This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.
Friday, March 27th
I’m not having any symptoms at all at this point, really itching to get back to work. All residents have been instructed to check their temperatures before and after every shift since last week, in the hopes of catching any early signs of infection. We were not supplied any thermometers by the program, local drug stores are all sold out, and checking online the cheapest thermometers that will arrive in fewer than 4 days are all over $50. Luckily, I have my son’s infant forehead thermometer but I’m pretty sure doesn’t really work—I use it anyway and consistently have a temperature below 95 degrees, whatever that’s worth. I hadn’t felt feverish so I continued to go in to work at the hospital.
I’ve been reading a lot of self-congratulatory posts on social media from those in healthcare, selfies with a mask on, a team posing for a picture in all their protective gear, etc. For the most part it’s pretty benign but important stuff—reminding people to wash hands and stay home. The other intention is to self-promote and remind others they’re putting themselves at risk for the greater good. A troubling type of post I’ve been seeing is from providers (often not directly taking care of any COVID patients) excited and proud at the prospect for the medical community to come together to defeat this invisible foe. Maybe these sentiments are posted because morale is low and physician burnout is even higher than typical at this time? Bully for those that go into the fight ready, willing, and able. This mentality seems to say that as healthcare providers we should all rush to the frontlines as it’s a commendable action. I suspect many people not working in healthcare may not realize that residents are not really given a choice whether to participate or engage with high-risk coronavirus patients.
Residents are at an even higher risk of burning out at this time because all “non-essential” employees are not permitted in the hospital and they are limiting the number of employees for the essential roles as a way to decrease overall exposure. Medical students typically make discharge appointments, obtain outside hospital records, and other vital tasks—but medical students are no longer permitted in the hospitals because in many ways they’re paying for the privilege of being there. That topic in and of itself could be another blog post. Gone or restricted hours also apply to many case managers, social workers, patient transporters, nutritionists, physical therapists, drug or alcohol rehab representatives, etc. The burden of caring for patients and providing a safe discharge now falls more squarely on the remaining, smaller medical teams, which includes residents (and more specifically the interns—first year residents). This is time-consuming and no doubt will hasten burnout. In our program we’ve been fortunate enough to be able to take certain measures to mitigate this, like shorter duration spent on COVID teams for residents, but we may not have that luxury in the coming weeks.
Is this what we signed up for as trainees? My institution for now has been remarkable in being able to accommodate residents that are particularly vulnerable or have vulnerable household members; others may not be so lucky. Hospital administrations have to make the decision as to who to put in harm’s way. It’s not always cut-and-dry—should we protect older attendings or younger trainees? Is the duty to provide the best care for these current patients or to minimize exposure of budding physicians who will be practicing for decades to come? We have no idea if there are any long-term repercussions to the lungs or any other organ systems in people with asymptomatic coronavirus, and they may confer a higher rate of complications not seen for years or decades—we just don’t know. The vast majority of residents and clinicians in Internal Medicine are very hesitant to jump right in, and understandably so. Initially no med students, interns, or residents were to take care of COVID patients. As the epidemic grew into a pandemic more and more hands needed to be on deck. But still, the decision regarding which specialties will be taking care of these patients is growing. The public may not realize it either, but some residents and even attendings from subspecialties that don’t have much clinical patient exposure (e.g. Radiology) may have to dust off their stethoscope and start taking care of loved ones in your hospital.
Similarly to reports about physicians having to decide which patients get a ventilator, we are also making the decision as to which providers get greater amounts of exposure, which is a morbid endeavor. In Philadelphia, we’re fortunate enough that we haven’t had the same patient burden as New York so it hasn’t been all-hands-on-deck, but we may have to start asking which residents can handle more exposure than others, sooner rather than later. Does taking care of an elderly family member, or a child at home come into consideration? What about providers with immune system issues? Where does my duty to provide for my patients trump my duty to keep my family’s risk of exposure at a minimum? Is it moral to ask a young, healthy, single resident to have repeated exposure or is it better to spread it out over several residents but lessen their daily exposure?
Although I personally hope to continue to be at or near the front lines, I understand those that are in a compromised position, and they shouldn’t feel bad for wanting to protect themselves or their family. There is no portion of the Hippocratic oath that implicitly or explicitly states that physicians have a duty to patients above their own safety. This is a nuanced situation that doesn’t have a blueprint in place. There are many features that as a society we’re having to figure out in real-time, which is just adding to our collective anxiety.
Healthcare workers are put in an awkward situation in these times. We need to be discussing this openly, with transparency about the treatment of healthcare workers, especially nurses and residents. How to improve the healthcare system is an important topic that hopefully will not be able to be ignored after we pass the emergency of the pandemic. It will not be easy to address this because the goals of the industry are not aligned with the goals of the public or those providing care. Even though we’re in the midst of the pandemic it’s a beneficial practice to reflect and think about the way we can improve the safety and efficacy of those delivering care.