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


AMA Chief Experience Officer Todd Unger speaks with AMA Vice President of GME Innovations John Andrews, MD, and emergency medicine residents Chris Clifford, MD, and Anna Yap, MD, on updates regarding COVID-19 including talking to the residents about their experiences during the COVID-19 pandemic and the resources AMA is providing to help them. The residents also spoke about innovative ideas that residents implemented to get personal protective equipment (PPE) to fellow residents. AMA is advocating for hazard pay for residents and forgiveness of loan debt during the COVID-19 response.

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 looking at how residents are experiencing the COVID-19 pandemic and how the AMA is helping them.

I'm joined today by Dr. John Andrews, AMA's Vice President of graduate medical education innovation in Chicago, Dr. Chris Clifford, an emergency medicine resident physician in New York City, and Dr. Anna Yap, an emergency medicine resident physician at the UCLA Ronald Reagan Olive-View residency in Los Angeles. I'm Todd Unger, Chief Experience Officer at the AMA in Chicago.

Dr. Clifford, Dr. Yap, you're both on different front lines of this pandemic on different coasts. What is your experience like right now, and where have you been?

Dr. Clifford: Thank you, Todd, for having us on and talking about resident issues. Life has been very different for us in New York City here. The past two or three months have been quite a whirlwind of experiences. We knew once we got our first patient in New York City that it was going to be a lot of people getting sick very quickly. We went from one patient to five patients to hundreds of patients very fast out here in New York, to the point that we had to get FEMA actually involved with our hospital to help manage our chaos a little bit. Luckily we are on the other side of this now. The curve has starting to flatten for us. Our ERs are definitely not even close to where they were about a couple of weeks ago or a couple of months ago. So we feel like we are getting better.

Unger: Dr. Yap?

Dr. Yap: Thank you so much. Yeah. Thank you so much for having me on. So in Los Angeles we've had a very different experience. Of course we're able to see what's gone on in New York, and due to the strong work of our public health officials here in California, and due to just everyone wanting to make sure that we flatten the curve, we've seen a definite decrease in the amount of patients coming here to the hospitals. And we've had the overall sense, has come down to the point where there's actually physician groups, emergency physician groups, who are losing money.

Overall, the acuity of our patients, however, are much higher. Like yesterday I just had a shift where a kid had a perforated appendix because they'd been dealing with appendicitis for like four days, and an adult who is four days past having their initial stroke and had had constantly small strokes since then and came in finally when their vision went away because they had a stroke in their eye.

And so we see all these stories of people who just come in and they're having heart attacks way later, and people just are so much sicker when they come in. And we of course had multiple COVID patients as well. And definitely in all of this the stress is much higher than—the question of, is our PPE good enough for us is much higher. But in all of this we've been able to have so much bonding with my co-residents, my faculty, with all the nurses, and other health care workers around us have been banded together. And the community has also come and bonded behind us and deliver us food and just all these well wishes to really help us along.

Unger: Well, you brought up two issues I want to dig deeper into. One is around resident safety and PPE, and the other is about wellness. Let's start on the PPE side and safety. What was your experience along the way? Is that still a concern for both of you?

Dr. Clifford: Yeah, sure. So yeah, the PPE was a very important issue to the residents and all the staff in the ER and in the hospital in general. There was a time when we were being told that we were going to only get one N95 mask a week, and we had to put it in a paper bag and do our best to keep it clean, basically. And that only lasted for about a week or two and then we got more PPE supplies. But we realized that this was going to be a different story than how we were planning it out to be. We thought that we had enough PPE for the longest time. We thought that maybe our state or federal governments were going to be able to help us out in terms of getting more of PPE, but that was unfortunately not possible.

What we ended up doing, actually, is that a couple of residents in my program came up with novel ideas to find PPE on our own, which was really innovative, I thought. There's one girl in my program, her name's Alicia Lu, and she started a GoFundMe page and raised $78,000 just for buying PPE for the residents in our program. So she was able to buy us full bunny suits, it's the white that goes all the way from head to toe. And so she was able to buy those for us, and it was a real game-changer because they're washable, we're able to wear them multiple times, things like that. We have another resident that, his name's Neil Doobie, and he asked one of his friends, about 100 headscarves were donated so that, sometimes we don't have enough hair nets.

So there's been a couple of people that have really stepped up to the plate and just came up with innovative ideas to help us get PPE. But I would definitely say to listeners and everyone that it's definitely something to not skimp on, and to make sure that you have enough of.

When we first got our first wave of people into the hospitals, we had about 30 to 40 nurses in one of our hospitals call out in the ER alone. So on top of having the worst pandemic that we've ever seen and the most patients that we've ever seen, we had a nasty staff shortage. And then also, a bunch of residents got sick. I actually got the virus myself. And I'm luckily on the other end of it, but I would say probably the majority of residents in my program have actually caught the virus and gotten over it, thankfully.

