On December 31, 2019, Wuhan City in the Hubei Provence of China reported cases of a novel pneumonia. On January 7, 2020, the causative organism, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified, and less than 1 week later the first case outside of China was reported.1 By March 11, 2020, coronavirus disease 2019 (COVID-19) was a pandemic and had spread to nearly every continent.2
No country was prepared for what was to come. Italy quickly became the symbol for a foreboding truth—that even well-developed health care systems could collapse under the weight of a pandemic. Due to an exponential growth of cases and high rate of admission to hospitals, patient volume rapidly exceeded capacity.3,4 To meet demand, 70% of staff physicians in Bergamo, Italy, regardless of their specialty, were redeployed to COVID-19 units.4 Redeployment in the workplace is defined as the moving of an employee from one job or role to another.5 More broadly, redeployment in the military or civilian context is the reassignment of people or resources to a new place or task. Redeployments also occurred in Singapore6 and the United Kingdom,7 and redeployments became necessary in the United States as well.8,9
Redeployment of physicians involves complex decisions, such as whom to reassign, where to reassign, them and how to balance the needs of frontline services with other critical services. Guidelines for these challenging decisions are scarce. Literature from disaster medicine, although helpful, tends to only address time-limited phenomena. Therefore, in the time of coronavirus, hospital systems are forced to make urgent decisions without precedent. Recommendations for redeployment have been proposed for surgical specialities6,10–13 and neurology,14 but to our knowledge there have been few published guidelines for psychiatrists.15 Recommendations are urgently needed, as psychiatrists have been redeployed in hard hit-regions of the United States and continue to support a robust portion of the COVID-19 effort. Psychiatrists, as referred to in this article, include all subspecialties, even child and adolescent psychiatrists who are at times redeployed to care for adults. Additionally, reassignment of psychiatrists requires a delicate and thoughtful approach, as psychiatry is bound to have its own concomitant increase in patient volume.
To address this urgent policy gap, the American Psychiatric Association Committee on Psychiatric Dimensions of Disaster (APA CPDD) developed a position statement on principles for redeploying psychiatrists to the medical front line.16 This article builds directly on the expert opinion consensus statement developed by the APA CPDD committee. Here, we put forth general guidelines for psychiatrist redeployment; however, each institution, city, and state will have their own individualized needs. Ultimately, this article is intended to assist local entities in making decisions during a pandemic, but it is not meant to be a “one-size-fits-all” guide.
Context of Redeployment
The National Academies of Science, Engineering, and Medicine outlined three levels of care in a pandemic.17 Conventional care represents care as usual. Contingency care occurs when demand for staff, equipment, or medication exceeds supply. Crisis care begins when resources are severely depleted or substantially overwhelmed. Redeployment of psychiatrists may become necessary during contingency or crisis levels of care.
Once an organization determines that redeployment is necessary, it is important to be thoughtful about who gets reassigned and where. At lower levels of contingency care, faculty and residents should first be selected on a voluntary basis. However, as institutions enter the crisis care phase, redeployments may become mandatory. Above all, psychiatrists that are sent to the front lines must be provided with current institutional, city, and state guidelines on prevention of transmission of COVID-19, as well as adequate access to personal protective equipment (PPE) and training in its proper use.
The decision about whom to select for redeployment is complex and will vary based on current need, the organizational structure of each health care entity, and local regulations. Working within these caveats, redeployed psychiatrists may be selected based on a range of key factors, including their personal comfort with practicing medicine, acuity of the deployment setting, availability of supervision by experienced internists, and individual risk associated with infectious exposure. Those with high-risk medical comorbidities should be excluded from treating patients directly. When possible, cultural, ethnic, and language diversity should be prioritized for effective clinical care.
Psychiatric outcomes from prior disasters have taught us that mental health needs may also exceed normal capacity due to surges of patients with anxiety or those who are acutely ill. Therefore, when balancing redeployments, one must also ensure that there are enough providers to staff acute psychiatric services and provide excellent outpatient care. Because of the harrowing nature of working in a pandemic, access to support services for frontline staff must be in place before, during, and after deployment.
