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July 1st, 2020

Dual Crises and the Call for Resident Unionization

Dr. Eric Bressman

Dr. Bressman is a Chief Resident in Internal Medicine at Icahn School of Medicine at Mount Sinai in New York, NY

On March 20th, as the chaos of the unfolding pandemic enveloped New York City, Governor Cuomo issued Executive Order 202.10, which, among other directives, temporarily suspended work hour restrictions for medical residents in New York State. These regulations, which had been enacted 30 years prior, were the consequence of the journalist Sidney Zion’s well-publicized crusade to investigate the tragic death of his daughter Libby at New York Hospital in 1984, which he attributed to the mistakes of overworked and under-supervised residents (N Engl J Med 1988; 318:771). A grand jury was convened, and although it did not indict any of the physicians involved in Libby’s care (as Zion had hoped), it did, in effect, issue an indictment of graduate medical training in the U.S. Depending on who you asked, it was either an educational system intentionally designed around long hours and self-sacrifice or exploitation of cheap labor at the hands of hospitals.

The grand jury’s recommendations, along with the subsequent Bell Committee report, paved the way for resident work hour limits as we know them today. Revisiting the literature from that time, it is clear that a campaign for reform that was sparked by concerns over patient safety, was in equal measure driven by concern for resident wellbeing (N Engl J Med 1988; 318:775). In the ensuing decades, we would begin to recognize that these parallel concerns were interconnected (BMJ Open 2017; 7:e015141).

This movement for reform, however, didn’t start with the Libby Zion case, and it didn’t end with the institution of duty hour limits. In 1975, the house staff of Cook County Hospital in Chicago went on strike for 18 days after months of dead-end negotiations. They successfully earned a (modest) pay increase and a reduction in their work week from 100 to 80 hours, by decreasing the frequency with which they had to take overnight call to 1 out of every 4 nights rather than every 3.

Students or Employees?

This was not the first organizing activity by residents, but it garnered the most publicity, and it fueled a debate that continues to this day: Are residents students or employees? In 1976, in the wake of the successful strike in Chicago, the National Labor Relations Board ruled that residents were in fact students, denying them the protections provided under labor relations laws, including the right to form a union. In their interpretation, residents’ primary purpose was to gain further training and skills, as evidenced by the many conferences, lectures, and rounds in which they partake. Their direct patient care is simply a means of learning, and their pay is nothing more than a living stipend.

It took 22 years for this ruling to be overturned, in a similar case involving house staff at Boston Medical Center. While not much had changed in the merits of the competing arguments — residents were still labeled with an intermediate status of “student-employees” — the environment clearly had, perhaps aided by the optics of two residents being tried for malpractice on a very public stage in the Zion case. Despite this decision, approximately 15% of house staff nationwide are currently represented by the Committee of Interns and Residents — the country’s  primary house staff union — and the “student versus employee” argument continues to be litigated.

The Reality

drive-through COVID testing staffed by residentsCOVID-19 came along and laid bare what had long been obvious to most observers: Residents might be learners, but they are — first and foremost — employees, and essential ones at that. As the tidal wave of the pandemic engulfed many teaching hospitals, the presentation of lectures, conferences, and most other formal teaching activities necessarily ground to a halt, and fears of a depleted workforce compelled suspension of various limitations that traditionally protect residents from being overworked. New York State, as noted above, lifted work hour restrictions. The ACGME, to their credit, insisted on preserving work hour limits, but suspended most other restrictions, including limits on the number of patients a single resident can care for at a given time.

In the wartime language that has become popular during this pandemic, hospitals formed “deployments,” and the backbone of the “front line” was undoubtedly the residents, working alongside their nurse practitioner and physician assistant colleagues. The difference was that their fellow soldiers had pre-existing collective bargaining agreements, with arrangements for overtime pay and channels to negotiate hazard benefits, whereas most residents were left to hope for the good will of their employers, with varying results.

The Imperative

The pandemic has highlighted not only the right of residents to organize, but also the necessity. As employees, residents are the very definition of vulnerable. During the recruitment process, they are deprived of any negotiating power by the Match, which precludes multiple offers and the leverage that comes with this. And, at the end of the day, they need the hospital more than the hospital needs them. Whereas other employees who are dissatisfied with working conditions, benefits, or other aspects of their jobs have the freedom to quit and seek employment elsewhere, residents need to finish out their program in order to receive certification and licensure, and the process of seeking a new position can range from onerous to impossible. When a crisis hits, as we just learned, working conditions can change dramatically overnight, with no obligation on the part of hospitals to adjust benefits or pay.

This is the most straightforward function of unions — giving a seat to the disenfranchised at the negotiating table — but historically, this has not been their only role. During the 1975 strike in Chicago, residents advocated not only for themselves, but also for their patients. They successfully negotiated patient protections, including readily available Spanish interpreters. In the ensuing years, the need for translation services has been recognized as so fundamental as to have been written into law in various patients’ bills of rights.

As a disenfranchised voice, residents have long been a voice for the disenfranchised. For a number of reasons, they have generally seen the injustice and inequity in our healthcare system earlier and more clearly. For one, they are not beholden to the financial structures that are very often the driver of these disparities in care. They are also on the ground, directly interfacing with patients of all backgrounds and in multiple contexts, and witnessing the kind of stratified care that has long been the norm in our healthcare system — one clinic for the privately insured, another for those on Medicaid, and a third for the uninsured. They are the only substantial part of the physician workforce that might split their time between private and public hospitals. This unique perspective helps them put the lie to the notion of separate but equal care.

There are many reasons health systems have historically resisted house staff unionization. It is far more convenient to present the terms of a contract than to negotiate them. There might be some discussion, but there is no need for lawyers or mediators or endless bargaining sessions. As short-term employees, residents are often viewed as interlopers at the policy-making table, not necessarily having the long-term interests of the institution at heart. There are fears, of course, of work stoppages, although these are rare (Chest 2014; 146:1369) and as anathema to residents as they are to administrators.

