J.T. is a general internist who completed residency in Atlanta early in the AIDS era. His daughter, R.T., is a third-year internal medicine-pediatrics resident in Los Angeles, and his daughter, D.T., is a second-year OB/GYN resident in Philadelphia. They describe and compare their experiences as residents during a pandemic.
Contexts of the pandemic eras
J.T.: I started residency two years after the first cases of AIDS were reported. We residents had not witnessed infectious disease epidemics save for hepatitis B and C, so HIV/AIDS was entirely unanticipated. Health care was not ready for it – there would be no approved antiretroviral medication for the first six years – and neither was society. Misinformation on how it was contracted abounded. The two main risk groups, homosexual men and injection drug users, already subjects of discrimination, became evermore social outcasts. Two differences from the COVID-19 pandemic were that people dying of AIDS were primarily in their 20s and 30s and that infected people were stigmatized.
R.T.: As a second-year resident at the start of the pandemic, I felt that COVID-19 infiltrated our lives and the world rather insidiously – starting gradually and spreading quickly until no part remained untouched. Although scientists had predicted a global pandemic of this scale for years, we were vastly underprepared for the toll it would take on our health care system and society at large: personal protective equipment (PPE) initially was scarce, all but the most “essential” businesses closed for weeks to months, and the death count rose exponentially due to the lack of a coordinated public health response. Cultural shifts have occurred with equally impressive speed: entire communities, including residency programs, have turned to online communication platforms like Zoom, and new phrases such as social distancing have entered our vernacular.
Feelings of clinical helplessness
J.T.: Much like with COVID-19 today, we residents felt helpless. We had no medications that would halt patients’ inexorable demise. That the patients were by-and-large our age made it especially difficult to bear.
D.T.: Feelings of helplessness among residents today have stemmed from the shortage of PPE and ventilators, the high infectivity of the virus, and the lack of curative treatments. Additionally, patients are often terrified when they enter the hospital, and we compound that fear by restricting visitors. I have had to tell infected patients that they must go through labor alone and have counseled them about separating from their newborns after delivery. While we assume our restrictions protect patients, we do not yet know if these policies improve outcomes. The unanswered questions regarding the effects of COVID-19 on pregnancy exacerbate the feeling of helplessness for patients and providers alike.
Concerns about personal infection
J.T.: Back then, residents did many blood draws and started many IVs. We were quite nervous about needlestick injuries. The risk of acquiring HIV from a needlestick injury is less than 1 percent, but anyone who got stuck was terrified. Remember, there was no post-exposure prophylaxis back then.
R.T.: Residents perform fewer phlebotomies now, although there are still opportunities for needlestick injuries. There are also many opportunities to become infected with COVID-19 while providing patient care. As a Med-Peds resident, I have seen this disease preferentially afflict older adults. But lest this provides false reassurance for residents in their 20s and 30s, there are constant reminders that we too are at risk. The widely-circulated picture of the young ophthalmologist whistleblower in Wuhan who succumbed to the disease has been burned into our collective consciousness from the beginning. Additionally, we have seen the infection rate surge among young adults and have witnessed devastating complications in children.
D.T.: As a junior resident performing surgeries, I agree that there are sufficient opportunities for needlestick injuries! Yet, I am less nervous about operating on a patient with HIV than about caring for a patient with COVID-19. Guidelines regarding PPE have evolved, and we now practice contact and airborne precautions for all laboring patients; thus, on-call, our N-95 masks stay on, bruising, and abrading our skin for 24 hours. Below layers of PPE, I know my risk of infection is ever-present. Ultimately, my job is to care for patients and hope that if I get infected, I will recover like most young and otherwise healthy people. The additional risk of becoming an asymptomatic carrier infecting patients and staff is perhaps more daunting and likely than a needlestick injury.
Impacts on residency training
J.T.: There is evidence that residents at training programs with larger numbers of patients with AIDS developed different attitudes regarding intensive care and resuscitation than residents at programs seeing smaller numbers of these patients. One additional impact of HIV was prompting the adoption of universal precautions in 1985.
R.T.: COVID-19 has impacted nearly every aspect of residency. Initially, schedules changed to accommodate the growing need for personnel on the “front lines”: electives were canceled, back-up pools were expanded, and dedicated COVID teams were created. The initial protocols continue to be adapted as the circulating knowledge and publications multiply as quickly as the virus itself. Early on, several colleagues spearheaded policies surrounding health care worker surveillance. Now, there is greater awareness of the intersection between health care disparities and systemic racism, which has prompted larger social justice movements. It is an exciting time to practice medicine: we can learn and contribute to systemic change in real-time.
D.T.: COVID-19 has profoundly affected my residency. Because elective surgeries and routine office visits were canceled for several months, I had to delay honing certain skills that I hoped to gain during internship. Nevertheless, I learned new skills – from practicing telemedicine to caring for patients in the ICU – that I never anticipated. As my sister elucidated, COVID-19 has exacerbated many health care disparities that unfortunately parallel those that marginalized patients 30 to 40 years ago during the AIDS epidemic. I feel honored to help advocate for my community during this pandemic, and at the pace that our lives and jobs are changing, I can only imagine what I will say to my children about how COVID-19 impacted my training and career.
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