial Hospital (KCMH) - Thai Red Cross, has been established since 1973 and handles more than 10000 outpatient visits, 400 inpatient admissions, and 1000 consultation cases annually. Each year the department trains approximately 300 medical students, 36 psychiatric residents/fellows (2–4 years, 12 each), 4 doctoral degree in mental health students (2 years, 2 each), 30 master degree in mental health students (2 years, 15 each), and 20 graduate diploma in cognitive-behavioral therapy (CBT) and in addiction students (1 year). The psychiatric residency/fellowship training program at CHULA has two residency programs, including general psychiatry and child & adolescent psychiatry, and two fellowship programs, including geriatric psychiatry and consultation-liaison psychiatry.

Before the COVID-19 pandemic, tele-conference/teaching, e-learning, or tele-medicine had never been used routinely in the psychiatric residency training setting at CHULA and KCMH. In general, all residents completed their first two-three years in general psychiatry and the rest in their program specialties. In general psychiatry, the residents learn through clinical experiences at diverse sites, including the psychiatric ward (year 1 and 3), outpatient units, geriatric psychiatry unit and consultation-liaison service (year 2). Apart from these settings, which are provided within the institution, some trainings outside CHULA are compulsory. For example, residents are required to complete training in addiction psychiatry, forensic psychiatry, community psychiatry, and to practice in the governmental mental hospitals. They can also choose four-week elective periods in their field of interest.

Residents were assigned at least two patients for long-term psychotherapy under supervision by faculty staffs who had competence in various types of psychotherapy. Individual and group supervision are performed weekly to continuously develop residents’ skills, knowledge, and attitudes. Research is mandatory in Thai psychiatric residency training. Residents were designated to accomplish their own research projects after receiving ethical approval from the Institutional Review Board and are supervised by the faculty staffs.

Residents are evaluated approximately twice a year. Different forms of paper-based examination are used to test the knowledge, meanwhile, an interview and oral examinations for measuring their skills and attitude to the profession. They have to achieve faculty examination which precedes the national examination each year. Residents from all training centers around the country are examined by the national committees prior to being certified and licensed for the profession by the Royal College of Psychiatrist of Thailand (RCPsychT).

Psychiatric residency training at CHULA at the time of the COVID-19 outbreak

At the time of COVID-19 pandemic, the Thai government declared a state of emergency in Bangkok and the psychiatry training academic program was consequently restricted. Aiming to provide the best clinical services together with continuing the residency training, the department set up a task force to reconcile the needs and safety of staffs/residents and patients.

The COVID-19 task force determined that almost all academic activities must be switched to online setting. A few classes, such as art therapy lessons, had been postponed because of the necessity of student interaction. Other academic activities involving patients, including case conferences, were continuously run but without the patient neither onsite nor online, to ensure patients’ safety and confidentiality. All lectures were also taught online and, beneficially, recorded for further on demand use.

Psychiatric clinical practicing as well as mental health services were the most concerned at the time of pandemic, since only one staff exposed to the identified COVID-19 positive case would lead to the rest being quarantined and prohibited from work. The task force separated the residents into three teams in order to freely service and maintain clinical experience in three different settings: inpatient ward (with a reduced capacity from 17 to 11 beds to spare the beds/staff capacity for COVID-19 patients in the hospital); outpatient unit (open only for refilling medication and urgent or emergency visits); and consultation-liaison unit (no reduction in capacity of service with increased capacity to give psychiatric service to the medical patients with COVID-19 by telephone or tele-clinic). Residents not in the inpatient service were assigned to rotate at the COVID-19 screening and testing unit to do a nasal swab for patients at risk for the virus infection. For minimizing the risk of viral spreading, an individual from each team was asked to live or stay apart from others in daily life. Individual psychotherapy was prohibited in the first three months of the first wave of pandemic, then was delivered online via the tele-clinic platform developed by KCMH.

The National Examination in the year 2020 was arranged both online and onsite at each institution throughout the country. An online meeting application was used for the knowledge and oral examination for each resident. The psychiatric interview examination was carefully performed onsite with social distancing and facial mask.

Although the national examination results of the residents in the first year of the COVID-19 pandemic were satisfactory and everyone at the institution were qualified and licensed as psychiatrists, the pandemic did not only affect the academic activities and services, but also the residents’ quality of living and satisfaction. Nearly 90% of residents reported being interrupted in their daily routine from a brief survey of the task force. Academic issues, including the inconvenience of studying online to maintain physical distancing, remained the most concerned problems among residents. In addition, the COVID-19 pandemic affected residents in terms of decreased number of psychiatric cases, new ways of performing psychotherapy, and more workload due to the direct service for the COVID-19 screening and testing.

