These are strange times.
I have been a practicing physician for nearly 30 years, and I frankly do not know what the future holds. The sudden arrival of the COVID-19 pandemic to America and to our dysfunctional health care system is terrifying.
As a program director, I am worried about my trainees who are already challenged with the usual stressors of graduate medical education (GME). This new illness is threatening to upend and disrupt our program in ways that I cannot even imagine, and therefore cannot plan for. The Accreditation Council for Graduate Medical Education (ACGME) does not have instructions for how to shepherd residents through this challenge. Core program requirements do not address what to do when residents are placed on mandatory quarantine or when the health care capacity of a hospital or region is overwhelmed. Anxiety is sky-rocketing, tension is mounting, and nerves are fraying already.
For the past two days, I have been reading postings from physicians on the front lines in the Lombardy region in Italy who describe a tragic triaging process akin to wartime medicine, because of a health care system overrun with COVID-19 patients. Their stories are already heart-breaking and the numbers of affected patients continue to increase daily. The triage decisions those physicians are being forced to make, necessitated by inadequate supplies and ventilator units, are almost inconceivable for most American physicians.
For the first time in a generation, residents and fellows are going to be learning in real-time with their supervising faculty how to treat an unknown and potentially fatal disease. This virus is moving faster and farther than HIV, SARS or Ebola and is more lethal than recent influenza strains. This is frightening business. Not since the emergence of HIV have I seen the kind of public fear that I am witnessing now.
The ACGME is offering updated and evolving guidance regularly to assist the understanding of where GME trainees fit into the care model for this new population of patients, but as realities and conditions are changing quickly, it has been difficult to keep up. Initially — just last week — training programs were informed that residents and fellows were not to participate in the care of patients with known or suspected COVID-19. As reported case numbers quickly rise and more states are found to have patients, guidance has now changed to having residents and fellows trained in proper protective gear usage and adequate supervision if they are members of critical teams.
However, the challenge remains that testing for COVID-19 is unavailable or difficult to obtain in much of the country. Residents are the front line for patient care in many, many hospitals. Faculty are equally untrained and inexperienced in the care of COVID-19 patients. Universal precautions and foundational medical knowledge will be guiding the care of patients presenting with potential COVID-19 infections, but I don’t think it is an understatement to say that no one is ready. Not really.
This COVID-19 pandemic scenario does not fit the ideal ‘education over service’ model that the ACGME has rightly championed. The risk of coming in to work suddenly feels much more acute. It is not entirely clear how to best protect ourselves as health care workers despite stringent personal protective protocols. We know that already Chinese physicians have succumbed to the virus. If patient numbers explode, the neat constructs of duty-hour regulations, days off, patient caps may soon be obsolete. The rules that have increasingly defined residency training may be impractical or even impossible to adhere to if significant numbers of health care workers are ill or quarantined.
Our health care system is going to be severely tested in the next few weeks, and the organization of graduate medical training will be significantly disrupted. For residents, what will this mean?
Unfortunately, no one really knows. How will absences for quarantine or prolonged illness been managed? At our institution, there is talk of an at-home reading rotation. Will training need to be extended for some people? There is chatter on program director discussion boards about whether a two-week at-home quarantine period will need to be made-up in hospital in order to graduate. Who will cover for absent resident physicians? At our academic institution, many faculty have not done in-house overnight call in years and some associate providers have strict daylight hours written into their contracts. What will happen if patients overwhelm hospitals? Residents have patient caps of a maximum of 10 on many services. Who takes over when hundreds of extra patients fill the hallways? What if there are insufficient supplies for personal protection gear? What is a physician is asked to perform a task that he is not yet certified to do, but there is no one else available? What will happen if a resident has to choose whom to treat and whom to not treat as is the case reportedly in Italy? How will the disruption affect graduation, match dates, or boards? No one has answers to these questions today.
The concept of physician wellness has always been fraught with tension between the duty to give of one’s self to the profession and the duty to care for one’s self to maintain equanimity. A health care crisis such as COVID-19 that is blossoming in front of us may obviate meaningful discussion of physician wellness, at least temporarily. Watching a few reruns of the television show M*A*S*H on Netflix may be the best information we have as to inform ourselves about the effect of unrelenting trauma on health care staff. Resiliency, if physicians in the United States are going to be faced with wartime-like conditions in our emergency rooms and ICUs, will be needed more than ever to get us through.
If we are to believe the dire predictions flying across the internet today, up to 150 million Americans could be affected, with up to 20% of those needing inpatient care. This will be extraordinary. We will all be learning from each other, supporting each other, and caring for each other. In times of great uncertainty, it can be difficult to sustain oneself. Anxiety, fatigue, potential isolation, and trauma are awaiting us as physicians if these predictions are accurate. I wish that as a program director I could shield my trainees from what may come and reassure them that we will be guiding and supervising them capably, but since I have never done this before, I cannot. Physicians are going to need to support each other through stressors the likes of which we perhaps have never before encountered. The passion that drove us to medicine will need to sustain us, because I suspect that very soon many physicians are going to the front lines of this pandemic. We are going to need each other for strength and compassion. Our definition of wellness may be a bit different for a while.
A program director’s perspectives on practical wellness in residency and how graduate medical education leadership can facilitate housestaff resiliency and self-advocacy.