Level of Readiness for Redeployment Based on Current Medical Proficiencies
Individual readiness for redeployment may be based on a combination of years out of training and the nature of one's practice. Psychiatrists differ in their level of familiarity with intensive care units (ICUs), emergency departments, and general medical wards, which are the prime areas of need during the current pandemic. An individual psychiatrist may feel more or less proficient in internal medicine based on how regularly they treat patients who are medically complex. Some psychiatrists operate in integrated medical settings and may consider themselves highly proficient. Others, who work in small individual practices, may feel less proficient. Psychiatry residents frequently work with patients who are medically complex and critically ill. However, they may have different levels of comfort working on internal medicine teams, based on their level of training and clinical exposure to date. The level of comfort may be most variable in postgraduate year (PGY)-1 residents.
In a rapidly unfolding pandemic, there is insufficient time to evaluate each psychiatrist's ability to practice medicine independently. Additionally, it is unlikely that resources would be available to provide ample training before deployment. Therefore, we propose a general set of 5 levels of readiness, which help serve as markers for more specific competencies (Table 1). Of note, these levels are meant to be guidance for deciding which psychiatrists may be most clinically prepared for redeployment and are not meant to be an assessment of overall competency. The levels are ranked from 1 (highest level of readiness) to 5 (lowest level of readiness).
Levels of Readiness for Redeployment of Psychiatrists
Deployment of Residents and Fellows
In most academic hospital systems, residents and fellows will make up a majority of deployed psychiatrists, as attending physicians need to remain available for supervision on primary psychiatric services. When possible, faculty and trainee deployment should be balanced. PGY-1, -2, and -3 residents who are closer to their general medicine training should be prioritized for deployment. PGY-4 residents and fellows should be considered for coverage of psychiatric services, as they are the most senior trainees that can manage acute psychiatric issues independently. In more critical circumstances, senior residents and fellows may be advanced to attending status.12
Designated institutional officials as well as program directors should be involved in determining which residents are appropriate for redeployment, based on their level of clinical competency and the anticipated level of supervision in the deployment setting. In the dual role of clinician and trainee, using residents in hazardous situations requires reflection and thoughtful consideration of their well-being.
Complexity of the Medical Setting and Risk of Exposure
Some redeployment settings, such as the ICU, will inherently house more patients who are medically complex and critically ill. Because critically ill patients can require frequent intubations and advanced cardiac life support, the risk of infectious exposure is also higher. Other services, such as general medicine wards, theoretically have more stable patients, and thus less acuity and risk of exposure; therefore, all deployments are not equal. The goal is to deploy psychiatrists to a level of acuity that matches their comfort level. However, this must be balanced with the urgent needs of the medical system. To help guide decisions about redeployment location, health care organizations may consider a tiered system based on complexity of medical tasks and risk of exposure for the providers.
ICUs have the highest level of acuity and inherent risk (Tier 1), followed closely by medical emergency departments (Tier 2). General medicine services, composed of primarily COVID-19 patients, carry a somewhat lower level of risk (Tier 3), although that is dependent on the number of active patients and available resources. General medical units without COVID-19 patients, but with high medical complexity, would have the lowest risk of exposure (Tier 4). However, working on these units may call on a broader range of clinical competencies. Finally, as appropriate, psychiatrists can be reassigned to less direct roles, such as telephone triage, supporting families of dying patients, going on rounds with the palliative care team, entering orders at a nursing station, and supporting frontline personnel (Tier 5).
“Just-in-Time Training” and Medical Supervision
While working outside of their usual scope of practice, redeployed psychiatrists may require additional training to provide the best care. Methods of training can include online modules, simulation activities, and frequent dissemination of up-to-date treatment guidelines. Even with available literature, including practice guidelines, redeployed physicians may have further questions about clinical care. When they find themselves at the limit of their expertise, consultation services should be rapidly available by text, internal chat system, phone, or in person. Some institutions have also recruited medical students to be “on call” to review literature and answer clinical questions rapidly.
In addition to the resources described above, all reassigned psychiatrists, should be provided with close supervision from experienced hospitalists and critical care providers. This helps ensure patient safety and provide support for those asked to work in unfamiliar settings. Those working in Tier 5 roles generally will require less direct supervision.
Medical Vulnerabilities of the Psychiatrist Who Is Being Considered for Redeployment
Some providers should be exempt from redeployment due to elevated risk in the face of potential exposure. This includes psychiatrists with underlying medical conditions or advanced age. Medical vulnerabilities of those living with the psychiatrist can also be considered.
