As she readies for an overnight shift on labor and delivery, Salomeh "Sally" Salari, MD, walks her usual route to work, through the now vacant campus of Case Western Reserve University to the University Hospitals Cleveland Medical Center. After getting her temperature checked at the entrance of the children’s hospital, she navigates the building’s winding hallways to reach the maternity ward. It’s there that she’ll begin another unusual day at the office.
"There are a lot of periods of time when things feel normal," said Dr. Salari, a first-year obstetrics and gynecology resident at University Hospitals. "Last night was a normal, beautiful labor and delivery shift. Until we got a patient [in the hospital] under investigation [for COVID-19], then everybody got a little stir crazy."
Resident physicians find themselves in a unique position amid America’s COVID-19 pandemic. They are physicians and trainees, balancing their growing medical knowledge with a deadly respiratory illness about which much remains unknown. They are developing their skills as clinicians, but doing so in the current health care environment means adjusting daily routines to embrace new norms while surrounded by uncertainty.
The AMA has developed a COVID-19 resource center as well as a physician’s guide to COVID-19 to give doctors a comprehensive place to find the latest resources and updates from the Centers for Disease Control and Prevention and the World Health Organization. The AMA has curated a selection of resources to assist residents and medical students during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events.
Despite the fact that the number hours residents may work is regulated, the rigors of a residency shift have grown significantly for some.
Anna Yap, MD, is a second-year resident in UCLA-Ronald Reagan/Olive View emergency medicine program. She has been spending many of her rotations in makeshift COVID-19 evaluation areas, where patients who are showing symptoms are evaluated for the virus.
"These shifts are harder than I cerebrally thought they would be," said Dr. Yap. "Having to wear personal protective equipment [PPE] all the time is uncomfortable. The worry about, ‘Am I going to get sick? Am I putting this on correctly? What if I do something wrong?’ There are so many what-ifs and it compounds anxiety, along with increased patient anxiety as well. As we are still early in the pandemic here in L.A., we are seeing fewer patients than we used to, but these shifts are more emotionally and physically tiring than they were in pre-COVID-19 times."
Impact on resident education
For the educational component of residency training, conference sessions—the weekly lectures for residents—have largely moved online, conducted through platforms such as Zoom. Grand rounds sessions have also been moved online. However, because of the demands these conferences place on physicians to do research and prep cases for presentation, they have been canceled in some instances.
UCLA’s emergency medicine program has moved its weekly resident conference to Zoom. Thus far, Dr. Yap said the value of the time was about equal to what it would be in a physical setting.
California has yet to be hit as hard by the virus as other regions, so the amount of time residents and program directors can dedicate to educational activities has yet to be significantly affected. If a surge in patients were to take place, that would change.
"Our emergency medicine administration and program leadership are doing the best they can to make sure we can protect our education, but that’s all in the setting in which we have the luxury to do that," said Dr. Yap, an AMA member.
Elective rotations, particularly for first-year residents, are also up in the air. In April, Dr. Salari is scheduled to transition from labor and delivery to a gynecological rotation, which is going to be mostly comprised of remote work to allow patients and physicians to avoid trips to the hospital. She’s unsure if that remote rotation will actually happen. If the virus spreads significantly in Cleveland she may be called on to help in the internal medicine or emergency departments.
"You spend a lot of energy trying to mentally prepare yourself for something you think is inevitable, but you hope won’t happen," said Dr. Salari, who recently wrote an essay on how the pandemic is impacting her training. "In actuality, you don’t know what’s going to happen. It’s very possible that I could go the entire month of April and not have to work in the ED or ICU."
Supervision and support
The Accreditation Council for Graduate Medical Education advised programs that "any resident or fellow who provides care to patients will do so under the appropriate supervision for the clinical circumstance and the level of education of the resident [or] fellow. Faculty members are expected to have been trained in the treatment and infection control protocols and procedures adopted by their local health care settings."
Both Drs. Yap and Salari feel that they have been well supervised despite the strain many attending physicians are feeling during the crisis.
"If we have a patient who is definitely coronavirus-positive, I might not be seeing them anyway," Dr. Salari said. "My attending would have to see them. So, why would you risk exposing another person and why would you waste the PPE?"
Support is another factor. Many residents are spending time apart from loved ones for fear of potentially infecting them with the virus. So, they are finding encouragement from the community of trainees they work with and met during medical school. They are also getting it from the public in the form of gestures of appreciation—both large and small.
"It’s been heartening to have food delivered by the community and get donations," Dr. Yap said. "It gives us a little smile during the day. It helps that my fellow physicians, nurses, health care workers in the ED have all banded together."