At this turbulent moment, however, as we grapple with the dual crises of an ongoing pandemic and the infrastructural racism that pervades every layer of our society, including the healthcare system, there has never been a more important time to empower the voices of residents. They are needed to help navigate a path toward greater justice — for themselves and for their patients. The only way to legitimize that voice, to give it a strength that cannot be ignored, is through collective action. The environment is primed for it; the moment demands it.

 

NEJM Resident 360

June 24th, 2020

Top 10 Tips for New Interns and Residents in the COVID Era

Frances Ue, MD

Dr. Ue is a Chief Resident in Internal Medicine at Cambridge Health Alliance in MA.

The month of June is traditionally an exciting time of transition across the country. A time where we welcome a new class of bright-eyed interns, and say goodbye to our senior graduates — who have become shining stars and leaders in our communities.

This year, however, is unique, with the start of the new academic year coinciding with an international pandemic — COVID-19. New interns might be feeling especially nervous and unprepared, as in-person medical school rotations were abridged in the spring. Rising junior and senior residents, the leaders and workhorses during the surge of the sickest of the sick, are likely feeling weary and are hoping for respite and recovery.

The start of the year is also mired by uncertainty. Uncertainty about when the next surge of COVID-19 patients will occur (modelling has been done at the Harvard School of Public Health by Drs. Yonatan Grad and Caroline Buckee); uncertainty regarding in-person curriculum turned virtual; uncertainty about how to effectively build community in a virtual space. To add, strife and conflict in the world around us is targeting the core underpinnings of our society and, arguably, humanity: injustices and inequities in race and access to healthcare.

Despite all of this, there is an overwhelming feeling of hope and energy. Now more than ever, we welcome these new doctors at a historic time. Residency training provides an avenue to not only learn clinical medicine, but also to develop as advocates and leaders. As I reflect on my leadership role as Chief resident this year, I’d like to offer some thoughts on what it means to train in the COVID-era. Not surprisingly, the principles of residency training remain the same.

Presentation of research to new physicians

Using research for advocacy at the Society for General Internal Medicine during my intern year (April 2017).

To the new interns:

  1. Stay curious. Try to learn at least one new thing from every patient.
  2. Spend time with patients; their stories will rejuvenate you. Learning to efficiently and effectively complete notes and tasks will help provide space for this.
  3. Seek feedback and spend time to reflect on your practice. Creating a habit of regular reflection will help you build your clinical reasoning skills. Specifically, debriefing rapid responses and codes in a structured way has been shown to improve emotional well-being of providers and future patient outcomes.
  4. Be kind to your multidisciplinary team — e.g., nurses, respiratory therapists, medical assistants, unit secretaries, case managers. They are here for you and have a wealth of knowledge and experience.
  5. Take time for yourself and for things that are important to you. Do not neglect to build your physical and mental health.
  6. Find your community in your tribe of interns and residents. Identify mentors early on; for example, find senior residents and faculty who can help guide you.
  7. Lastly, be present and enjoy every moment of this experience! I have come to find truth in the adage, ‘the days are long but the years are short.’ Don’t let these moments in your formative development pass you by.

To the rising junior residents:

8. You survived and thrived during a very difficult intern year amidst a global health crisis. Take time to reflect and rest, as you transition to your role as team managers and teachers. Remember to continue to foster your own growth and learning, as you guide new interns.

To the rising senior residents:

9. Your last year is an opportunity to add the finishing touches to your portrait as a resident physician. You have gained a depth and breadth of experiences during your last 2 years of training. I challenge you to be mentors and leaders in your program. Lead by example; the interns are looking up to you. 

To the graduates across the country:

10. Congratulations! You certainly deserve it. You have shown your clinical acumen and grit, all while inspiring others around you. We are so proud of how your class came together in the face of adversity and can’t wait to see all the good you will do in the world. 

Dr. Ue's last day as chief resident

Last day in the Chief resident office!

It has been an honor and privilege to serve as Chief resident for our residency program and hospital this past year. There have certainly been many successes matched with unexpected challenges. Throughout, I have come to reflect on the following quote on leadership:

“We must be silent before we can listen. We must listen before we can learn. We must learn before we can prepare. We must prepare before we can serve. We must serve before we can lead.” – William Arthur Ward

Do you have advice for new interns and residents? Feel free to leave a comment below or tweet at me @UeFrances.

 

NEJM Resident 360

June 10th, 2020

Resident Wellness Doesn’t Need to Be Expensive or Elaborate

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

“We’re not like Stanford” she said to me as we sat next to each other during our breakout session. My cheeks reddened. Somehow, suddenly, I felt as if I became the embodiment of my entire institution. And my furrowed brow revealed my surprise.

Her tone softened. “What I mean is, resident wellness is easier when the program has money. Your program has money. We, though, don’t have the funds for it.”

I looked toward the corner of the room as I thought about this statement. It was interesting. So I decided to examine this a little bit more thoroughly. 

Does resident wellness require a large financial commitment?

essential medications

Photo by Anna Shvets from Pexels

A Study

A large academic general surgery program created a program that delivered a care package to residents, at work or at home (J Surg Edu 2020; 77:13). This package included essential medications, vitamins, nutrition, and hydration. Residents themselves could request a package or colleagues could send one to them.

All (100%) of the residents felt that this package addressed an unmet need in residency and also felt that the supplies helped them recover faster. The majority of packages, 83%, were requested by colleagues, rather than self-requested. The recipients’ narrative comments focused in on feeling valued and supported, and having a feeling of belongingness. 

And here is the most important part – each package cost $7.