Unger: That's interesting, because I did talk to another resident that you probably know, Omar Maniya.

Dr. Clifford: Yeah.

Unger: And that's a thing that people weren't expecting, is that you're getting sick, you're taking time out to recover, and then you're back on the front lines. That's a pretty tough thing. Dr. Yap?

Dr. Yap: Yeah, it's amazing to hear all the wonderful things that your co-residents have been doing to really come up with innovative solutions, but I see that as a huge flaw and a failure in our system to properly protect you all.

Like I said, here on the West Coast we had a little bit of warning from what happened in New York. And definitely in the early days when we were scrambling, trying to figure out what's the best way for us to have proper PPE, what's the right amount of PPE given the conflicting information from the CDC and different, from OSHA, all these different competing factors. It was frustrating to figure out what we were supposed to be wearing and how much we were supposed to be wearing at the very beginning. And I know there's a lot of controversy there with our faculty, with admin. But at least, for us, we've been able to mobilize and figure out ways to ensure that we have enough PPE.

We've had access to N95s almost the whole time if we have so chosen to need it or felt like we need it in high risk procedures. Definitely in the earlier days when we weren't too sure about how to acquire our lines for PPE. There was more stringent guidelines on what exactly we could use. But definitely as we're moving along, my institution has been doing a better job of just making sure that we have enough. Because I know that at one point, a couple of weeks ago, we were down to like 12 days of N95s, or 20 days of N95s and like 12 days of surgical masks. And there was definitely a lot of concern about how we were going to move forward. I think, since then, it's looked a lot better. And at least in the emergency department, our administration has been very, very responsive to our concerns and just making sure that we are safe. I think at this point none of our residents have actually gotten COVID. So just an example how different our residency is to the one in New York.

Unger: Well that's a good segue. I want to talk a little bit about the experience of residents and how it's been different and been affected by this pandemic relative to other physician students. And you pointed out it could be geographic in nature. But Dr. Andrews, why don't you start by talking about, you hear a lot from different graduate medical programs. What are you hearing as some of the key issues that residents are dealing with today?

Dr. Andrews: Thanks, Todd. You know, there's a lot of uncertainty with this. And Chris and Anna both alluded to the fact that there's concern about access to PPE, but there's even further uncertainty about when and how to use the PPE. It's obvious that if you're working in an emergency department with patients with respiratory symptoms coming in, you need to don and doff PPE appropriately. But if you're working on a labor and delivery ward or in another area, should you be protected, and in what manner? And so I think that creates a lot of stress for residents. I also think that the impact of the pandemic goes beyond just the direct clinical response to patients who have contracted COVID-19.

So regardless of whether you're working in Mount Sinai in New York and you're on the front lines or whether you're in a more rural area that hasn't yet seen a peak in COVID cases, your training as a resident has been impacted. Because elective surgeries are on hold, outpatient clinics have been canceled.

And so the very nature of what you're doing in training has changed. And I think that programs have a responsibility to communicate clearly about what they know and about what they don't know, and to work together to address the stress of a situation that's uncertain and rapidly evolving.

Unger: Dr. Yap, Dr. Clifford, does that resonate with you in terms of the impact on your training and how your job has changed?

Dr. Yap: Absolutely.

Dr. Clifford: Yeah, definitely. I would say that one of the biggest things, for at least residents here in New York, is that we've been getting new residents from other rotations, podiatry, neurology, ophthalmology, they've been coming into the ER and just almost donating their time. It's been a really big help for us, and we've really liked having our colleagues be in the ER with us. For us residents in the ER, I'm supposed to be on a pediatric rotation actually right now. But we obviously need the staff inside the ERs as much as possible. So I got pulled from my pediatric rotation to work inside our county hospital in Queens. So I would say the education is very different.

We see a lot different type of patient also. The classic COVID patient is fairly straightforward to actually work up. You do the x-ray, you do the walking pulse ox, you do the labs, and you see the exact same thing on all of them. It's the same x-ray, the same labs. It's crazy. It's really a unique scenario. So I would say more of the education in terms of the bread and butter stuff that we've seen in emergency medicine has gone down as well.

Dr. Yap: So for here we've had to come up with more novel ways of education. We've moved to Zoom online because we no longer can have, really, in-person conferences. I think the bigger problem, though, is that nationwide, I've been talking to residents, and the big issue is that residents, because of our unique situations that we're in where we have to finish residency in order to become full-fledged physicians, we have this lack of agency to be able to speak up about our situation, to be able to fly if we have issues or concerns, for fear of any retribution or any negative blowback by their administration.