Discussion

Although Thailand and some other developing countries have some experience to the state of emergency that directly affected clinical services and residency training such as political turmoil that invaded the KCMH in 2010 (The Guardian, 2010) and natural disasters including the great flooding in Bangkok and Thailand in 2011 (BBC, 2011) or toxic air pollution in Bangkok in 2019 (CNN, 2019), the COVID-19 pandemic can be considered the worst situation affecting the residency training, especially in the underserved areas. We illustrated the impact of COVID-19 pandemic in psychiatric residency training in a university hospital in Bangkok, Thailand as an example of psychiatric training during COVID-19 pandemic from a low- and middle-income country in the Asia-Pacific region.

Training of psychiatric residency at the time of pandemic has been modified to conform with the new context of the way people interact and learn. According to decreasing number of psychiatric cases especially during the initial phase of the pandemic, the residents received less experience regarding to the variability of cases. Only psychiatric patients with urgent conditions were able to see doctors at the outpatient unit of the hospital at the time. The capacity of inpatient units was also reduced to minimize the admission number as well as the risk of COVID-19 spreading. All inpatients needed to test negative for SARS-CoV-2 before admission. Referral service from other hospitals had been shut down with the exception of only chronic cases, whose treatment plans were less complicated, could still be admitted. Nevertheless, the residents, not only from psychiatric training but from all specialties, had the extraordinary opportunity to practice their clinical skills during the global pandemic.

Residents from all departments were asked to take on additional services during the outbreak. Thus, residents were also accountable for more workload including services at the COVID-19 screening clinics and at the alternative state quarantine settings. Although much more extra work for residents was assigned, this was compensated with the reduction of psychiatric work in all settings. Inevitably, direct experience on psychiatric learning from the clinical practice was significantly compromised.

In psychiatry, psychotherapy sessions, which were run totally online at the time of COVID-19 pandemic, limited the residents to fully practice face-to-face with their patients. Patients were not allowed to be enrolled for long-term psychotherapy sessions to protect patients’ risk, safety, and confidentiality.

To the best of our knowledge, Thailand had no official regulation in tele-medicine yet; however, in May 2020, RCPsychT launched a recommendation for telemedicine in psychiatric services proposing that this should be an alternative for further mental health services in Thailand (The Royal College of Psychiatrists of Thailand, 2020). Opportunities given to psychiatric residents to learn about tele-medicine at the time of pandemic may be useful for future use in similar context. Also tele-conferences and webinars have become a major tool for lecturing and case discussion. Residents reported some technical difficulties in the use of online learning at the beginning of pandemic. The caveats of online learning in the underserved area may include illiteracy of the online technology and inadequacy of location/equipment (i.e., strong signal of Wi-Fi) (Abu Talib, Bettayeb, & Omer, 2021). In addition, difficulties to include psychiatric patients to be involved in a large-class online setting, is a major issue for online learning as shown here that the academic activities involving the patient both online and onsite were prohibited for safety and confidentiality.

Nevertheless, though exam score and knowledge acquired from the online learning was not included in this report, previous studies showed comparable results between synchronous online learning and traditional learning (He et al., 2021). In addition, benefit of the synchronous online education from world-class institutions given to the institutions in developing countries as shown in other specialties (Gonzales-Zamora, Alave, De Lima-Corvino, & Fernandez, 2020; Kiwanuka et al., 2015; Tomlinson et al., 2013) could be used and promoted at the time of pandemic and later on. In fact, such method has been observed in psychiatric education organized by the Section on Psychotherapy of the World Psychiatric Association before the time of the pandemic and has been proven to be a useful method for training in remote and underserved areas (Alfonso, Michael, et al., 2018; Alfonso, Sutanto, et al., 2018).

Conclusion

The occurrence of COVID-19 pandemic affected psychiatric residency training at university sites in low- and middle- income countries in a number of ways, including decreased clinical experience, increased need to adjust to online education, and interference of social relationship at work. However, new experiences gained at the time include clinical exposure and management both psychiatrically and medically for the COVID-19 patients and more literacy for online education and telemedicine that can be useful even when the pandemic will be over.