Redeployment of psychiatrist trainees during the COVID-19 pandemic: evaluation of attitude and preparedness

Background: The coronavirus disease-2019 (COVID-19) pandemic has imposed an unprecedented strain on healthcare systems worldwide. In response, psychiatrist trainees were redeployed from their training sites to help manage patients with COVID-19. This study aimed to examine the attitude of psychiatrist trainees toward redeployment to COVID-19 sites and their perceived preparedness for managing physical health conditions during redeployment. Methods: A cross-sectional researcher-developed online survey was administered among psychiatrist trainees in May 2020 at the Department of Psychiatry, Hamad Medical Corporation, Qatar. Results: Of the 45 psychiatrist trainees, 40 (88.9%) responded to the survey. Most trainees reported being comfortable dealing with chronic medical conditions, but less so with acute life-threatening medical conditions. Half reported feeling anxious about redeployment, and most felt the need for additional training. We found that trainees’ perceived redeployment preparedness was significantly associated with their level of postgraduate training and the time since and duration of their last medical or surgical training. Conclusion: Adequate preparation and training of psychiatrist trainees is important before redeployment to COVID-19 sites to ensure that they can effectively and safely manage patients with COVID-19.


INTRODUCTION
The novel coronavirus disease-2019 (COVID- 19), which was first reported in Wuhan, China, was declared as a public health emergency by the World Health Organization (WHO) in March 2020. The State of Qatar confirmed its first positive case on February 29, 2020. By July, Qatar had one of the highest numbers of patients with COVID-19 per million population. 1 The pandemic puts strain on health systems and essential public services worldwide, including Qatar. Public health facilities were overwhelmed with numerous cases of COVID-19. The global response to this public health emergency varies because of different healthcare systems, policies, and resources available to countries. 2 -5 Qatar is a peninsula located amid the western coast of the Arabian Gulf. It is one of the world's wealthiest nations in terms of per capita gross domestic product and has a population of 2.7 million. 6 Qatar launched a public health strategy and commissioned special hospitals and national quarantine sites for managing patients with COVID-19. 7. Hospitals suspended non-urgent care and elective procedures, and healthcare workers were redeployed to COVID-19 facilities owing to the high demand at the time. This included physicians regardless of their specialty to meet the medical needs of patients with COVID-19. However, the literature on trainee redeployment during the current pandemic is scarce, mainly consisting of correspondence articles, with very little literature about psychiatrist trainee redeployment. 8,9 Psychiatrists at all levels of clinical training encounter patients with various physical health problems, ranging from chronic medical conditions to acute medical and surgical emergencies during their daily clinical practice. 10,11 The Accreditation Council for Graduate Medical Education (ACGME) identifies the ability of psychiatrist trainees to perform a complete basic physical examination as a mandated core clinical competency. It also mandates psychiatrist trainees to be skillful in administering all diagnostic and therapeutic procedures considered essential in their clinical practice setting. 12 However, compared with other medical specialties, a proportion of mental healthcare professionals exhibits lower levels of self-perceived proficiency in managing physical health emergencies. 13 Thus, this study aimed to gain insight into the attitude of psychiatrist trainees toward their foreseeable and established redeployment. This study also aimed to assess the readiness and preparedness of psychiatrist trainees to manage physical health conditions that they might encounter during redeployment. The results can help in developing appropriate training interventions for any possible redeployment of psychiatrist trainees in the future, should the need arise.

Setting, participants, and redeployment process
During the first wave of the pandemic in Qatar, multiple healthcare facilities were appointed as dedicated COVID-19 sites, including newly launched hospitals and upgraded general hospital wards. 7 These were initiatives to boost the healthcare sector's inpatient and intensive care capacity to accommodate moderate and severe COVID-19 cases. On March 31, 2020, the country's COVID-19 command center -System-Wide Incident Command Committeenotified the Department of Psychiatry, Hamad Medical Corporation (HMC), to nominate 50% of its trainees for potential redeployment to these new facilities to support the increased healthcare demands. The Department of Psychiatry in HMC has the only psychiatry residency program in Qatar, which is one of a handful of ACGE-International (ACGME-I)accredited graduate psychiatry training programs worldwide, 14 and hosts the majority of fellowship programs in psychiatry in the country. Trainees who were pregnant, breastfeeding, or immune, or medically compromised were exempted from redeployment. Selected eligible trainees were notified of their imminent deployment to dedicated COVID-19 sites covering moderate and severe cases and were redeployed shortly afterward. Redeployment transpired in waves from April to June 2020. A cross-sectional survey was circulated among psychiatrist trainees (residents and fellows) at the Department of Psychiatry, HMC, Qatar. The survey took place in May 2020, during the COVID-19 outbreak in Qatar, when doctors from different departments were being deployed to work at COVID-19 sites.

