|NARRATIVE MEDICINE SYMPOSIUM ON COVID-19: PANEL DISCUSSION
|Year : 2020 | Volume
| Issue : 2 | Page : 124-131
Graduate medical education: A walk in our shoes during the COVID-19 pandemic
Alex Hoey1, Nakosi J Stewart2, Tony Xia3, Alex Alers3, Ric Baxter4, Brian Hoey5
1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
2 Department of Trauma and Critical Care; Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
3 Department of Trauma and Critical Care, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
4 Department of Palliative Medicine and Hospice Care, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
5 Sidney Kimmel Medical College at Thomas Jefferson University; St. Luke's School of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, USA
|Date of Submission||05-May-2020|
|Date of Acceptance||27-May-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Brian Hoey
Department of Trauma and Critical Care, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA. St. Luke's School of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hoey A, Stewart NJ, Xia T, Alers A, Baxter R, Hoey B. Graduate medical education: A walk in our shoes during the COVID-19 pandemic. Int J Acad Med 2020;6:124-31
|How to cite this URL:|
Hoey A, Stewart NJ, Xia T, Alers A, Baxter R, Hoey B. Graduate medical education: A walk in our shoes during the COVID-19 pandemic. Int J Acad Med [serial online] 2020 [cited 2020 Jul 7];6:124-31. Available from: http://www.ijam-web.org/text.asp?2020/6/2/124/287960
| Introduction|| |
As of April 30th, 2020, the Centers for Disease Control and Prevention (CDC) reported 1,031,659 patients tested positive with coronavirus disease 2019 (COVID-19) in the United States, causing approximately 60,057 deaths with New York, New Jersey, and Massachusetts leading the country in cases. Despite initially lagging behind nations such as China where the virus originated, as well as some of the earlier hit countries like Italy and Spain, the US quickly plowed ahead to the forefront of the pandemic. Within the span of <3 short months, the US accounted for nearly one third of the world's 3–3.2 million cases, and 25%–28% of global fatalities brought on by COVID-19.,,
Given the high rate of infectivity seen with the virus, one of the largest challenges is the impact sustained by health-care facilities and their ability to remain adequately equipped. The spread of COVID-19 has caused many hospitals throughout the country to experience a vacuum in revenue due to the suspension of elective procedures in an attempt to conserve hospital resources and blunt the spread of the virus. As medical professionals all over the nation are burdened by increased workloads, hospital employees and support staff much like the rest of the country, have been forced to deal with reduced work hours and wage cuts., In addition to the handicap that the reality of this outbreak has placed on health-care infrastructure, facilities have had to overcome the simultaneous obstacle of international shortages of personal protective equipment (PPE), and the considerable risks posed to patients and health-care workers alike.
As practitioners around the world work to quell the effects of COVID-19 with limited or depleted resources, medical professionals struggle to deliver safe, timely care to these patients. This commentary is meant to illustrate some of the specific experiences and challenges that have arisen during the COVID-19 pandemic by highlighting the concerns, strategies, and adaptations of several medical professionals from the world of graduate medical education (GME). Each author [Table 1] was asked to respond to a series of five open ended questions and provide their unbiased thoughts and feelings on questions related to the COVID-19 pandemic.
| Experiences|| |
Question #1: How has the COVID-19 pandemic impacted your daily life at your workplace (office/hospital)?
As a 3rd-year medical student, I would say that the pandemic has changed my life dramatically. I went from working side by side each day with my teachers (residents and attendings) to not being allowed to step foot in the hospital. The pandemic eliminated our time with patients, clinical skill sessions, and in-person classes. We are now forced to finish our final clinical rotations from home, using virtual patient encounters and lectures to supplement our learning. At this point, it remains unclear how and when we will take our medical licensing exams. Furthermore, the virus has influenced our 4th-year schedule as our school has already prohibited “away” rotations at other institutions over the course of the next few months. As one can imagine, this is causing tremendous stress for our 4th year class as these rotations can prove to be important experiences prior to applying to residency programs in September. For now, we remain in a scheduling limbo and work to stay on track with our remaining requirements.