The Take-Home Points

package components

Photo by Polina Tankilevitch from Pexels

First, this study suggests that interventions for resident wellness need not be expensive or elaborate. It is time we reevaluated the kneejerk association of wellness with fancy retreats and expensive counseling sessions. A phone call, a text message, a handwritten note, or even a heartfelt verbal acknowledgment of hard work goes a long way.

Second, this study reiterates what is already well-known and established in the literature — residents won’t ask for help. It is time we design interventions that go to the residents. Or, allow co-residents and family members to take an active role on behalf of the resident. Most residents I’ve been around want to work hard. They don’t ask to be excused — they ask to be supported.

Third, the intervention is targeted. It provides what is needed and at the right time. No more ‘one-size-fits-all’ approaches that residents themselves didn’t vote on or ask for. On the surface, the care packages might seem reductionist and simplistic. The authors themselves acknowledge that burnout is multifaceted and this study only addressed one aspect of burnout. But the point here is that what the care package communicates is incredibly powerful: 

Residency is hard and the system is complex but you are valued. We care about you in a meaningful way that is useful to you. We want to support you in your journey to be a better physician. 

Conclusion

So to be clear, resident wellness doesn’t necessarily require a large financial investment. It can be a simple, targeted, low-cost intervention that goes to residents and meets an unmet need as determined by the residents

What low-cost interventions have you seen? Continue the conversation @SolvngResBrnout

 

NEJM Resident 360

 

June 3rd, 2020

Will the Real Doctor Please Stand Up?

Allison Latimore, MD

Dr. Latimore is the Education Chief Resident at the MedStar Washington Hospital Family Residency Program in Washington, DC

I stood in the hospital elevator yawning and rubbing my eyes, waiting to get off on my floor. A woman looked over at me and said, “Congratulations.” I began to look over my body. Did I look pregnant in these scrubs? Did I have on my real engagement ring instead of my silicone ring? After a few seconds of wondering why she could possibly want to congratulate me, I asked, “On what?” She looked at my physician badge and said, “Your job.” I was stunned. Here I am. Frustrated with working long hours. Unable to realize my position of privilege in that moment. There have been moments in residency that I’ve had people of color tell me how proud of me they are. I’ve had little girls tell me that they want to be like me when they grow up. But the reality is, I struggle to believe that I even belong in this career.

Dr. Latomore at her med school graduation with her parents

You Are the Doctor?

black female physician

I am a short black woman, in her 20s. When I walk into an exam room with a white coat on, so many patients tell their relatives on the phone, “Hold on. The nurse is here.” My personal favorite is being called a baby doctor, because at least I still look young. I’ve stood on a hospital floor reading an EKG with a stethoscope around my neck, and have been asked, “Are you the secretary?” The person who asked was the night secretary reporting for her shift.

It’s hard for me to go along with some of the simplest things in medicine. For example, some of my colleagues don’t wear white coats for a myriad of good reasons. When I’m in the hospital, I feel it is necessary to wear a white coat, because a badge that says, “Physician” or “MD” is not enough to remind people that I am indeed a doctor.  There are people who feel that referring to yourself as Dr. to others in the medical field or to patients is pompous or reserved for attendings, but I feel I need to, just so people understand my role in their care. I’ve had a patient ask me if I was legally a doctor before just observing an in-office procedure. There have been times when I’ve been disrespected by colleagues or others in the medical field, and I can’t help but wonder why they felt it was okay to speak to me in that way. Is it because I’m young, black, a woman, all of the above, or am I being overly sensitive because of the aforementioned reasons?

Pay it Forward

Meharry Medical College Class of 2018

For every uncomfortable situation, there have been positives. I have had the opportunity to mentor at my alma mater and to  share my story, my setbacks, and my successes with students to encourage them to pursue this career.

As of March 2019, ≈300,000 out of the ≈1 million doctors in the U.S. are women. I feel that it is imperative to tell the truth about this path, because I didn’t come from a lineage of physicians. I was a 5-year-old with a dream to become a doctor, whose parents never stopped believing in her when she stumbled. I was fortunate to make connections with people who helped me figure out my path, and I feel a responsibility to do the same for others. Even with 3 degrees, a closet with multiple white coats, and a stack of ID badges for different hospitals and offices, I sometimes still don’t feel like I should be here. Some days, I don’t feel qualified to be writing this blog. But for whatever reason, I am here. So how do I get over the feeling? I know that anyone can feel like an imposter in this profession. If you did, how did you get over it? Does it just take time? I’m still looking for answers!

NEJM Resident 360 QI Challenge Finalists!

May 27th, 2020

Virtual Residency Recruitment in the Time of COVID

Dr. Prarthna Bhardwaj

Dr. Bhardwaj is a Chief Resident at UMMS – Baystate Medical Center in Springfield, MA

COVID-19 has undeniably altered life as we know it. As if getting into residency wasn’t hard enough already, COVID has made it a notch harder. Graduate Medical Education across the nation is preferably adopting video interviews for a virtual residency recruitment. This noncontact change was further endorsed by the Association of American Medical Colleges (AAMC).

Top Virtual Recruiter Company | Remote Virtual Recruiting Services

What are some of the implications of this? It is pertinent to look at this from two different perspectives — the applicants’ and the programs’.

Financially — More Viable 

One of the greatest advantages of virtual recruitment is the time and money an applicant saves on travel and accommodation during interview season. On average, depending on number of interviews, applicants spend between $1000 and $5000. Not having this expense is a nice breather for medical students who already have heavy loans on their backs!

It goes without saying that programs will be saving a ton of money as well. A large portion of money that is usually spent goes towards social events, including pre-interview dinners and lunches and breakfasts on interview days. This is especially important for programs that already had lower funding and budgets for recruitment. One hopes that residency programs will offer virtual pre-interview social interactions with residents.

More Interviews?