Instruments and data collection
A survey was adapted based on previous studies assessing the attitude, readiness, and preparedness of psychiatry and other noncritical care trainees and physicians-in-practice in managing acute medical emergencies. 10,11,13,15,16 Candidate survey items were extracted from these studies and adapted to our study context. Consequently, adapted items were incorporated into our survey based on a consensus between the authors, which was achieved through unstructured group discussions (via emails and online meetings). An email was sent to the professional email addresses of all medical residents and fellows at the Department of Psychiatry. The survey was created using Microsoft Forms (Appendix 1). To optimize the participation rates, reminders were sent on a WhatsApp group dedicated to all psychiatrist trainees in Qatar. The survey consisted of questions about the following: . Medical and life support training (five questions) . Experience in managing the most common medical emergencies (seven items) and in using and interpreting the most important emergency medicine diagnostic instruments (11 questions) . Preparation for redeployment to COVID-19 sites (eight questions) . Perceived confidence levels in managing medical emergencies (seven questions) and in using and interpreting the most important emergency medicine diagnostic instruments (11 questions) . Rating of trainee's preparedness to be deployed to a COVID-19 site on a 5-point Likert scale.

Ethical Considerations
The study was considered a service evaluation project by the HMC Institutional Review Board (IRB) and was exempted from IRB approval (MPF-23-02-21). All necessary departmental approvals were obtained before commencing the study. The study was conducted in accordance with the World Medical Association Declaration of Helsinki.

Statistical Analysis
For each categorical variable, we calculated absolute and relative frequencies. Continuous data were presented as mean and standard deviation. Mean scores of the four major questionnaire subscalesfrequency of encountering physical health problems and performing emergency clinical skills, in addition to the confidence in managing and practicing themwere calculated. The internal reliability of these subscales was evaluated using Cronbach's alpha coefficient, and values .0.7 were considered acceptable. 17,18 The normality assumption of the data was examined using the Shapiro -Wilk test.

RESULTS
The overall response rate was 88.9% (n ¼ 40 of 45 psychiatry trainees). As shown in Table 1 less was reported about their experience with acute life-threatening medical conditions, such as respiratory distress, myocardial infarction, stroke, or loss of consciousness ( Figure 1). Similarly, while most psychiatry trainees reported that they were commonly performing and interpreting basic laboratory tests and electrocardiography (ECG), most reported having no experience in managing airways, performing external cardiac compression, collecting arterial blood gases (ABG), or administering emergency drugs ( Figure 1). Around two-thirds of psychiatrist trainees (65%, n ¼ 26) felt that their physical examination skills deteriorated since they started working in psychiatry ( Table 1). Half of the participants felt worried or anxious about being redeployed, whereas one-quarter felt ambivalent. Only 15% (n ¼ 6) felt honored, excited, or enthusiastic about their redeployment to COVID-19 sites ( Table 2). Although more than half of the psychiatry trainees rated their confidence levels in managing chronic medical conditions such as diabetes and hypertension as moderate, their confidence levels in managing acute life-threatening medical conditions (such as myocardial infarction, stroke, or respiratory distress) were mostly low ( Figure 1). While many psychiatry trainees were moderately confident in performing a physical examination, inter- preting basic laboratory tests, or analyzing an ECG, most reported having low confidence in airway management, cannulation, administration of emergency drugs, or collection and interpretation of ABG ( Figure 1). Most (87.5%, n ¼ 35) respondents shared that they should receive further deployment training (Table 1).    As presented in Table 3, a significant association was identified between feelings toward redeployment and perception of the effect of psychiatric training on physical examination skills ( p ¼ 0.017, Fisher's exact test). However, the post hoc analysis showed no significant differences between the comparison groups. Furthermore, a significant association was noted between perceiving a need for further training before redeployment and the time of being informed about the possibility of redeployment ( p ¼ 0.025, Fisher's exact test), with pairwise group analysis showing that only those who were informed within a week of their potential redeployment were significantly more likely to report feeling a need for further training than not (n ¼ 7, 17.5% vs. n ¼ 4, 10.0%, Bonferroni adjusted p ¼ 0.005). No significant associations were noted among the remaining training and redeployment-related variables, preparedness ratings, perceived need for further training, or feelings toward redeployment (Tables 3 and 4).
Tables 5-7 present the correlation matrices evaluating linear relationships among trainees' clinical practices, their training, and various redeploymentrelated factors.
Overall, a significant direct correlation existed between the frequency of encountering physical health emergencies and the confidence in managing most of them (Spearman's correlation, p , 0.05) ( Table 5). Similarly, a significant positive correlation was noted between the frequency of performing emergency-related clinical skills and the confidence in performing them ( Table 6).
As displayed in Table 7, Spearman's correlation showed a significant inverse relationship between trainee's clinical level and the time elapsed since their last medical/surgical training with the frequency of encountering emergency physical health problems and performing emergency-related skills and with their confidence in performing emergency-related skills ( p , 0.01). Only the duration of trainees' last medical/surgical training was significantly positively correlated with their preparedness ratings (r s ¼ 0.34, p , 0.05) ( Table 7).