As a 3rd year general surgery resident, I was initially quite worried about the impact of this pandemic on my training. Initially, our surgical residency program was relatively unaffected as cases trickled into our hospital network. This rapidly changed over a 2-week period after we experienced our surge and our hospital was inundated with COVID-19 positive patients. The administration and senior physician leadership are now constantly meeting throughout the day to strategize on multiple significant issues including dealing with a potential shortage of PPE, ventilators, and blood products. The operating rooms (OR's) are now used exclusively for urgent and emergent cases. This resonates especially with our group of surgical residents as we collectively worry about how long this will go on and how it will affect our overall education, both inside and outside of the OR. On top of worrying about the decreasing numbers of operative cases, there are new issues we must address daily. How often should we be re-using surgical masks between patients and cases? What members of the team should physically see the COVID-19 positive patients? How do we adjust resident staffing issues?
As a senior critical care fellow, I have noticed that the COVID-19 pandemic has visibly increased the levels of stress in the ICU and throughout the hospital. Co-workers are more on-edge while performing their day-to-day activities, second-guessing how they go about their tasks and taking longer to provide care as they hyper-focus on infection control. Families are distraught over not being able to visit their loved ones in their hour of most need, or even grieving their deceased family member through the closed doors of an ICU room. Though the attention is often placed on bedside health-care providers, the entire hospital staff is affected by this crisis. As an example, security personnel are strained by maintaining new visitation policies and environmental services personnel are called upon more often to clean and sanitize not just patient rooms, but all the surfaces that could have been exposed to the virus. This anxiety is compounded by the lack of scientific knowledge about this disease and the ever-present misinformation throughout social media. Increasingly, hospital officials are finding themselves grappling with this disaster not just at the systems/operational level, but also at the personal level. Those in charge need to parse their time between designing protocols to keep the hospital running during surge scenarios while also fielding questions not just from the public, but from their own employees about how to keep everyone safe from this disease. Finally, as manpower and material needs are stressed to the limit, some of the patients most affected by this catastrophe are those not infected. There are still many patients dying from other devastating diseases who will undoubtedly suffer from resource shortage, not the least of which is health-care provider's time.
As an employed specialist, each day is now full of gearing up to be able to handle the expected onslaught of COVID-19 patients. As a trauma and critical care surgeon, I continue to see and take care of patients although we have scaled back our elective practice and are only performing urgent cases to conserve resources. The typical day now consists of some patient care and a lot of virtual meeting time to tackle the pandemic.
As a general surgery program director (PD), the new normal has become reduced operative volumes and censuses and continued education of the surgical residents. While we have been able to continue some of our weekly scheduled education sessions, we have fully transitioned to a virtual format. We have also had to reprioritize the education of our residents and rapidly bring them up to speed with our ever evolving COVID-19 hospital treatment protocols.
As a hospice and palliative medicine specialist, the COVID-19 pandemic has had a significant impact on my ability to do my job effectively. Families are now limited in their ability to visit and be present and supportive of a loved one in a hospice facility (Skilled Nursing Facility, Assisted Living, Inpatient Hospice Facility), raising the question of “how do we balance safety with compassion, caring, and the value of being present?” Each of these factors considered on their own are capable of significantly impacting bereavement. Furthermore, families are restricting hospice workers from entering the home to provide care out of fear of having the virus introduced into the home, thereby raising the question of how can we perform our jobs effectively and manage legitimate fears and concerns? Long-term care facilities are refusing to allow patients to come from home for respite care to give caregivers an essential reprieve. As an organization we must develop plans to provide the essential aspects of care in a changing environment. Finally, the hospice staff has legitimate fears and concerns for themselves and their own families which must be addressed with solid and transparent information, understanding, and support. It is crucial that this be done while providing the necessary education, equipment, and leadership to assure that they can continue to care for patients.
Question # 2: Should trainees (medical students, residents, and fellows) be involved in the care of COVID-19 patients?
