The life of a third- or fourth-year medical resident is stressful enough without a global pandemic landing on the hospital's doorstep. Yet, land it did, harder in some places than others, leaving residents with no choice but to help attend to the sick, outside their area of specialty in many cases.
Since the first case of COVID-19 was reported in Washington state back in January, medical residents have found themselves in unique and, sometimes, conflicting circumstances. They are doctors on the one hand and trainees on the other, forced to develop their skills while treating patients with a respiratory illness about which little is known. If the term "new normal" applies to any group, it certainly does to medical residents.
No better illustration of how residents' professional lives have changed since the pandemic's onset can be found than a KevinMD post where one resident reflected on a typical shift rotation:
"As I change out of my scrubs in the resident lounge bathroom, I am exhausted and numb. I put on sweatpants and a T-shirt, taking care of folding my scrubs to avoid touching the dirty spots. I wipe my phone and keys with an antibacterial and antiviral hospital wipe and place them into my bag.
"I hang my white coat on a wall hook in my workroom, my stethoscope in the pocket. In the opposite pocket of my coat sit two used face masks, and two used N95 masks that I am too afraid to throw away. Another workday comes to an end; every precaution taken in order to keep the stress and the fomites at work and away from home. I am an Internal Medicine resident in Chicago, and this is my life during the global pandemic of COVID-19."
A third-year emergency medicine resident from Mississippi that we spoke with shared this experience during the early stages of the crisis:
"What started off was a drop in the number of patients who come in for other chronic medical conditions," he said. "It shocked us that no one was coming in because we see so many patients on a daily basis."
He attributed the decline to people staying home and practicing social distancing but added that soon gave way to a hospital filled with patients infected by the virus. He also spoke about the change in procedure and diagnostic uncertainty that came with treating patients who were possibly affected.
"For training purposes, when we're evaluating a patient, if they come in saying they’re short of breath or having chest pains, after discussing the main issue that brought them in, we already have a running list of what the likely causes are," he said. "The pandemic adds the question, 'Could this be coronavirus?' It created more diagnostic uncertainty, elements of surprise, and things to consider than when you're not in a pandemic."
Of all the areas of a resident's life affected by the virus, education may have taken the largest impact. The goal of educating and developing competent, compassionate physicians ready to practice medicine has been upended.
Students have been pulled from clinical rotations or sent home from physical classrooms to learn virtually; residents are moving from their specialty to assist in other clinical areas; elective surgeries are being canceled, so surgeons in training don't have access to the clinical experience they need to learn life-saving skills; the curriculum has to be manipulated to fit the new virtual learning environment because residents can no longer gather in discussion groups, grand rounds, or other in-person formats to receive didactic education.
"We have quickly come to recognize that COVID-19 has created a learning environment of its own and has presented a unique opportunity for us as medical educators," said Academic Medicine, the AAMC journal. "Our learners are experiencing a pandemic, a rare event that in itself is stimulating the parts of the brain that facilitate deep learning. Our task has been to work with this material and provide our residents with an effective educational experience."
To assist, the AMA has developed a COVID-19 resource center as well as a physician’s guide to COVID-19 to give doctors a comprehensive place to find the latest resources and updates from the CDC and WHO.
AMA has also selected a list of resources to assist residents and medical students during the pandemic to help manage the shifting timelines, cancellations, and adjustments to testing, rotations, and other events.
A Medscape article addressing the effect of COVID-19 on residents says that even though residents are being lauded as heroes for their frontline work fighting the disease, some trainees may feel they are being taken advantage of.
"Residents are overwhelmed and working longer hours for the same pay, sometimes with inadequate personal protective equipment," the article said. "They're doing jobs outside their scope of work and facing burnout and emotional and physical fatigue. And they're doing it all, in some cases, for little more than minimum wage."
Though this reality and these concerns are real in some facilities, most hospitals and health systems are going above and beyond to provide support for all frontline workers, including using surveys to track stress levels, distributing workloads, rearranging schedules to move residents from high-stress to lower-stress environments, and making therapists available to doctors to provide psychological support. Tools like this checklist helped facilities plan out how to best plan for the pandemic and support residents and other staff through this challenging time.
Another critical element of support adversely affected by the virus is the sense of community that residents build with their peers. Whether it's debriefing about an emotional patient encounter, discussing an unusual clinical case, sitting together for lunch, or destressing via post-shift social time, COVID-19 has put an end to in-person gatherings for the time being. Social distancing policies, while essential, can, lead to feelings of isolation and lack of emotional support so badly needed during this time.
Communication is another area where residents have experienced change. The resident we spoke with said that communication about the virus has come as a "rolling kind of dispersal" in various forms.