DISCUSSION
In this survey about the attitude and preparedness of psychiatrist trainees in Qatar toward their redeployment to COVID-19 sites, most trainees believed that they were moderately prepared. Postgraduate medical training programs are increasingly focused on specialty; as a consequence, trainees exhibit lower levels of proficiency in managing physical health conditions. It was not surprising that most trainees reported being comfortable dealing with chronic medical conditions, but less so with acute life-threatening medical conditions. Psychiatrist trainees manage general health conditions commonly found in populations with mental illness and pursue a referral to appropriate medical care for medical emergencies because they encounter these conditions less frequently than routine conditions. Psychiatrist trainees are well versed with the medical manage-   26,27 and radiology. 28 Our analysis identified a significant association of the clinical level of trainees with the ratings of redeployment preparedness; however, a post hoc comparison failed to detect a significant association possibly because of a type 2 error given the small sample size. Likewise, a nonsignificant inverse correlation was noted between the advancing level of training and preparedness ratings. These findings can be explained by the higher exposure of early-stage psychiatrist trainees to physical health problems, especially during their first 2 years of training, compared with more senior trainees; since psychiatry residents are required by ACGME-I to complete rotations in various medical/surgical subspecialties during their first 2 years of training. 29 This possibility is supported by other findings from this paper. First, higher preparedness ratings were significantly associated with the time and duration of the last medical/surgical training. Second, advancing level of training was significantly inversely correlated with the frequency of exposure to physical health problems, and the frequency of practicing emergency medicinerelated clinical skills and the perceived confidence in performing them. These results are consistent with existing literature reporting higher confidence in assessing and managing medical emergencies among psychiatrist trainees than among consultant psychiatrists, which was attributed to the lack of learning opportunities. 30 Furthermore,  there are reports of perceived deterioration of physical examination skills among psychiatrists at various levels of training since working in the field. 31 Surprisingly, the level of redeployment preparedness or feelings toward redeployment were not significantly associated with the frequency of exposure to or confidence in managing physical health emergencies or the frequency of practicing or confidence in performing emergency medicine skills. Similarly, redeployment preparedness ratings or feelings toward redeployment was not significantly associated with the type or time since the last life support training or receiving any COVID-19-related training. Further research can determine whether this is due to the small sample size, quality of life support, or COVID-19-related training received.
To the best of our knowledge, no studies have examined the preparedness of psychiatrist trainees per se and their attitudes toward redeployment; nonetheless, we came across a study that examined the experience of redeployed physicians in training from different specialties. There have been reports about physicians in training in both Canada and France, in whom better training before redeployment was associated with better psychological outcomes. 32,33 Residents in Canada reported dissatisfaction when they were given short notice before being redeployed, when they were not offered adequate orientation, and when they perceived gaps between what they were trained to do and the requirement of COVID-19 cases. 32 Likewise, a survey sent to urology residents in training at 15 different departments in France revealed that "being welltrained" had a protective effect on resident burnout during the pandemic. 33 Our study shares similar findings, as the importance of planning redeployment was also reflected in the association of the level of redeployment preparedness with being informed in advance about expected duties and when deployment is perceived as well planned. Besides being trained or not, residents who chose voluntarily to be redeployed felt safer and more confident. 34,35 The hours spent at work were also taken considered when redeploying residents. At the New York-Presbyterian/Columbia University Irving Medical Center, residents certainly did not exceed their maximum number of working hours. Despite the potential risk to expose more personnel to the virus, the work duration was prioritized to prevent burnout of residents and improve patient care. 8 Various considerations were undertaken to avoid work-related stress and burnout among redeployed trainees in our study. Trainees' typical working schedule, in most of the frontline sites in Qatar, was reduced to 8 h a day with 1 day off per week, averaging 48 working hours per week, which is nearly half of the maximum regular weekly working hours per the ACGME standards of psychiatry training programs. 12 Furthermore, redeployed trainees were exempted from on-call duties and other after-hours clinical or healthcare-related activities during their redeployment period. In Singapore, physicians in training redeployed to the disease epicenter were asked to rate the level of stress they experienced during redeployment and their level of resilience on a scale of 0-10, and the mean levels were 4.7 and 7.52, respectively. Interestingly, family medicine residents were the most stressed, reporting an average rating of 8.3/10. 36 Although these results cannot be generalized, it could be argued that residents who are used to the fastpaced work in emergency settings were less stressed than residents who usually work in less acute settings. A few studies have examined the challenges faced by residents who originally worked in non-urgent settings before being relocated to help at COVID-19 sites, as well as the different strategies followed to overcome these challenges. In the Head & Neck Clinics in Lombardy, Italy, as the need for more medical personnel increased, head and neck specialists, given their little training in infectious diseases, joined the treating teams as junior doctors after being provided with brief COVID-19 training. 37 In New York, psychiatry residents were redeployed at New York -Presbyterian/Columbia University Irving Medical Center preferentially to intensive care units, to allow for closer supervision compared with working in the emergency department or in the wards. 8 Another example of effective use of psychiatrist trainees during the COVID-19 pandemic was the same as that implemented by the New York -Presbyterian Columbia University Irving Medical Center where psychiatrist trainees participated in a psychiatry -palliative care liaison team. In this initiative, trainees provided compassionate end-of-life care. 38 Some surgeons conquered the new challenges practically by taking small steps toward better management of acute emergencies. They started with collecting ABGs and placing nasogastric tubes, and they moved up the ladder to fulfill more challenging tasks. Their team effort was essential to their wellbeing individually. 34,35 The realization that they were part of a bigger medical body helped them focus on the job at hand. In New York City, orthopedic surgeons explained that despite being out of their comfort zone, the majority was involved in COVID-19 teams. To prevent crosscontamination, they made sure to keep the department and COVID-19 teams separate. To maintain their mental wellbeing and support systems during this unprecedented time, they remained connected through online meetings. 39 This also created a safe space for information dissemination and sharing of experiences for trainees and others. 9 Regarding our trainees, various measures were put in place to ensure trainees' psychological wellbeing during their redeployment period. The Outreach Staff Support Service, a division of Qatar's National Mental Health Helpline Service, was established during the first wave of the pandemic to proactively provide telecounseling services to frontline healthcare professionals, including redeployed trainees. This service is run by an interdisciplinary team of mental health professionals adopting the WHO mental health and psychosocial support recommendations amid the COVID-19 pandemic. 40 Additionally, frontline healthcare workers, including redeployed trainees, had direct access to staff support clinics hosted in COVID-19 sites. 7,41 ) Moreover, structural modifications were made to their working structure. Redeployed trainees functioned as a part of interdisciplinary teams composed of 4-5 trainees redeployed from various medical and surgical specialties and led by a senior clinician. This new structure has the potential of enhancing trainees' integration into their new roles and reducing their alienation while redeployed from their original training sites.