I certainly advocate that all learners, including students, should remain in the hospital and stay involved in the care of these patients. The unique learning opportunities that we would experience are endless. These experiences would be invaluable to us in the future when we are the physicians during the next pandemic. Furthermore, with proper up-front training, we could become a vital part of the work force depending on the needs of each hospital. The one caveat to this would be if there was not enough PPE to allow us to safely care for patients.
I do feel that residents and fellows are in a different category and as such should be treated differently than students. They truly are an essential part of the work force and need to be involved in the care of these patients.
Residents need be involved in the care of these patients for multiple reasons. With proper up-front training, residents are a resource to treat these patients and provide relief for the front-line providers. This experience is essential as we will potentially be on the front line during the next pandemic. Medical education is a series of gradual transitions, and not every aspect of patient care must be done by the highest credentialed individual in the room. We should not dismiss our skills and knowledge or shy away from our duties for fear of exposure. We are a resource to be utilized and we should be part of the care team.
Our knee-jerk answer to this question should be “absolutely.” We became doctors to care for those in need, regardless of their affliction. We are in training, and for some of us, this might be the last time we will ever have direct oversight during patient care. We have spent over a decade sacrificing time away from loved ones, potential earnings, and our health to complete our chosen specialties. These are not the first patients we have treated with a disease that could infect us and take our life, and they certainly will not be the last. After this pandemic is over, we must recognize the fact that we are just another antigenic shift away from facing a new slew of patients that put our lives in danger. Most of our attending physicians have stories from when they were trainees during the 2009 H1N1 (swine flu) pandemic and several others have stories from the early days of treating patients during the HIV/AIDS epidemic, before they even knew what their patients were dying from. We should also recognize that this might serve as a gut-check moment for many trainees. A moment of self-reflection: “Do we really want this risk for ourselves and our loved ones for the rest of our lives?”
Although we received initial pushback from our COVID-19 leadership team, they came around and recognized the value of our residents and fellows being involved in the care of these patients. With proper up-front education and training, there is no reason to exclude them. In fact, in my opinion, they should be at the table with the leadership team helping to develop our hospital protocols and learning about how a system plans for disasters. After all, they will be the future leaders leading the charge during the next pandemic.
Our medical students, on the other hand, remain at home. While a pause may be appropriate to allow time for comprehensive education regarding this disease process as well as preservation of PPE, they too need to be in the hospital to learn and gain experience for the aforementioned reasons.
Unequivocally, yes! How will the next generation of physicians know how to respond to a crisis if they are prohibited from participating? Unfortunately, we have been presented with a unique learning opportunity, one that most of us have never seen or experienced. Beyond the medical aspects of direct patient care, there is also the opportunity to explore our personal and collective psycho-emotional and social responses. How are decisions made? Who is impacted and how do we account for each person and situation? How do we manage fear and uncertainty? Will we openly discuss the implications of our choices and decisions? Can we function as a team and allow each person to contribute to their strengths?
Question # 3: Is it ok for a provider to refuse to care for these patients? If not, what should be the consequences?
If a patient is in dire need of our aid and we do not provide it, we quite literally are not doing our job. In any other field, if you fail to fulfill the fundamental responsibilities of your position there is likely going to be repercussions. Potential options include suspension or even termination depending on the circumstances. Certainly, there are situations where refusal of care may be appropriate. In this case it includes all the workers that fall into the high-risk category of potential carriers of the virus. Every other provider needs to follow proper precautionary measures and take care of these patients as you would any other patient.
In my opinion, in certainsituations it is okay for a provider to refuse care. Obviously if this occurs, it is our duty to make sure another provider is available. Our profession has always had inherent risks associated with it, but everyone has a different limit. If we place consequences on refusing, how do we find the limit on who or what can be refused, and who would enforce this? Can an immunocompromised provider refuse care that requires direct contact with COVID-19 patients without consequence? What about care for suspected or at-risk patients with other medical problems? The better solution would be to incentivize those who are willing to provide care to these patients and to maximize the resources we have in an organized and thoughtful way. This also highlights the importance of transparency while requiring any proposed solution to have its basis in data. Maybe my view will change if and when there is a shortage.
