Residency

AMA COVID-19 daily video update: How residency programs are adapting to pandemic challenges

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


Featured topic and speakers

AMA Chief Experience Officer Todd Unger speaks with AMA Vice President, GME Innovations John Andrews, MD, AMA Board of Trustees resident member Grayson Armstrong, MD, and internal medicine resident Bryanne Standifer, MD, on updates regarding COVID-19 including how resident and residency programs are adapting to the challenges posed by the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Transcript

Unger: Hello. This is the American Medical Association’s COVID-19 update.

Today we're discussing how residents and residency programs are adapting to the challenges posed by the COVID-19 pandemic. I'm joined today by Dr. John Andrews, AMA’s vice president of Graduate Medical Education Innovations in Chicago, Dr. Bryanne Standifer, an internal medicine resident physician from the Henry Ford Health System in Detroit, and Dr. Grayson Armstrong, chief resident in ophthalmology at Massachusetts Eye and Ear Infirmary in Boston and the resident member of our AMA Board of Trustees. I'm Todd Unger, AMA’s chief experience officer in Chicago.

Dr. Standifer, this must be a very different residency than you were expecting. Can you tell us what it's like on the front lines of a hotspot in Detroit?

Dr. Standifer: Well, let's see. I think day one, coming into the ICU, you instantly were greeted by MAs and nursing staff that require you to be temperature checked. They also ask you different questions about how you're feeling. So that was a huge change, just walking into the hospital. When you walk into the hospital, everyone's wearing masks, the hallways aren't filled with families and loved ones anymore. It's just staff that are trying to briskly walk to their destinations and cover their faces with masks.

The first thing I do now, which is a lot different than before, is I go and I immediately find just standard PPE to wear, just as I'm circulating in the halls, not even mentioning going into patient's rooms. So finding a head gown for my hair, wearing a mask at all times, shoe covers. I now keep my phone in a biohazard bag and text through that instead of actually touching the surface of my phone now, which is very, very different than before.

Unger: How are you and your fellow residents holding up during this period?

Dr. Standifer: Honestly, we go through times where we feel very scared as we have colleagues that are hospitalized as a result of a couple of weeks ago. So, we go through these periods where we're very scared. I'm in the actual intensive care unit, where we're retreating only COVID patients right now. We go through phases where we're hopeful, because we're able to get patients off ventilators, get them out of the ICU. And then you have those cases that you just don't know what's going on exactly. So we kind of up and down, wax and wane with how we feel.

Unger: Dr. Armstrong, how's that compare with your experience in Boston?

Dr. Armstrong: Well, here in Boston, things are starting to hit the peak. It's ramping up slowly. The residents across the city are trying to manage. It's not easy for any of us. Even in ophthalmology, a field that's kind of removed from the ICU and medicine normally, a lot of us are being redeployed to that area. So, we're feeling the stress too. We're not trained for that, necessarily. We might be a few years out from seeing patients in an ICU setting or for managing a vent or any of these things. So, it's been a totally different experience from what we were expecting.

There's a lot of social distancing. But unfortunately, social distancing can lead to social isolation for people. A lot of people are feeling alone and stressed. And so, it's a totally different environment than you would have found a month ago.

Unger: Obviously residency programs are very different than you expected. How are you both dealing with these changes to these programs and your preparation for it, and the kind of sudden change in expectations about what you're doing?

Dr. Standifer: I think as an internal medicine resident — and as most residents, I think, think in general— I want to get to the end destination. What does this look like for my training? Will I be eligible to graduate? I think our program in all has been doing a really good job by communicating with ABIM, making sure that they understand what's going on, changing test dates if need be. But the fear is still there. I think from our perspective, an ICU is a requirement for me, so I don't really feel off track necessarily with my learning. I feel bad for my other colleagues, my surgical colleagues, who aren't in the ORs as often. And I think it's a day by day analysis of what's going on and we just kind of go with it.

Dr. Armstrong: Yeah. And at our institution, we've split our entire residency up into two teams, where one team is working per week and the other team is at home. The team that's working, hopefully they don't get sick. But God forbid they do, the second team could come in and back them up. And again, the people that are at home are working hard on lectures. So as far as didactics and lecturers go, for a little while there, they all shut down. But now we've transitioned everything to Zoom. And in fact, all the ophthalmology residents in the city and all the programs in the city and the surrounding area have pooled all of our lectures so that everyone can attend each institution's lectures throughout the day. So, there's no lack of things going on, per day, for the residents to do.

But this is all in hopes of actually getting to the other side of this and being ready to reenter the ophthalmology workforce. The senior residents aren't getting their surgical training like was just mentioned. They're not getting the numbers that would have necessarily been required by the ACGME to meet their case minimums for licensure and eventual independent practice. And this is going to have a huge impact down the road and we need to really be thinking ahead as to what to do to make sure that residents across the country are ready to manage these gaps in their educational experience when all is said and done.

Unger: Well that's a perfect entree for you, Dr. Andrews. You're hearing from a lot of program directors right now. What are you hearing and how's the AMA helping?

Dr. Andrews: Well, first of all, I just want to emphasize a couple of good points that both Dr. Standifer and Dr. Armstrong have made so eloquently. Residents are being called upon to work in situations that raise concern about their personal safety, just like all healthcare workers are. They're being asked to deviate from the curriculum that is a pathway to board certification for them in their various disciplines. And in some cases, as Dr. Armstrong pointed out, they're being redeployed to areas in which they have limited clinical experience and that's an added stress.