Strengths and limitations
To the best of our knowledge, this study is the first to examine the attitude and preparedness of psychiatrist trainees in Qatar toward redeployment during the COVID-19 pandemic. It involved all psychiatry residents and fellows, and the response rate was high (88.9%). However, our sample size was relatively small, and the possibility of a type 2 error cannot be ruled out. Our survey demonstrated high levels of internal consistency. Nevertheless, since this study was based on self-reported information, the findings are subject to response bias. The survey was also created for this study following a consensus among authors, but it was not formally pre-piloted or prevalidated before distribution to trainees. Finally, this study examined the attitudes of residents and fellows in Qatar, and the findings might not be generalizable to other countries with different health systems.
CONCLUSION COVID-19 took the world by storm and called for the healthcare systems to take unprecedented actions in response to its spread. 42 Shortage of medical personnel and high demand in COVID-19-related clinical areas necessitated redeployment of trainees from different specialties. The prospect of working outside the usual scope of practice and environment is bound to raise feelings of anxiety. Experience from Qatar's response during the pandemic includes the novel provision of anonymous helpline services with an adjunct medical staff outreach program, in addition to staff support clinics in all COVID-19 hospitals. Additionally, providing redeployed trainees with flexible, on-call-free working schedules while engaging them as members of multidisciplinary teams helps prevent their exhaustion. Recommendations based on examples from our own and other specialties include the provision of enough notice and skills training before redeployment. We recommend deploying psychiatrist trainees to noncritical medical areas where they can contribute to the general medical care as well as to psychiatry -palliative care of patients. Once redeployed, local induction and working in teams with appropriate supervision can be helpful. Allocating "buddies" with trainees already part of the team can provide further peer support and ensure COVID-19 competency through online training. 43 Additionally, creating a safe environment, such as online platforms, for residents and fellows to share their experiences might be beneficial.