It is not ok to refuse care for these patients. Society relies upon the professionalism and compassion of health-care workers everywhere to ensure patients afflicted with COVID-19 are not left helpless. A health-care provider without the professional integrity to show up when most needed should not retain the privilege of serving those who trust them. Care must be taken to not mistake a provider's calling for his willingness to be a sacrificial lamb however. For example, every provider has a responsibility to not waste PPE. By the same token, health-care administrators must follow the ethical principle of reciprocity, by which they ensure providers have the equipment they need to protect themselves and that providers and their families have access to treatment if they contract this disease. Finally, the real question should not center on refusal of care, but rather on a paradigm shift specific to a pandemic. In the event of our resources being close to exhausted, are we courageous enough to allocate resources by defining utility not by most lives saved, but rather by helping those who would benefit most from the help, while also safeguarding compassionate care to those we simply do not have the resources to treat?
On a daily basis, we continue to learn more and more about COVID-19, including how to protect ourselves, epidemiology of this disease, and how to treat those affected by this virus. CDC guidelines continue to evolve as we learn more about this virus. Given this moving target, it should come as no surprise that providers across the spectrum are anxious about caring for these patients. Continued education and availability of adequate amounts of PPE is essential. Those providers who are deemed high risk given the CDC criteria, are the only subset of providers who should have the option of refusing care of COVID-19 patients. Otherwise, given our moral obligation to care for all patients, regardless of the disease process, those providers who refuse care should be terminated.
No, it is not ok for providers to refuse to provide care. This goes to questions of professionalism and personal integrity. Fear cannot overwhelm knowledge, common sense and compassion. I am reminded of the early days of the HIV-AIDS crisis. For me, the real ethical questions are about our collective ability to make decisions to limit or ration the care we provide. Can we shift our thinking from a position of making autonomy the leading ethical principle in our daily decisions, to one of openly discussing distributive justice in response to the doomsday scenario experienced by Italy? What will be the personal and ethical implications of deciding not to offer an individual the highest level of care if they are deemed to have a very poor prognosis for survival? The ethical principles of autonomy, beneficence, nonmaleficence and justice must come together as equally valued. Discussions about the ethical framework that we will openly use should mitigate the consequences that may come from both sides of the system.
Question # 4: Issues in wellness – How do providers stay emotionally and physically fit throughout this pandemic?
This issue is much more difficult for those still working in the hospital. Many providers are being called upon to work longer hours than normal with the growing number of cases throughout the nation. In their situation, I can imagine it is incredibly difficult to strike a balance between the workplace and their physical and emotional health. As for us students, we are utilizing the time away from the hospital to finish the work required to conclude our final rotation and prepare for our upcoming board exams (whenever they may be). In addition, with much of Philadelphia currently shut down, many of my peers are finding creative ways to make use of the additional time they have. I've watched a large portion of my class “socially distance” themselves to their homes outside of the area to spend additional time with their families. Others are active picking up new hobbies like cooking, painting, home improvement, and creating home/outdoor workouts. While the situation is incredibly unfortunate, I can say that most students are making good use of their time.
To keep emotionally well, I would have to echo the general sentiments of staying positive and focusing on what remains unaffected. Staying in touch with family and friends, focusing on nonclinical duties, and keeping up with hobbies is essential. Team sports are gone, so I've been taking advantage of more outdoor activities. During the winter I enjoyed skiing, but now that it's becoming warmer, I'm enjoying more hiking with my dog, Mia. Of course, the internet is always an option; however, I have made it a point to stay off the news sites.