"It isn’t just one thing used to disperse information, but a combination," he said. "The CDC updates guidelines that change every week, and we are required to keep up. The department chair sends out COVID-19 updates weekly via email, which are then dispersed to residents as well as attendings, to recap major changes."
It's an understatement to say that emotions are running high right now, but they also run the gamut, from fear and anxiety to a sense of excitement at the prospect of making a real difference in patients' lives.
The resident we interviewed said he wasn't worried about contracting the disease, but was stressed about what's going to happen when he goes home to visit his parents — a once common activity from which he has refrained the past few months for fear of infection.
"I am in the hospital around the clock, not knowing if I've been exposed," he said. "It has affected my interaction with friends and family and makes us long for of the times when we were able to interact more freely."
A survey conducted by the University of Washington (UW) and UW Medicine found that other residents shared similar concerns.
“I’m excited to be able to make a difference, but I’m just as scared as everyone else," said one resident.
“When the COVID epidemic hit, I was on my anesthesia rotation," said another respondent. "I dealt with the ethical dilemma of going in to get my intubation numbers higher while knowing I was still nonessential personnel."
“I feel underutilized ... It’s so hard to be a student and not help when you feel morally and ethically inclined to do so," another remarked.
“As strange as it sounds, I feel lucky to be working during this time," said yet another resident.
The resident we interviewed directly also talked about his feelings regarding interacting with patients during rounds.
"The biggest logistical issue when seeing patients suspected of having the virus is to get as much initial information as possible," he said. "We have to gown and glove up and protect ourselves. It puts distance between you and the person. You lose the personalized physician-patient relationship and bedside manner."
He also commented on the inability to build rapport with families of sick patients.
"Unfortunately, for some of our sickest patients, the ones that may not make it, we can't allow family members back there due to the risk of spreading the virus," he said. "We're taking a massive step back in our ability to build rapport. Patients are by themselves until they are able to be cleared."
As you can imagine, the idea of putting residents in training on the hospital floor treating patients comes not only with significant risk but also quite a bit of controversy. Opinions differ as to the wisdom of the practice, regardless of the degree of need.
The American Heart Association left no room for doubt with its opinion: Protect medical trainees on the COVID-19 frontlines, or do not send them in.
“All medical professionals want to help, but fellows and residents are being asked to do things they are not fully trained to do and that take them longer to perform than attending physicians,” said Mariell Jessup, MD, chief science and medical officer at the American Heart Association. “At the very least, we need to ensure they are protected with proper PPE.”
As surprising as it may sound, some physicians, including the resident we spoke with, feel there are benefits to be derived from being in the midst of medical training during a pandemic.
"We were given more autonomy in our COVID-19 unit," he said. "As residents, we see these patients on a regular basis. Attendings rely on our evaluations in examination to limit interaction to prevent the spread. We tag-team with video chat while in the patient's room. We now have an extra layer of trust."
Lawrence G. Smith, MD, founding dean of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, said that the outbreak will make residents better doctors.
"As they work at the bedsides of those with COVID-19, new doctors will discover a skill too long ignored by most medical schools: empathy," he said. "No matter how great physicians’ technical skills are, they may not be considered healers until they’ve learned how to soothe and inspire, to comfort patients and family members alike (even when it’s compassionately delivering bad news), to deliver not only treatment but also hope."
When asked if, given the choice, would he have preferred the outbreak happening during residency or later on, the resident we interviewed said, "I'm glad it happened in residency because we had the mindset of learning on the job. With the pandemic happening during residency, we're used to adapting to change. It made it easier. Having co-residents with you going through training adds a level of support. You're not by yourself dealing with this as an attending."
Certainly, the COVID-19 crisis is a teachable moment that educators can use to instruct medical students on ways to improve end-of-life care, allocate scarce resources, and care for patients who are noncompliant with self-quarantine recommendations.
"As the health care system becomes more adept at providing COVID-19 care, there will be innovative ways to assimilate students into care processes," the New England Journal of Medicine said.
Let's end this post the same way we began, by hearing from the resident in KevinMD, who leaves us with a message of hope:
"As a medical resident, I remain hopeful, for the sake of my colleagues, patients, and my own mental health ... My hope for the world moving forward through the pandemic is that we never take for granted the power of community and our ability to come together. I hope we never take for granted our healthcare system and the importance of public health infrastructure. I hope we collectively have the strength to make it through the crisis. I hope we remember it’s a small world, after all, and we’re better together."
SCP Health prides itself on providing proactive support to residents through our Residency Resource Team. If you have questions or would like more information about our medical residency program, feel free to contact us.