A troubling type of social media post I’ve recently seen from providers (often not directly taking care of any COVID-19 patients) is one of excitement at the prospect for the medical community coming together to defeat this invisible foe. This mentality seems to say that as health care providers, we should all rush to the frontlines as it’s a commendable action. Maybe these sentiments are posted because morale is low, and physician burnout is even higher than typical at this time? I suspect many people may not realize that residents are not really given a choice whether to participate or engage with high-risk coronavirus patients. Residents are put in the awkward position of still being trainees and not having the option to quit, take a leave of absence, or change jobs like many other professions.
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. 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). This is demanding, and no doubt, will hasten burnout.
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 decide 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 interns, residents, or fellows were to take care of COVID-19 patients at my hospital. As the epidemic rapidly grew into a pandemic, more personnel needed to be reassigned to COVID-19 teams, and now all trainees will be certain to care for COVID-19 patients at this point. The various specialties which take care of these patients are growing as well. The public may not realize it, but some residents and even attendings from subspecialties that don’t have much clinical patient exposure (e.g., radiology) may be forced 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? The speed at which the virus is spreading is forcing administrators and clinicians alike to have to come up with plans and solutions on the fly. Some of them will work, and some of them won’t, which is adding to our collective anxiety.
Although I personally hope to continue to be at or near the frontlines, I understand those that are in a compromised position, and they shouldn’t feel ashamed 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. Even though we’re in the midst of the pandemic, I’ve found it to be a beneficial practice to reflect and think about the way we can improve the safety and efficacy of those delivering care. While it may be commendable to rush to be directly involved in patient care, we need to take a step back and review the role that residents play: who is being put on the frontlines, how is that being decided, and how is this impacting resident burnout? This is one of the many questions I hope can be thoughtfully revisited after the emergency of the pandemic is over.
Image credit: Shutterstock.com