Each provider should take this opportunity of social distancing to do a bit of introspection. Our lives are so hectic that we often forget to pay attention to what truly gives us fulfillment. I must thank my wife for motivating me to take a mindfulness course earlier this year. Padma, our teacher, showed me the tools needed to identify all the extra thoughts coloring and affecting my reactions to stressful situations. She also guided me through exercises to quiet my mind, to identify details in my day that bring me joy, no matter how small. Technology is an invaluable tool to stay connected to family and friends, to provide each other with comfort and peace. My wife and I have turned to engaging in new projects around the kitchen and watching online videos about new recipes to keep ourselves busy whenever we are not in the hospital. Finally, staying physically fit can be achieved by looking up home exercise routines online, going on walks around the neighborhood while maintaining proper distancing and using the stairs while in the hospital.
Although even more challenging in this day and age, emotional fitness must remain a priority for all of us. The challenges of ramping up and caring for this patient subset is only made worse by the instant access we have to news in today's world. Beyond this, all of us are bombarded with texts from family and friends who are nonmedical looking for answers regarding this pandemic. The challenge is made more difficult by the constraints put on us by social distancing and the closures (gyms and restaurants) that many of us use to find balance in our lives. The answer is to get creative. Exercise at home – running and biking with proper social distancing is allowed. Stay off the news networks – how much more sensationalized COVID related news do we all need to hear? We can use the time to catch up and spend real time with our families and friends (virtually if they don't live with us). This is n opportunity to find time for those home-based hobbies and interests that many of us have neglected. As things get more hectic in the hospital, this balance will be essential.
For me the key ingredients to personal wellness are mindfulness, family, community, and exercise, and my dog Riley. I am mindful of my own fears and anxieties along with my values and responsibilities. This opens me up to be fully empathic to patients, families, peers and staff. I understand and acknowledge the risks and continue to serve. I am a primary reference point for my family and am strengthened by our shared experiences. I am a leader in my work community on a local and state level, and relationships help to sustain me.
My dog is a somewhat goofy Golden Retriever rescue who loves to be petted and go for walks. He reminds me constantly of the simple joys of life in the moment. Riding a bicycle is my centering and my salvation. During these difficult times, finding strategies to maintain wellness and peace of mind is a matter of recognizing who you are, and seeking out what you need to sustain your own well-being.
Question # 5: How has this pandemic affected your life outside of the workplace?
Philadelphia, the city where I attend medical school, has shut down for all “nonlife-sustaining” businesses. Therefore, any and all social life that medical students had has come to a screeching halt. We are now unable to meet up with friends after work, go out to dinner, or get a drink at a bar. What was once used as an escape from the seemingly never-ending schoolwork has now been eliminated. Still, many of us are finding new ways to utilize the time we now spend at home. Personally, I have been unable to play basketball due to both the closing of our gym and the recommendation to limit gatherings of large groups of people. Instead, I have forced myself to focus on stretching and strengthening my core with home workouts during the shutdown period. In addition, I too have returned to my family home to catch up with my siblings who have all been required to do the same by their universities and jobs.
Outside of work, the biggest impact the pandemic has had personally has been the disruptions in vacation and travel plans. This will affect the rest of the year now that many residents have needed to bundled vacations to later in the year in hopes that travel restrictions will ease. The residents in our group also get together weekly for different wellness initiatives including team sports and playing in a resident band. These activities, which we all enjoy, have also been put on hold. Overall, I think people have been staying positive, but as the pandemic lingers on in our region, morale may suffer.
It has been incredibly disheartening to see a complete lack of consideration for each other when going to the grocery store. As this pandemic continues, we must not succumb to the fears that drive our neighbors to hoard supplies and food. While driving back from work, it is almost impossible not to see the effect this pandemic has had on businesses and seeing all the streets so empty has an eerie quality to it. My wife and I are purposefully attempting to avoid a lot of the COVID-19 coverage in media since we are also facing it while at work. We had trips planned to go visit family in Puerto Rico and a medical mission trip to Cameroon, both of which were canceled. The uncertainty regarding our preparations to gain credentials and move out of state have also added anxiety to our daily lives. In closing, despite all the new difficulties, we can find new perspective amidst this crisis. We can now accomplish more from home than we ever thought possible. Also, take this pause to cherish any more time you get to spend with your loved ones; the fragility of human life is being displayed before our very eyes.