There is a chance that programs might choose to interview more applicants, given that applicant behaviors will be more difficult to gauge, to maximize their chances of filling their slots. Virtual recruitment might also allow for multiple interviewers to be available, thus allowing programs to interview larger numbers of applicants. This could mean more interviews for each applicant.

Culture of the program and the ‘fit’

The flip side of a virtual recruitment, for both applicants and interviewers, is that it might be difficult to get the ‘vibe’ of the program and know if the fit is good. ‘Fit’ has anecdotally been rated consistently high among students who are choosing a residency program. Applicants might find it difficult to learn how happy the residents in the program are, unless the program offers virtual socializing opportunities.

For applicants, it will be incredibly hard to show personality in just 20 to 30 minutes on video chat — opportunities to socialize will be much more limited. This means that you will have to shine during your interview – you better have your elevator pitch ready!

Video Fatigue

Having resorted to Zoom for virtual educational conferences this spring, I can say for certain that there is something exhausting about staying glued to a computer screen and remaining engaged. After about 40 minutes, I want to stretch. Worse still, I am looking down at my phone if the content is not stimulating and interactive enough.

Video fatigue could be an even bigger problem for interviewers who are interviewing several applicants consecutively. To avoid it, one should ideally be taking breaks between each interview and should do no more than 2 hours of interviews consecutively.

How do FMGs fit into the picture?

Personally, I believe that Foreign Medical Graduates (FMGs) are at a slight disadvantage, compared with their American counterparts, during virtual recruitment. A few things for FMGs to consider: Can you even travel to the U.S. right now? Some countries are restricting all travel. Is your home country in a time zone that would make interviewing difficult? (For example, a 11am interview with a U.S. East Coast program would be a 9:30pm interview for an applicant in India.) Programs and applicants will need to be mindful of time differences. How is the Internet connection in your country? Not every country has uninterrupted and great Internet to ensure smooth functioning of the interview itself. .

Tips for Applicants During Virtual Recruitment

Regardless of advantages or disadvantages, the mantra to a successful recruitment season during COVID is to embrace the unknown. Here are my top 5 tips to prepare for a virtual recruitment:

  1. The set-up

Ensure you are in a well-lit room with a neutral background. Several video interfaces like Zoom allow you to choose a virtual background or even blur the background. It is also vital to choose a quiet space where you will not be disturbed. Try to avoid distractions. While some interviewers might be charmed by children crying in the background, not all will appreciate it.

Ensure you have good internet access and a reliable desktop or laptop, of course. Nothing is worse than choppy internet video. While programs might be understanding of technical difficulties, they are more likely to remember the encounter for the wrong reasons.

  1. Dress the part

This is a virtual interview, so dress the part, just as you would for an in-person interview. A lot of people love to wear pajamas on the bottom and their formal attire on the top. We all know what happened to Will Reeve on Good Morning America. Trust me, you do not want to be that person during your job interview. Make sure you are well-groomed.

  1. Body language is everything

  • Avoid the temptation to look at yourself on the screen. Instead, look directly into the camera to allow for direct eye contact.
  • Use a stationery chair — swivel chairs are distracting.
  • Have a balanced power pose! If you have not heard about power posing, watch this TED Talk by Amy Cuddy.
  1. Keep your virtual identity professional

In today’s digital world, your email address or username is often your first impression. Don’t give the interviewer a reason to question your professionalism before they even meet you by providing a once-hilarious high school email address you still might be using. Keep your email and usernames simple.

  1. Prepare ahead of time

Ask a friend, your advisor, or a mentor to do a test run with you to make sure someone other than yourself can assess your performance. In addition, saving time in travel should allow you to research a program more thoroughly. So have good questions ready for the interviewer!

Tips for Programs During Virtual Recruitment

Here are my top 5 tips for programs:

  1. Make your program stand out

One of the biggest challenges for a program showcasing the culture of the program. Pre-interview dinners served this purpose traditionally, so programs are going to have to think harder about how to stand out virtually. Some ideas are ‘Virtual Happy Hour’ or ‘Virtual Teatime’ with the residents or perhaps even a dedicated themed chat channel. You can make a short video of ‘a day in the life of an intern’ to provide more realistic appeal. Involve your residents — ask for ideas to make your program stand out!

  1. Put your candidates at ease

Reach out to applicants and give them a rundown on the details of their interviews, just as you would if they were coming to talk to people onsite. These are times of high stress and uncertainty for everyone. Some useful things to share are:

  • Tips on how to access the videoconferencing technology and whether applicants need to download any software.
  • Your team’s expectations for the interviews.
  • A timeline that details when interviews will start and end along with name and title of each person applicants will meet.

Finally, as an added precaution, give them a backup phone number to reach you, in case there is a glitch. Ask them to share the same with you.

  1. Go with the flow

Expect to have internet and connection issues. In addition, applicants often live with spouses, children, and pets. If life interrupts the interview or a dog is barking in the background, candidates should not be penalized. Use a little extra compassion and thoughtfulness during these challenging times. Be flexible and forgiving as an interviewer.

  1. Your Digital Presence

Put simply, Digital Presence is the space that your brand owns online. Some ideas for that are:

  • Create an Instagram or Twitter account for your program if you do not already have one. Celebrate your residents and ensure you post at least once a week. Applicants are often more tech savvy that you are. Talk to them in their own language.
  • If you do not have a great website, now is a great time to update it! With applicants having limited social interactions with your residents, they are more likely to resort to your website, Doximity, SDN, Reddit – you name it! Consider having resident testimonials and resident bios on your website.
  1. Be prepared

Carefully read the applicants’ resumes and personal statements beforehand. As an applicant, I appreciated interviewers who have made the time to discuss the finer nuances of my personal statement. This also adds a nice personal touch to the interview, which is especially important now.

And the Virtual Recruitment Season Starts … Now!

In conclusion, we are learning new ways of leading our daily lives in this era. Being flexible yet professional is key to combating the stress of virtual interviews. I cannot wait to see how the virtual recruitment season will turn out for applicants and programs alike.