Psychiatrists with medical vulnerabilities can provide care for COVID-19 patients without coming in direct contact with them. For example, they may provide telehealth consultations or update patients' families by phone. They can also be asked to back-fill vacancies on acute psychiatric services or cover outpatient practices; however, such redeployments may still be associated with increased risk of exposure depending on density of patients with COVID-19.
Sustaining Critical Psychiatric Services Vacated by Redeployed Psychiatrists
Psychiatry is likely to experience its own surge of patients, given the loss, isolation, and uncertainty that accompany a global pandemic. Previously stable patients may require more frequent follow-up or higher levels of care. Frontline staff should also have access to ongoing support. Combined with people who are newly seeking care during this crisis, the volume of patients has the potential to overwhelm the behavioral health system. Therefore, psychiatric services must be adequately staffed to provide timely and thorough care. All vacancies created by deployed psychiatrists should be filled by nondeployed providers, ideally by those with commensurate experience.
Ethical, Legal, and Regulatory Issues
In a pandemic, ethical challenges will arise in regard to resources, such as ventilators, dialysis, and medications. Deployed psychiatrists will need to be familiar with their institution's policies. Otherwise, they will be left to grapple with difficult choices in an already new and stressful environment. Furthermore, deployed physicians may want to inquire about relaxed legal liability while working on acute medical services, providing them with another layer of protection. They should also be informed if they are covered for malpractice in their redeployed roles.
A critical element in the preparation and training of psychiatrists for redeployment is education about self-care.18 This is much broader than infectious disease precautions and PPEs. Initial elements are knowing one's own limits (not working alone, monitoring responses to the work, and supervision by trusted colleagues), preparing food, fluids, and clothing, and developing a plan for deployment with one's family. The next elements include both physical and psychological components, such as diet, exercise, sleep, rest, recreation, meditation/spirituality, and personal time. Lastly, interpersonal elements should not be ignored. Social contacts are restorative. Interpersonal self-care can involve informing one's support system of their needs, working within a team, asking for help when needed, and having others be available to recognize signs of physician, behavioral, or emotional stress.
Access to Peer and Professional Support Services
Due to the high level of stress and exposure to trauma, deployed physicians may be at higher risk for various psychiatric illnesses, such as acute stress disorder, posttraumatic stress disorder, depression, anxiety, and suicide.19 To mitigate such risks, emotional support services must be readily available and confidential. These services may include process groups, individual treatment, opportunities for informal peer support, and resilience-based outreach (ie, psychological first aid).20 Psychiatric services should also make their own contingency plans for triage, intake, and rapid implementation of treatment. Furthermore, mental health services should be provided remotely whenever possible to decrease risk of exposure and increase accessibility.
In hotspots of COVID-19 infection, where demand of medical services exceeds capacity, redeployment of psychiatrists has become urgent and necessary. Within hospital systems across the world, physicians, nurses, and other health care providers have been asked to step outside of their comfort zones to meet demand. Even scientists have been redeployed to study coronavirus in this great time of need.21
Because we have not seen a similar pandemic in modern times, there are no established guidelines to aid decision-making. Each country, state, city, and institution are rapidly adapting as best they can, based on their current needs, structure, and available resources. Therefore, no guidelines could comprehensively cover all scenarios, nor could they cover all specialties. This article is an attempt to provide thoughtful general guidelines for those faced with the daunting task of reassigning psychiatrists to provide medical care in ICUs, on medical wards, and in emergency departments.
A combination of factors should be considered in deciding which psychiatrists to redeploy and with what priority. These include proficiency in general medical care, acuity of clinical care required, availability of supervision, and vulnerabilities of those being considered for redeployment. All of these factors must be balanced against the demand for care. There should be a balance between faculty and resident deployments where appropriate. Additionally, cultural, ethnic, and language diversity among deployed providers is encouraged. Psychiatrists with high-risk medical comorbidities could be exempt from deployment and be placed in roles that do not require direct patient contact. While deployed, psychiatrists must be provided with resources to build self-efficacy, self-care, peer support, and mental health support services. Current guidelines to prevent COVID-19 transmission, including proper use of PPE, should be readily available. Lastly, every deployed psychiatrist must be provided with up-to-date and thorough information on institutional policies regarding ethical and legal issues.