My days have grown longer and longer for a number of reasons. First, as a PD I am obviously affected by this pandemic. Like most PDs, our world has been turned upside-down as we rapidly educate our residents, deploy them to help wherever needed, and do what we can to maintain resident morale. Much of this work is done outside of the hospital as my day job (trauma and acute care surgeon) has not slowed significantly. I also find myself doing damage control with my friends and family who are nonmedical. The never-ending sensationalized stream of COVID-19 related new stories has affected all of them. Finally, I have made it a point to find time to decompress, primarily through increase exercising, knowing full well that staying emotionally healthy is paramount to doing my job effectively in the hospital.
In spite of the empty store shelves, waiting in line at the supermarket in search of toilet paper, and closing the public library, I try to live a simple life resulting in minimal personal impact outside of work. I can still ride my bicycle and take my dog for a walk without worry of social distancing. My family however, has faced more of the daily stress due to the closing of schools and having to work from home. My wife has had to find Health Insurance Portability and Accountability Act compliant networking platforms to be able to continue to provide counseling services without direct office appointments. Discovering virtual communication platforms has opened communication with family and friends which will help to combat the feelings of isolation. Being able to order take-out from the restaurant that employs my son allows us to feel supportive and connected with him. We often take technology and the internet for granted; this may be what keeps us connected and breaks down the isolation. I remain very concerned for senior citizens that are truly isolated and may not be facile with technology.
| Conclusion|| |
After several trying months, the world, including the United States is beginning to put the pieces together as the curve flattens and hospital systems are less overwhelmed. While the battle with COVID-19 is far from over, the forthcoming sense of some normalcy provides an opportunity for people to reflect on the unprecedented toll that this pandemic has taken.
Based on the commentary from our panel in the world of GME, much work remains to be done. First and foremost, all providers, including medical students, should be involved in the care of these patient. Nearly every commentator saw it as an essential duty that comes with the job. Beyond the immeasurable experience gained by preparing for and treating this population of patients, properly oriented medical trainees are a desperately needed source of relief. As the pandemic exploded, it exposed just how thin our work force is and how much we need to address surge capacity for future regional/national disasters. Preparation and training will be paramount. Second, beyond the physical toll of long days spent preparing for and treating these patients, the emotional impact was perhaps even worse. All of the panelists described this emotional toll both inside and outside of the workplace. As appropriately stated earlier, the current setting is a “gut-check” for everyone involved in the care process. An essential part of our future disaster preparation must be to have support networks in place for all hospital personal. In addition, everyone must use any mandated time away from work to focus on their own forms of wellness and avoid the sensationalized news from media outlets.
The leaders of GME must embrace this opportunity to address some of the weaknesses that this pandemic exposed. Comprehensive disaster education of providers that begins in medical school and continues throughout residency training is paramount. It is a detriment to residents and trainees if there is not a prearranged system to continue education and learning during times like these. Moreover, protocols need to be put in place immediately with our hospital administrative colleagues to define the trainee's roles prior to the next disaster/pandemic. As we begin the long process of recovery as a nation and society, we must learn from our mistakes and plan together to improve outcomes following the next global pandemic.
Financial support and sponsorship
This article is supported by St. Luke's Department of Trauma and Critical Care, and required no sources of funding.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
This work was determined not to require Institutional Review Board approval. Author-specific contributions were as follows: Mr. Alex Hoey contributed to the introduction, discussion, conclusion and editing. Dr. Nakosi Stewart contributed to the introduction, conclusion and editing. Dr. Tony Xia contributed to the discussion. Dr. Alex Alers contributed to the discussion. Dr. Brian Hoey contributed to the discussion. Dr. Ric Baxter contributed to the discussion.
| References|| |
McNamara A. CDC ConfirmsFirst Case of Coronavirus in the United States, in CBS News; 2020.