Feel free to shoot me a tweet @prarthnavb for more comments and thoughts. 

NEJM Resident 360

May 19th, 2020

Safety Net: Reflections on the Elmhurst Experience

Dr. Eric Bressman

Dr. Bressman is a Chief Resident in Internal Medicine at Icahn School of Medicine at Mount Sinai in New York, NY

Elmhurst 2014

I first arrived at Elmhurst Hospital in Queens, NY, in the summer of 2014 as a medical student on my surgery rotation. We would take occasional night shifts as part of the trauma team. It was the first time I held a pager. Code yellow meant hurry, code red meant run. One of our first patients was a code red, a young man, not much older than I am now, who had fallen several stories from a rooftop.

I remember a few things from that night: the humid July air; the symphonic chaos of the operating room; running through the halls of the hospital, from the OR to the blood bank and back, as the impromptu courier for the massive transfusion protocol. What remains most vividly in my mind, however, is standing outside his bay in the SICU, after he had briefly been stabilized, and hearing his father thank us, through tears, for doing everything we could. His prognosis was grim, but his family remained appreciative, nonetheless.

Residents moving medical supplies into the hospitalI have returned to Elmhurst every year since then, for weeks or months at a time, first as a medical student, then as an intern, a resident, and a chief resident. Although only a few miles away, it has always been a world apart from hospital life in Manhattan. The hierarchies less rigid, the class lines less visible, the rhythm entirely its own. And in a city where the patients can be exacting, at Elmhurst they have been, on the whole, gracious and grateful for the care they receive, even under difficult circumstances.

Elmhurst 2020

When we first heard about a novel pathogen wreaking havoc on major cities and beginning its inexorable march around the world, our thoughts turned to Elmhurst. The demographics of the neighborhood and the relative paucity of healthcare infrastructure servicing the community all pointed toward a perfect storm. It is easily one of the most diverse square miles in the world; about 70% of the population is foreign-born. Every direction you walk from the hospital finds you immersed in a different outpost of transplanted culture and distant national pride. Its proximity to two major airports makes it the point of first contact for many new arrivals to the U.S. who require healthcare. On a normal day, Elmhurst sees disease processes that are relatively common in the developing world, but generally buried in the footnotes of U.S. medical textbooks.

When it came to SARS-COV-2, the neighborhood was not so much a melting pot as a pressure cooker. For a host of reasons — including tighter living quarters and holding essential jobs that did not afford the luxury of working from home — social distancing was not a simple option for much of this community. Within a couple of weeks of the first confirmed case in New York, Elmhurst was overrun with COVID-19. This was a code red.

The latter half of March was a complete blur. Regular wards turned into ICUs overnight. Multiple codes an hour. An incomprehensible daily death count. Overflowing morgues and freezer trucks outside the building. Patients came in, got intubated, and died so quickly that often there was no time to obtain a family contact. They died alone, while their loved ones waited by the phone.

Elmhurst’s Future

There will be time to count the losses, to recount what took place here. There will be stories of personal sacrifice, of staff stretched to the limit, of fear and fearlessness, of the trauma of uncertainty. There will be a necessary examination of what was missing and how we can better prepare for the next wave or the next pathogen. But we must be careful, too, because anyone who has spent any time around Elmhurst, or similar safety net hospitals, knows this: There are no heroes and there are no villains. There are only dedicated but overburdened staff, working tirelessly with limited resources, and victims of an indiscriminate virus, and a broken system.

There is a nagging, painful question I can’t quite get out of my head: If these patients had shown up somewhere else — if they had crossed the East River and found a hospital with more ICU beds and more critical care staff — might some of them have been saved? But this misses the point entirely. The question we should be asking is why Queens, a borough the size of Houston, has fewer than 200 ICU beds. Why a population larger than that in neighboring Manhattan is serviced by threefold fewer acute care beds, primarily at public hospitals and community affiliates of larger academic medical centers based across the river. The battle here was over before it started. There was no amount of curve-flattening that could bring the peak within range of capacity.Thank you sign in Elmhurst NY

Elmhurst has been stabilized. And the community, through tears, is thanking us, showering us with food and gifts and words of encouragement. The staff deserves it. But our city, our system, does not deserve their gratitude. We deserve an outpouring of anger and demands for more resources. This can be a moment of unity while still being an impetus for change.

Safety nets are there to catch us when we fall, but they can only bear so much burden. A system designed to chase a certain payer mix will, over time, leave communities with high proportions of the under- and uninsured overly reliant on underfunded public hospitals. Universal health coverage is an imperative step, but we also need a more cohesive system that can allocate resources thoughtfully and equitably, rather than by the guiding principles of the invisible hand. Elmhurst will carry on, even as it fades from the public view. This moment, however, will be defined not only by what we did, but by how we responded to it.

 

NEJM Resident 360

May 12th, 2020

Our Public Hospital Leads Massachusetts in Caring for Coronavirus Patients

Frances Ue, MD

Dr. Ue is a Chief Resident in Internal Medicine at Cambridge Health Alliance in MA.

Cambridge Health Alliance (CHA), where I work, is a small hospital system serving the north Boston-metro area across two campuses in Cambridge and Everett but, despite its modest scale, it has arguably become the center of Massachusetts’ fight against COVID-19. This is no small feat, given that Massachusetts has the third largest number of coronavirus patients in the U.S.

Frances and another resident unload N95 masks at CHA

Coordinating the delivery of 10,000 N95 masks from @MADmasks2020 and Harvard Business school alumni in China & Singapore! Myself with Eugene (transitional year intern).