And for attendings, if you feel like you're not being protected or listened to, you can just leave your job and find another one. Even though, yes, that may be difficult, but there isn't these ramifications for your practice in the future. And I think that's the issue about having residents be, oftentimes, much of our frontline in America when we take care of patients, especially in these county hospitals, especially in these places with low resource settings.

And that's been such a huge, difficult thing for so many residents to deal with. And that emotional hurt with all of that, having to see so much death, see so many sick patients, but also know that you don't have a ton to say about the circumstances that you're working in, can be so tough for so many residents. And that's why I think it was so important that the AMA came out with our guidelines like CME to say, these are things that we should make sure that residents have. Because it's so important for us to be speaking up for our residents who are not able to speak for themselves.

Unger: Dr. Andrews, tell us about those guidelines that the AMA recently released for residency programs.

Dr. Andrews: Well, in the current climate, with all the uncertainty and distress that's evolved quickly, we wanted to work with members of our resident fellowships and understand what those concerns were and, as an organization, issue some guiding principles for the treatment of residents during the response to COVID that would guard the interests that Dr. Yap raises.

So it was a collaborative effort. It was one that gathered input from members of our resident fellows section, from members of our board, from members of our council of medical education, and it was an effort to offer some guidance to programs sponsoring institutions and health systems about the unique concerns that residents have in the COVID response and make sure that their interests are protected.

Unger: A big, or at least one of the parts of that was about the financial burdens for residents. Obviously the situation has created financial impact on all workers, all physicians in health care, but they're a special situation for residents. Do you want to talk a little bit about that?

Dr. Andrews: Well, the unique financial situation that residents face are, they are often bearing high debt loads from medical school. And relative to other health care workers on an hourly basis, they're underpaid. And this just creates added financial stress when they don't have access to opportunities to supplement their income to service their debt through things like moonlighting and other avenues. So they are in a somewhat unique financial situation. So we've advocated for consideration of hazard pay consistent with what might be offered to other health care workers, but we don't want residents to be left out of those discussions. And certainly consideration of forbearance or forgiveness of loan debt during the time of response to COVID seems like a reasonable consideration as well.

Dr. Yap: I think to give some real numbers, I myself am about a quarter million dollars in debt, and that is a typical amount for many graduating residents nowadays. And we typically make, on an hourly basis, anywhere between $15 to $20, which are some of the lowest paid individuals in the hospital in general. And that can be really disconcerting and disheartening when you're working with a whole team of individuals, and you have gone through so much schooling and yet are paid so little. And this is especially difficult for my co-residents who have families, who need to pay for childcare, especially when they're working during this time. And childcare is difficult to get access to because now all your childcare centers are closed down. We've always been underpaid in this whole system. But now this is just coming to an even higher forefront of just how broken the residency system is currently.

Dr. Clifford: I think it's really interesting, the aspect of hazard pay. We've been, to give a couple of examples, I guess, here in New York, it really depends on what type of program you're in. Some programs here in New York are doing $400 extra a week, and that's retroactive going back to March, which is probably on the extreme end of things. And then there are some programs that aren't doing anything, and then there's some programs that are giving maybe a little bit more on the food stipends. So the AMA coming out with a strong statement supporting hazard pay is definitely something that I think we needed and I really appreciate.

Defining what hazard pay is, though, is, I think, going to be the next step for hospital systems and everyone around this issue, to determine what is an adequate hazard pay for residents, and also who might pay for this. The GME structure system for paying for residents is already so complicated and nuanced. Our hospital is currently giving us, is footing the bill for the hazard pay. But I know there are discussions amongst other residents amongst the country that I've been talking to about an overall restructuring of residency pay system in general.

Dr. Yap: Yeah. There's also an even opposite situation in many other parts of the country, where residents are actually having any pay bump held. We normally have 2% or 4% up per year. There are places, residencies in America, that are just saying you're getting no raise at all. Because of the, for those that have been happening to other parts of the hospital systems. And that's definitely very discouraging to many residents, especially when they see their administration, who is not taking any pay cut, but yet residents who make so little in the scheme of things in the health care system are just being told that you're getting your pay cut, or you're not getting your constant rates that you're supposed to be getting.

Unger: Well, Dr. Yap and Dr. Clifford, I want to thank you for taking time out of what I know is a very, very busy schedule, and thank you also for all the work that you've done. Dr. Andrews, thanks for joining us today and for the work the AMA is doing to support residents.

That's it for today's COVID-19 update. We'll be back tomorrow to look at challenges of being an international medical graduate in the COVID-19 pandemic.

For updated resources on COVID-19, including guidance for residents, go to ama-assn.org/COVID-19. Thanks for being with us today.

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