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Residency training and suicide risk assessment in the COVID-19 era

August 19, 2020

Coronavirus graphic

By Shannon L. Loeck, M.D.

Starting in March of 2020, emergency departments in the Wichita area went from busy to almost empty, likely due in part to fear of COVID-19, but also due to the shelter-in-place order for the state of Kansas. People were avoiding high-traffic emergency rooms unless very sick or it was unavoidable. Surprisingly, this also included the psychiatric population. I say surprisingly because psychiatric patients do not get better overnight. People do not stop using substances, and these are stressful times, which one would think would increase psychiatric symptoms. ED physicians and psychiatrists at Ascension Via Christi St. Joseph ER commented often about the absence of the psychiatric population (that frequently would fill half of the available rooms) and expressed concern for their well-being.

Shannon Loeck, M.D.As the immediate threat of the first wave started to subside nationwide, and as the states gradually lift restrictions, hospitals are starting to see a post-COVID wave of psychiatric decompensation. Wichita is no exception. In the last month, the number of psychiatric patients in the ER has returned to pre-COVID levels, but the level of severity has increased. Previously stable people were arriving with acute psychosis due to inadequate follow-up with their outpatient providers or noncompliance with their medications. People without a history of psychiatric illness presented with symptoms of depression or anxiety due to lack of social interaction and/or financial stress. Adolescents and children are struggling with staying at home, not getting to be with their friends or struggling to do classwork via online learning. Geriatric patients in nursing homes that are unable to leave and unable to have visitors are having suicidal thoughts or new behavior outbursts due to a change in routine and feeling abandoned by loved ones.

Since these new and more severe psychiatric issues are presenting themselves, psychiatrists are having to adjust how they evaluate patients, how they provide care and how they treat in the most effective and safe manner in this new and ever-changing situation. Starting July 1, when the new KU Wichita Psychiatry interns begin their residency training, they will be learning to practice medicine in very different ways than everyone who came before them.

One of the most important parts of psychiatric residency in the early months is learning the fundamentals of a suicide risk assessment. During every patient interaction, a psychiatrist includes some form of this question, "Are you having any thoughts of harming yourself or ending your own life?" But, that is just scratching the surface. Risk assessment is not just about asking a straightforward question. You are observing the person, reviewing his or her history and obtaining information about the person that would possibly increase or reduce the risk. Psychiatry residents are not born knowing how to do this. It takes training, practice and lots and lots of interviewing. During the first three months of training, each new resident spends two weeks with an upper level resident in the emergency department learning how to perform a basic psychiatric assessment. We follow the model "See one, Do one, Teach one," although it is more like "See one, Do ten ..." in these early days.

Last July through September, I was the senior resident on the psychiatric emergency room consult service and in charge of teaching the first-year residents, but most of the training and observation was performed by the second-years on the service. We worked together to make sure the first-years were able to observe two different styles of interviewing, but also two different styles of feedback on their interviewing and risk assessment. Most first-years start out with a very superficial interview that sounds a lot like they are reading from a script or checklist and their observation skills are very minimal. After each patient encounter, we would compare notes on what the patient said, but more importantly on what they didn't. The patient's body language, facial expression, activity level, speech and grooming are just some of the things residents need to consider when assessing the patient for risk.

At first, residents notice the most obvious things; the patient who hasn't been caring for themselves (i.e.: not showering) or when a patient has slurred speech, indicating they might be under the influence of a substance. More subtle findings take pointing out by someone experienced so that the resident will learn to watch out for that in the future. For example, patients might be very talkative through most of the conversation but switch to one-word answers if they are uncomfortable or hiding something, or they will switch from maintaining eye contact to not looking at you or glancing around the room. Patients also communicate how they are feeling in their facial expressions or their "affect," which may be very different from what they say their mood is now. These incongruencies are vital to note in a risk assessment, because someone could say they feel fine but appear to be near tears, and that makes them a higher risk.

Facial expressions with a mask on and offCOVID-19 has changed many things about how we live our lives and how we interact with each other. This has affected the way medicine is practiced in many fields, but I believe this has impacted the field of psychiatry in many ways we could not have anticipated. Physicians are taught/trained to be observant so that you don't miss a finding on a physical exam that could lead to a misdiagnosis. As a psychiatrist, a significant part of our physical exam is evaluating a patient's mental status, which is also a key part of the risk assessment. As mentioned previously, we watch the face, but we also communicate to our patients with our own expressions: empathy, concern, excitement, sadness or disbelief. The risk of COVID-19 has resulted in the mandatory use of masks by physicians in patient-care areas, but in the ER, both patient and physician are masked.

Over the last several months, I have noticed in interactions with peers while masked, that I try to communicate more with my tone of voice, eyes and other body language because I have realized that so much information about what I am trying to say is lost by the presence of a mask. Humans communicate with their expressions far more than we realize, and when interacting with patients in crisis, it puts everyone at a disadvantage.

The post-COVID wave of psychiatric patients are presenting with more severe illness, so their ability to communicate is limited, and even worse is their ability to interpret the expressions of a masked psychiatrist. People who have never experienced psychiatric symptoms before, never interacted with a psychiatrist under typical circumstances, will be more uncomfortable and have difficulty opening up to a masked interviewer. Seasoned clinicians are struggling with how to build a connection with their patients who are established, let alone building a key therapeutic alliance with a patient being evaluated for the first time. The 2020 first-year residents are going to face these and many other new challenges during their training, They will have to learn to observe differently, will have to rely on their other senses and learn different ways of communicating with patients who are in crisis. Attending psychiatrists will be taking on the challenge of teaching and guiding them through a new system that is evolving rapidly.

As a soon-to-be attending psychiatrist covering the emergency department psych consults, I find myself reflecting on my training, the changes I have witnessed in the last several months and looking ahead at the challenges I face starting in a position that was created for me. Up until now, supervision of psychiatric residents in the emergency department has been indirect via the attending for the inpatient adult service. Between the emergency physicians and psychiatrists, they determined there was a great enough need to have a psychiatrist in the ED on a more consistent basis to help see patients, provide treatment and aid in the flow of patients out of the department. I'm looking forward to the opportunity to help provide better care for psychiatric patients in crisis, and to teach residents not only how to perform crisis assessments and management, but also how to work with a multidisciplinary team of other physicians: APRNs/PAs, RNs, social workers and security.

My first career was as a certified athletic trainer in a high school in Connecticut (near where I grew up), which was mostly on-field emergency care of athletic injuries, determining if they needed to seek advanced medical care or if I could manage the injury. I worked with a wide variety of teachers, coaches, counselors, physical therapists and orthopaedic surgeons in order to provide the most appropriate care for my athletes. I believe the same strategy can be applied to my new position and in training our future psychiatrists.

Above, left: Shannon Loeck, M.D., clinical instructor in the Department of Psychiatry & Behavioral Sciences at KU School of Medicine-Wichita

Above, right: Dr. Shelby Nix, PGU-1, demonstrates different expressions without a mask and with a mask. (Photographs taken by Dr. Shannon L. Loeck)

KU School of Medicine-Wichita
Last modified: Aug 19, 2020
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