As of April 28, 2020, according to the statewide COVID-19 inpatient update, CHA has the greatest proportion of hospital beds and resources devoted to suspected and confirmed COVID-19 patients — 85% of our general medicine beds and 88% of our critical care beds. As a result, we greatly outrank similar-sized counterparts and even many hospitals with greater capacity. While we have been able to transfer very sick patients to tertiary care hospitals, it is alarming how disproportionately this virus is affecting the poorest and most vulnerable patients — patients for whom CHA is a lifeline.

Our capacity has more than doubled since the start of this pandemic more than 8 weeks ago, with additional medicine and critical care spaces. These spaces hardly resemble life in the hospital before COVID-19, with dedicated areas on each floor for donning and doffing personal protective equipment (PPE). Each provider is covered from head-to-toe with a face shield, scrub cap, goggles, N95 mask, Tyvek suit, nitrile gloves, and shoe covers. With only eyes visible, it is a miracle that I can recognize all our new colleagues that we welcome to the inpatient medicine teams — from primary care, family medicine, psychiatry, podiatry, and surgery. In this fight against coronavirus, we have collaborated to maximize our resources to meet the needs of all patients.

My role as Chief resident has greatly evolved during this pandemic, that role is addressed in this Academic Medicine article by our colleagues at the Beth Israel Deaconess Medical Center: Five Questions for Residency Leadership in the Time of COVID-19. There are, however, additional challenges faced by residency leadership in small community hospital settings. CHA is unique, as it is one of the few major publicly funded, safety-net healthcare systems in Massachusetts and serves as the main care provider for some of the most diverse patient groups.

Challenges have included:

 1. Delivering just and culturally appropriate care to patients

More than half of our patients identify as racial or ethnic minorities and receive their care in another language, and during this COVID-19 pandemic, that percentage has continued to rise. Similar to other contagious diseases, like HIV/AIDS, coronavirus highlights health disparities of race, class, and socioeconomic status.

CHA has become a hotspot, with our Everett campus as the closest hospital to Chelsea, an 8-minute drive away. Alongside this influx in patients, there are increased demands on interpretation and dealing with the trauma felt by these communities. Vonessa Costa, director of multicultural affairs and patient services, highlights our response in this New York Times article on April 17th 2020.

2. Providing meaningful mental health support for residents

With the ongoing high acuity and volume of cases in Massachusetts and at CHA, we have started to see symptoms of distress in many of our resident physicians — recurrent nightmares about patients, anxiety, grief, and difficulty processing the death of loved ones and patients. Caring for critically ill patients is challenging during the best of times. Caring for critically ill COVID-19 patients during an evolving pandemic has taken a significant emotional and psychological toll. In response, we have partnered with psychiatry to provide a space for trainees to reflect on their caregiver trauma.

How do we provide support, while also acknowledging the ongoing trauma that our resident physicians are experiencing? Our goal for these sessions is to provide a supportive and reflective space; identify coping and self-care strategies; provide psychoeducation about crisis, stress, and trauma reactions; and identify further resources for help. Our psychiatry colleagues have been instrumental in these sessions.

3. Building community and hope

Residents having a virtual pizza party on Zoom

Pizza making party on Zoom!

Some initiatives have included:

  • Sharing ‘stories of hope’ from the frontlines at our virtual residency meetings. These include successful extubations, discharges from the hospital, and reunions with family.
  • Songs and videos of successful discharges. (Here Comes The Sun by The Beatles plays at our hospital.)
  • Team bonding activities, like virtual pizza making night and trivia.
  • Advocating for ourselves and our patients #GetUsPPE.
  • Engaging in scholarship, like analyzing our patient outcomes related to IV fluid use and collaborating on evidence-based grand rounds.

As the COVID-19 cases start to plateau, we anticipate our patient population will continue to be disproportionately affected. For many, CHA provides a safety-net to the failings of our fragmented medical system. We are an essential resource for those who have nowhere else to go. 

We might be small in size, but we are expansive in capacity and innovation. I want to give credit where credit is due. Pound for pound, I am proud that CHA and our frontline resident physicians are leading the state in caring for coronavirus patients.

Please share your perspective on caring for coronavirus patients! I would especially love to hear from others at public hospitals across the country. Leave a comment or tweet at me, @UeFrances.

Special thank you to Martin Kaminski for his contribution to this article.

 

NEJM Resident 360

April 30th, 2020

Why Is Burnout Still Occurring, Even with Work-Hour Restrictions?

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

“Daniel, this guy is one… sick… puppy,” he stated emphatically, drawing out the last three words. 

I put my phone down and turned my chair away from the computer. He had my attention. Not because I haven’t taken care of any sick patients before, but because this statement was coming from him.

I’m sure your hospital has someone like him (or her), too. A physician who stays up to date on the current literature yet has enough experience to know the previous guidelines and recommendations. One who really has ‘seen it all’ and remembers when the old wing of the hospital was new. A colleague who others curbside to glean insight, which he gladly shares. And of course, the highest compliment of all — someone who is trusted to take care of other physicians’ family members. 

His tanned face leaned in as he told me about this patient who was getting ready to go to surgery. Looking down at his beige and hunter green hiking boots, it dawns on me — I’m in a moment. This type of patient, this type of case, this type of responsibility with someone of his caliber could only make me a better physician. 

But then something happened. The case got pushed back. A few hours later, it was pushed back again. Pretty soon it was morning. The patient didn’t go to surgery that night.

What could have happened?” I thought to myself, as I stopped by Starbucks. I was looking to indulge in a little more caffeine to make up for the lost learning opportunity. Just then my phone vibrated: “CASE TO GO LATER THIS AFTERNOON,” the page read. And, the case finally did go that afternoon. And also long into the night. 

The Connection with Resident Burnout

What does this story have to do with resident burnout? When it was all said and done, I was at the hospital much longer than the ACGME recommended limit. And, despite this, I felt less burned out, rather than more burned out.