The main thing that I hear from program directors is a level of concern about the physical wellbeing of their house staff as they confront the care of patients with COVID-19, and also concern about the access to personal protective gear and the ability to deliver the curriculum effectively. I think the concerns of the program directors are the ones that are shared by the residents with whom they're working.

Interestingly, I've heard a couple of other perspectives from program directors in programs that aren't as directly impacted by this. For example, I'm a pediatrician. And I think many people know that children seem to be less impacted by this disease than adults. What we're seeing at children's hospitals is that wards are being consolidated, in some cases closed, because business is so light there right now. No one's coming in for the elective procedures and the hospitalizations that might otherwise occur.

It's a different stress on the delivery of curriculum to those residents. They're not being called upon to take care for COVID-19 patients, but their training, in a sense, is also on hold due to limited exposure to other experiences that are now being postponed as a result of the response to the pandemic.

Unger: Dr. Andrews, where do you see the AMA being able to help in this kind of crisis and these kind of changes? I know we're working with a number of different partners to help.

Dr. Andrews: Yeah. I've been in contact with a number of other organizations, such as the ACGME and the ABMS that are working hard to address some of the concerns that you heard Dr. Standifer raise about eligibility to graduate from her program and eligibility for board certification. Both of those organizations are working to make sure that it's not a strict bookkeeping exercise and that programs and program directors have some latitude to assess the competency for advancement.

In addition, we're lobbying with the government for other considerations that might ease the strain on residents. Things like loan forbearance, hazard pay, changes in caps that CMS will provide to reimbursement to residency programs to allow for the expanded capacity that might be necessary for residents to extend their training while new residents join the program. We're trying to work at an organizational level to create an environment where residents can continue to be successful while contributing on the front lines to the response to the pandemic.

Unger: Well, yesterday I had a chance to speak to another resident, Dr. Omar Maniya, who's an Emergency Medicine Resident Physician at Elmhurst Hospital, at the epicenter of the pandemic in New York City. And I asked him what piece of advice would he give to other residents, maybe who are in different locations and haven't seen the level of pandemic that he had, and he had a very interesting thing about familiarizing himself with the supplies that he never thought he'd be putting together in so many variations. Let me ask you, Dr. Standifer, Dr. Armstrong, what advice would you have for your fellow residents across the country, to prepare themselves and their systems and practices for the onslaught of this pandemic?

Dr. Standifer: Yeah, I would definitely agree with that. I never thought I'd be an expert on the different masks, and how long they're used for, and different things like that. So that's definitely an excellent point. I think also finding the good, I think with COVID in general, for what we've been seeing, nothing is predictive. There aren't any predictive models of what's going to happen to a patient and it seems to affect different patients very, very differently.

And I think that having that in mind. Our hospital doesn't allow visitors except if the patient is giving comfort, for example. So, I try to communicate with families daily. Just make that in your mind. Even if there are not any updates, making sure you have that rapport with the family over the phone so that the family kind of builds a trust within you, because they can't be here like they used to, let's say three weeks ago. So that's one thing. I think keeping families updated while you're caring for these patients, as well as finding camaraderie in your team. The other day, I couldn't find any N95s to go in a room, and a nurse was like, "Hey, Dr. Standifer, I actually saved you one until they bring more up." So, finding that in your network I think is extremely helpful too.

Dr. Armstrong: So, I guess I saw Omar's talk yesterday and it was super crazy to listen to what New York City is like and the fact that he caught COVID himself, as did his wife. And so, to that point, I reflected on this a little bit overnight and was thinking that what I would tell residents is that it's okay to advocate for yourself. As an educational experience, we are closest to medical school training and so we're relatively undifferentiated and have that knowledge in our back pocket more so than some of our older colleagues. So, in some ways it makes sense that we're the ones that are pulled to the ICUs or the ones that are pulled to the medicine floors, even if that's not our recent sub-specialty training. But we are a vulnerable population. We have limited ability to our concerns and opinions, because we rely on our hospitals and our residency programs to employ us so that we can eventually graduate and go into the specialty we chose.

But instead of feeling powerless, like we don't have a say in what's going on in the decisions that are being made, whether it's related to N95s or ventilators or our schedules, I'd say that now more than ever, it's way more important to advocate, to make your voice heard and to partner with groups like the AMA to make your needs heard and to advocate in that way.

The other thing I'd say is that when it comes to N95, as chief resident, I often have to advocate for my residents in various ways, but rarely was it like this. I got a call three nights ago that one of my residents who needed to go see a patient who was being ruled out for COVID was being asked to go in without proper PPE, because they just couldn't find an N95, similar to what you were saying. And I thought this was super inappropriate. She has a two-month-old child at home and she was worried about bringing this back home if she got sick and not being able to care for her family.

People in our age group are often in a situation where we have young families and young children. And we feel this fear of coming home and needing to take off all of our equipment and bathing right away and feeling disconnected. And I feel like people are even scared to take care of their children. Maybe they feel that they should give it to their parents and not spend time with their loved ones. It's a terrible time. So, I'd say in all these situations, advocate for yourself, advocate for wellness. Make sure that you're taking care of yourself and make sure that you do what you need to do to make sure that you are a priority.

Unger: Well, thank you Dr. Armstrong and Dr. Standifer for everything that you and your colleagues are doing on the front lines. And thank you, Dr. Andrews, for joining us today.

That's it for today's COVID-19 update. We'll be on break just for tomorrow for the AMA Town Hall. Please join us to hear Dr. Patrice Harris, Dr. James Madara, and a panel of AMA experts talk about the issues that you care about.

You can find information about how to log on to the Town Hall on the AMA website, as well as additional resources for COVID-19 at ama-assn.org/COVID-19. Thanks for joining us.