Psychiatrists as internists: Some considerations following a COVID-19 redeployment experience

Dear Editor,

We have read with enthusiasm the recently published article about the changes that we can expect in psychiatry after the pandemic caused by the novel coronavirus SARS-CoV-2.¹ In particular, we believe that the authors are fully correct when, in first place, they highlight the medical nature of psychiatry. Since the first outbreak in China, several authors have warned about the mental health problems that the pandemic might cause. Also, they have pointed out the need for psychiatric care networks to adapt to this new reality.² However, few have mentioned the fact that, in the most critical moments of the pandemic, many psychiatrists had to put aside their common clinical practice to act as general practitioners and directly treat patients with COVID-19. Fortunately or unfortunately, this was the fate of the authors of this article when, one day in mid-March, we were told that a few hours later we should join as doctors a COVID-19 hospitalization facility in our general hospital in Madrid, Spain.

It is important to briefly put in context the place of psychiatry in modern medicine. To be honest, psychiatrists are not especially popular among other medical specialists. Psychiatry is one of the most reviled specialties within medicine.³ Although this is probably largely based on prejudice, sometimes we ourselves contribute to this bad reputation. For example, when we overlook the physical comorbidities of our patients, disregarding the risk that this may imply.⁴ Or when we insist on ruling out “organic” causes of mental disorders, apparently ignoring their obvious biological bases.⁵ Thus, in recent years psychiatry has gone through an identity crisis, and its scientific nature has even been questioned.⁶

The authors of this article fit pretty well with these stereotypes about psychiatrists. Currently working in community mental health, our last professional contact with general or internal medicine was many years ago, as first-year psychiatry residents. We had not touched a stethoscope (figuratively and almost literally) for a long time. All these shortcomings made the experience of the first days stressful and overwhelming. Whereas our fellow infectionists faced the novelty of an unknown disease and its dramatic consequences, for us everything was new. The critical situation of the hospital, on the verge of collapse, and the general climate of catastrophe possibly also influenced us. However, after a few days, we recovered from the initial shock. Stress began to shape us and our routines, in parallel to the society that, hit by COVID-19, initiated its own adaptive effort.⁷ Then we remembered that psychiatrists are also doctors, and we understood that the distinction between “medical” and “psychiatric” patients is useless. When we were able to return to our regular practice at the end of April, the redeployed psychiatrists shared the feeling of having achieved considerable clinical autonomy and that the experience, brief but very intense, had contributed to our professional development. Undoubtedly, the high protocolization of the clinical management of COVID-19 and, above all, being part of a multidisciplinary medical team, increased our perception of clinical accountability.⁸

Although, as mentioned, the balance of our experience was not negative, the SARS-Cov-2 pandemic has exposed gaps in the medical skills of the psychiatric community. It must be said, in our defense, that this is largely due to the high degree of specialization achieved in modern medicine. In fact, psychiatrists are not the only who have experienced difficulties during the COVID-19 outbreak, other specialties have also suffered from their lack of medical training when responding to the crisis.⁹ However, psychiatrists are often prone to despise the more medical part of the biopsychosocial model, perhaps because of the mistaken belief that a biological approach is not compatible with a humane, patient-centered management. Several proposals have been made to try to enhance general medicine skills during residency in psychiatry. Nevertheless, experienced psychiatrists should also continue to update regularly, and not lose touch with general medicine. Ideally, psychiatrists should acquire enough skills to be able to lead integrated health teams.¹⁰ Otherwise, the psychiatric community runs the risk of becoming irrelevant in major public health decisions, especially if it continues to strive to distance itself from major “physical” health problems. It is time for psychiatrists to react and prepare for an uncertain future of health crises, in which our knowledge and skills cannot be restricted to the field of our specialty.