Resident burnout is more than hours worked. In the situation above, I clearly went beyond the arbitrary hour limit. That artificial number, in the midst of a complex, large, and imperfect system, was crossed. But to focus solely on a number fails to take into account other important drivers of resident burnout.  

To be clear, hours worked is an important factor. And this piece is not about the “hours worked” debate. It’s easy to point out when something is excessive. It is harder to define when something is right. Of course, hours worked is an easy metric to track, but it provides an incomplete assessment. 

Solely focusing on hours worked drives a wedge between those who trained before and those who trained after work-hour restrictions. I completely understand that some of those who trained before the limits have trouble understanding how hours have gone down, but resident burnout currently is at epidemic levels. There is no doubt that the training system has improved, yet we are still mired in a suboptimal environment. 

Four domains of resident burnout

Four Domains of Burnout: Physical, Mental, Emotional, Moral

Four Domains of Burnout

To obtain a more complete understanding, I conceptualize the drivers of resident burnout into four categories – physical, mental, emotional, and moral. By framing the conversation strictly around hours worked, only the physical domain is addressed and the others are neglected. 

The other domains:

 

 

Mental: E.g., How does my mind keep up with the pace of the day?

  • The average patient’s length of stay decreased from 14 days to 4.8 days from 1983 to 2009.

Emotional: E.g., Is the system tolerating harassment?

  • Sexual harassment was the most common form of abusive behavior in training programs with about 36% of residents reporting it, according to a systematic review (Acad Med 2014; 89:817).

Moral: E.g., Am I here to connect and serve another human being or to document and bill?

  • Research specifically focused on Internal Medicine residents suggests the ratio of documenting to direct patient care might be as high as 5:1 (Ann Intern Med 2017; 166:579).

So why did I feel better after taking care of a complex patient, despite being at the hospital past the recommended hour limit? Using the framework provides the answers. Mentally, I knew that I had built on my foundation of knowledge. Over the past 4 years, I have been incrementally and appropriately given more challenging cases. I was prepared for this case. Emotionally, I felt incredibly supported. My attending even shared a cookie from the attending-only lounge with me. It sounds trivial, but that gesture personified the solidarity we had throughout the night. He made sure I had enough time to grab a drink of water. He knew I was up for many hours and asked me if I was still able to provide good care. And he supervised me closely — with various checkpoints throughout the case — to see if my words matched up with what was needed. I knew I could say at any time that I wasn’t fit to continue — and there would be no retribution. Morally, I felt the patient was receiving high-quality care. The communication amongst teams, coordination with other services, and plan were thoughtful, deliberate, and done in accordance with best practices. I felt respected as a person when the program paid for my Uber ride home as my adrenaline faded away. 

Perhaps we spend too much time focusing on the hours worked. It is a part of the picture but not the entire picture. I cannot tell you the perfect amount of hours worked. By overly focusing on that question, we fail to take into account other pertinent influences. We can all agree that past a certain point, the educational value of more hours is suboptimal. But again, where is that point? And how does it apply to my specialty compared with yours? And how do we define the value of hours as a newly minted intern versus a nearly graduating soon-to-be attending? 

It is time to consider interventions that address the other domains that drive burnout — physical, emotional, and moral. These interventions must address the pressing and timely concerns of modern training. In addition, they should be effective and high-yielding  without requiring a complete retooling of the system nor a large financial commitment. The next logical step of addressing resident burnout is to consider these other domains and incorporate practical and targeted solutions. 

 

NEJM Resident 360

April 24th, 2020

Pass or Fail — USMLE Step 1

Allison Latimore, MD

Dr. Latimore is the Education Chief Resident at the MedStar Washington Hospital Family Residency Program in Washington, DC

We All Take Tests

In January 2020, it was announced by the US Medical Licensing Examination that USMLE Step 1 scoring would change from a 3-digit score to pass or fail. I’m sure some budding and current medical students are jumping for joy. Some residents and attendings probably are brooding jealously, thinking of all the stress, depression, and anxiety that they developed or exacerbated as a result of Step 1 testing. I’ve heard people say, “if you are a doctor without anxiety, something is wrong.”

A large part of the anxiety that medical students and doctors face stems from the constant testing. We take the MCAT, NBMEs, USMLE Steps 1-3, subject boards, in-training exams, and, finally, boards for our specialty. All of those exams are necessary to become a board-certified physician. Personally, I felt that every time I turned around, I was inputting my credit card information to pay for a new test. As inconvenient as it is, being tested constantly as a physician is necessary. People want to know that the person treating them is intelligent and up to date on the latest research. However, have we proven that all these standardized tests correlate to how “good” a doctor someone is or their potential to become a good doctor?

Good Doctor or Good Medical Student?

According to a study published in the Advances in Medication Education and Practice Journal in April 2019, “USMLE Step 1 and Step 2 CK scores moderately correlate with the number of honors grades per student in core clinical clerkships. This relationship is maintained even after correcting for gender, institution, and test-taking ability. These results indicate that USMLE scores have a positive linear association with clinical performance as a medical student” (Adv Med Educ Pract 2019 Apr 26; 10:209).

Why the change from a 3-digit score to pass/fail, if this test correlates with how well people perform in medical school? The USMLE released the following statement from Humayun Chaudhry, DO, MACP, President and CEO of the FSMB, in regard to the policy change: “These new policies strengthen the integrity of the USMLE and address concerns about Step 1 scores impacting student well-being and medical education. Although the primary purpose of the exam is to assess the knowledge and skills essential to safe patient care, it is important that we improve the transition from undergraduate to graduate medical education.”

Peter Katsufrakis, MD, MBA, President and CEO of NBME, stated, “The USMLE program governance carefully considered input from multiple sources in coming to these decisions. Recognizing the complexity of the environment and the desire for improvement, continuation of the status quo was not the best way forward. Both program governance and staff believe these changes represent improvements to the USMLE program and create the environment for improved student experiences in their education and their transition to residency.”

