With coronavirus putting a halt to normal life in the United States, times are uncertain for all, but the strain is undeniably shouldered in large part by health care workers. In the war against COVID-19, healthcare workers are relied on to battle it head-on, despite the risk of exposure. Newest to this frontline are interns who, after four years of working towards their desired specialty and career, have been thrust into an unexpected reality.
Dr. Michelle Keyser, Dr. Meera Reghunathan, and Dr. Tyler Lanman are all UCSD interns going into different specialties but share the unexpected scenario of experiencing their training in the face of a global pandemic.
Changing Shift Schedules
Residency is an intensive time for newly minted doctors to experience independent physician interaction for the first time. 80-hour weeks with extensive patient interactions are commonplace for any resident. In the face of the current public health emergency, however, resident shifts have drastically changed. Dr. Michelle Keyser, an intern going into internal medicine-pediatrics, is still going to Jacobs Medical Center for her Cardiac ICU inpatient rotation, but her fellow interns are not in a similar situation. “Residents have had their outpatient rotations canceled and been assigned to a call pool,” she states. “In the scenario where a resident at the hospital gets sick, someone from the call pool will cover. Also, if an additional medicine or ICU team needs to be formed in response to a spike in coronavirus cases, residents from the call pool will be called.”
Dr. Tyler Lanman, an intern going into neurology, shares that his fellow residents are taking a Heroes Curriculum, a general medicine online curriculum in lieu of canceled rotations. These residents are prepared as a backup if more healthcare workers are needed. All of these changes to resident shifts have been in place for more than a month now. Outpatient rotations are expected to start up soon, but whether these rotations will have to be made up in the future is still in question and may also depend on the year of residency and type of residency.
Surgical residency programs have also adopted strategies to reduce exposure in the hospital. Dr. Meera Reghunathan, a surgery intern at UCSD, described the platoon schedule, in which some residents cover more services while other residents take time off. “Elective surgeries have been canceled and patient caseload is lower, so we can collapse our surgical services down in response to the pandemic. This means fewer people at risk at the hospital.” Dr. Reghunathan is currently working full shifts, but many of her fellow residents have reduced their hours in the wake of the platoon schedule. When and how an elective surgery schedule will start up again, however, is uncertain.
Hospitals are also placing emphasis on testing health care workers potentially affected by the virus. According to the Center for Disease Control (CDC), currently, 2 kinds of tests are available for COVID-19 testing: diagnostic tests that involve a nasal swab and antibody blood tests, which check for antibodies against COVID-19 in the serum. Current guidelines for coronavirus testing rely on the presentation of symptoms or contact with a known patient with coronavirus. Dr. Michelle Keyser and Dr. Tyler Lanman have not been tested yet, but Dr. Meera Reghunathan has. Testing guidelines are changing though with the recently approved UCSD Rapid Test that provides coronavirus test results within a day. With this new test available, hospitals are now expanding testing to include all admitted patients.
Even though testing guidelines are in flux, hospitals are screening all healthcare workers before the entrance. “You have to enter a special staff entrance where you are asked about any symptoms of fever, cough, and chills. You scan your badge and get a special sticker and PPE for the day,” Dr. Keyser states. “Patient families are not allowed into the hospital aside from rare exceptions.” In cases where coronavirus infection is suspected, only one resident is allowed to enter the room. “I’ve had to interview patients over the phone in these cases,” says Dr. Lanman, “because the senior resident had to examine the patient.” All of these policies are to ensure the safety of the healthcare workers while also providing patients the best care.
Reduced Patient Interaction
A core component of residency is interacting with patients and learning how to provide the best care possible. With the risks posed by in-person interaction, however, the traditional patient care model has been restructured. “We used to have everyone enter the room during rounds, but now only the senior physician enters the patient room,” says Dr. Reghunathan. “We try to have the patient see a physician only once a day to reduce the spread of the infection.” Telemedicine has also been heavily implemented to continue to provide quality doctor-patient interaction. Through video conferencing, interns can practice meaningful interaction while eliminating infection risk.
In addition to reducing patient exposure, typical patient volumes in the hospitals have changed. “The hospital is really empty,” Dr. Keyser, who is on her Cardiac ICU rotation, says. “Patients with heart failure exacerbations, acute cardiac syndrome, and pacemaker infections are still being admitted to the hospital, but the overall number is less.” Dr. Lanman had a similar scenario until the Surgeon General advised individuals who are showing symptoms to not wait. “After that announcement, we had a massive influx of patients into the medical wards,” says Dr. Lanman. Although patient interaction may have decreased for several residents, other learning opportunities for residents continue through video conference – with an emphasis on education about developments concerning COVID-19. Lately, a large proportion of resident education for Dr. Keyser is focused on coronavirus, despite being on her Cardiac ICU rotation. “Grand rounds, noon conferences, morning reports are still happening but through video conferencing, and most of them cover coronavirus and present case reports of coronavirus patients.”
For Dr. Reghunathan, video conferences presented by the surgical department are valuable but still cannot fully replace elective cases. “Elective cases are a huge part of how we learn. The operative experience is definitely a lot less on services during coronavirus.” Despite the changes in their training, Drs. Keyser, Reghunathan, and Landman agree that interning in COVID-19’s wake is an interesting challenge, and they are learning as much as they can from it.
For Drs. Reghunathan, Landman, and Keyser, this global pandemic was not what they expected during their first years as physicians, but they are vowing to learn as much as possible and stay prepared for whatever happens. “It’s a guessing game trying to predict when and if there will be a spike of coronavirus cases in the hospital,” says Dr. Keyser. “However, right now, we are focused on being prepared.” There is much uncertainty about the course of coronavirus and how this will impact resident education and the hospital environment in the next couple of weeks and, potentially, months.
Medical examinations that are part of the typical resident education have been canceled by Prometric testing unless deemed essential. For Dr. Lanman, who had his USMLE Step 3 examination scheduled during this time, he must figure out what this news means “Do I study and assume my test is not canceled or do I scramble for another date? Will I have to take Step 3 past my intern year, which is not typical?” With the public health crisis ongoing and Dr. Lanman’s neurology residency at Stanford upcoming, many questions still remain.
For Dr. Reghunathan, the patient volumes have been greatly reduced due to elective surgeries being canceled, but this may be the calm before the storm. “There is going to be a huge backup of elective cases, so it will be very busy within the coming weeks,” says Dr. Reghunathan. “And we don’t know if there will be a spike in coronavirus, putting more restrictions on elective surgeries.” Residents have been trained in a specific way for decades; now, they are being forced to adapt in a matter of weeks, with their future medical education remaining uncertain. Additionally, residents are mapping out their future careers, but with the healthcare system hit hard by the pandemic, the future of medicine and physicians is unpredictable. “It is hard to say when things will go back to normal,” states Dr. Reghunathan, “and what that normal will be.”