Transition to Residency

I must confess, my initial response to this change was jealously that this didn’t happen while I was crying incessantly over Step 1. Then, I began to read some of my colleagues’ thoughts on social media. I read people recount their suicidal thoughts after Step 1. I also read about people who had no issues with Step 1 at all and who couldn’t relate to these feelings. What surprised me were the people who disagreed with the change completely. At first, I could not understand why anyone would disagree. But when I think of minority students, students aiming for very competitive residencies, and international medical graduates, I realize that 3-digit score is the key to their destiny.  Some feel that the one way to separate themselves from the others in the stacks of residency applications lies in a 3-digit score — which is not wrong. People who don’t have a big-name school behind them might count on their step 1 score to get them into the door. What sets your application apart from anyone else with a pass?

Long-Term Effects

It’s possible that this change will push medical schools to change their curriculums and schedules. Will students need to take Step 2 CK early enough to have an impressive 3-digit score to match into their desired specialty? Will this make medicine even more of a “who you know” field? Away rotations already are expensive for students. Will everyone need to complete more away rotations to increase their likelihood of matching? I’d love to hear your thoughts. Do you think changing Step 1 scoring to pass/fail will be conducive to the medical school experience or detrimental?

 

NEJM Resident 360

March 5th, 2020

Should We Avoid Exposing Residents to Coronavirus?

Dr. Eric Bressman

Dr. Bressman is a Chief Resident in Internal Medicine at Icahn School of Medicine at Mount Sinai in New York, NY

The arrival of the novel COVID-19 to the U.S., and the inevitability of its eventual spread, raises an interesting question: Should we avoid exposing residents to the virus?

Before we try to answer this question, we should start with some important qualifiers. While a good deal about this novel virus remains unknown, the majority of cases appear to be low risk, particularly for the demographic of the average resident. Furthermore, if this outbreak does reach pandemic levels, exposure to healthcare workers of all levels ultimately will be unavoidable. Finally, even with the best of protocols in place, it will be impossible to triage out every potentially infected patient at the point of first contact.

With all this in mind, COVID-19 may not be the best case study, but it’s an interesting opportunity, nonetheless, to pose a broader question regarding the role of trainees during epidemics and pandemics.

History

Let’s start with a brief historical overview of this question. Physicians have always been at the frontlines of deadly outbreaks, and as a result, were regularly infected by the same diseases as their patients. The first century of U.S. history can be recounted in a sequence of epidemics, from yellow fever to cholera to typhoid fever. In an era of unregulated medical and graduate medical education, and limited understanding of the spread of these diseases, there was scarcely any thought given to the protection of students and trainees during these outbreaks.

Graduate medical education evolved over the course of the twentieth century from a mix of apprenticeships and a limited number of more structured programs, to a landscape of predominantly hospital-based internships, and eventually specialty-focused residencies with a unified accrediting body. Important questions that persist to this day were considered during this time, including the place of the resident on the spectrum from student to employee.

The AIDS epidemic was likely the first major infectious disease outbreak during which the unique experiences of students(Health Educ Res 1999; 14:1) and residents (Ann Intern Med 1991; 114:23) were explored, although the emphasis tended to be on the duty to treat in spite of the fears and perceived risk. In the intervening decades, however, the vulnerability of the trainee has been reconsidered, and this has shifted the conversation. By the time of the 2014 Ebola epidemic — although different in scale and mode of transmission from HIV — much wider efforts were undertaken to protect trainees from potential exposure, prompting a healthy debate (Acad Emerg Med 2015; 22:88).

Pros

We can entertain a couple arguments in favor of trying to protect residents from a potential pandemic exposure:

  • The infection control argument: Because residents are mid-level providers, any patient a resident sees will also be seen by a supervising attending. To limit total number of exposures and mitigate the potential for disease spread, the fewest number of providers possible should see any at-risk patient.
  • The student versus employee debate: During the Ebola epidemic — which was vastly different from the current pandemic — nearly all medical schools forbade students from providing care for rule-out Ebola cases (Acad Emerg Med 2015; 22:88). There may not be one unifying theory about why these policies were developed, but the reasons probably include insufficient training, liability, and a less than clear moral imperative. Conversely, faculty are compelled to care for all patients, at times even in the face of personal risk, by virtue of their training, their contracts, and their professional codes of conduct (Am J Bioeth 2008; 8:4). The question, as always, is where residents fall on this spectrum; this has been argued both ways over time, often according to what is most convenient for the employer.

Cons

At the same time, some real downsides might occur in trying to shield residents from potential exposures:

  • Missed training opportunity: This is especially true when it comes to outbreaks that require rigorous infection control practices, as was the case with Ebola. If rule-out protocols exclude trainees, health systems will be less likely to invest resources in training them. This may, in fact, put residents at higher risk, both now and in the future.
  • Modeling professionalism: Residency is about attaining not just the knowledge and skills, but also the attitudes, necessary for life as a physician. At times, this encompasses embracing some risk in the service of our patients. Whatever the status of residents — student, employee, or student-employee — there might be value in imparting this message.

Conclusion

The role of the resident during a pandemic raises interesting questions; although they generally operate at the front lines, the instinct is there to protect them when personal risk is involved. COVID-19 might not be the best case study for a number of reasons, but it is more than just a thought experiment. Health systems are developing protocols at this very moment, and the role of trainees will be an essential consideration. In some instances, the protective instinct of a particular attending might be to handle the rule-out cases personally. But most importantly, the next pandemic might pose even greater risk, and it will be all the more essential to find the right balance between expectation, education, and limitation.

 

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2019-2020 Chief Resident Panel

Prarthna Bhardwaj, MD, MBBS
Eric Bressman, MD
Allison Latimore, MD
Daniel Orlovich, MD, PharmD
Frances Ue, MD, MPH

Resident chiefs in hospital, internal, and family medicine

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