Student and Trainee Responses to Covid-19 Pandemic

1. Perspective
The NEW ENGLAND JOURNAL of MEDICINE

n engl j med nejm.org  1
O
n January 20, 2020, the first U.S. case of
Covid-19 was reported in Washington State.
Substantial challenges lay ahead. Covid-19
is highly contagious, it can cause severe illness, and
no proven, effective treatments or
vaccines are available. As leaders
at the University of Washington
(UW) and UW Medicine prepared
for a tsunami of patients, there
was extensive discussion about the
role of students and trainees (resi-
dents and fellows) in our response.
How should clinical and educa-
tional imperatives be balanced
with their safety and well-being?
Risk is inherent in medicine
— for patients and for health
care workers. Usually risks to cli-
nicians are small, manageable,
and accepted by these workers as
part of their responsibility to act
in a patient’s best interest. But pro-
viding care to patients with com-
municable diseases can be fright-
ening. Today’s medical leaders
remember the anxiety involved in
caring for patients who were dying
of an infectious disease with an
unknown cause during the early
years of the AIDS epidemic.1
More
recent outbreaks (including H1N1
influenza, SARS, and Ebola) have
further reminded clinicians of the
personal risks they face when car-
ing for patients.
The Covid-19 outbreak has re-
quired us to address questions
about students’ and trainees’ in-
volvement in the care of infectious
patients. The high probability that
medical students in the hospital
would be exposed to Covid-19 and
the need to conserve personal pro-
tective equipment (PPE) seemed to
outweigh the educational benefits
of students’ participation. This
assessment prompted UW senior
leaders to remove medical stu-
dents from clinical rotations on
March 16. The following day, the
Association of American Medical
Colleges recommended that mem-
ber schools suspend clinical rota-
tions for medical students for at
least 2 weeks; this recommenda-
tion was recently extended through
at least April 14, 2020.2
Involve-
ment of residents and fellows in
Covid-19 care has varied by spe-
cialty and is rapidly evolving. Some
of these trainees may be caring
for patients with Covid-19 during
assigned rotations. When there is
a surge in Covid-19 cases, others
may be voluntarily redeployed to
services with these patients.
To learn more about how Co-
vid-19 is affecting our students
and trainees, we conducted a brief,
anonymous survey and received
responses from 316 third- and
fourth-year medical students, in-
terns and residents in internal
medicine and emergency medi-
cine, and fellows in pulmonary
and critical care at our institu-
“We Signed Up for This!” — Student and Trainee Responses
to the Covid-19 Pandemic
Thomas H. Gallagher, M.D., and Anneliese M. Schleyer, M.D., M.H.A.​​
“We Signed Up for This!”
The New England Journal of Medicine
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2. PERSPECTIVE
2
“We Signed Up for This!”
n engl j med nejm.org 
tion. A sampling of the respons-
es we received is shown in the
box, and additional responses are
presented in the Supplementary
Appendix (available with the full
text of this article at NEJM.org).
We learned that students and
trainees feel anxious about and
vulnerable to Covid-19 and that
these fears are amplified for train-
ees serving on the pandemic’s
front lines. One internal medicine
resident wrote, “It’s a constant di-
alogue of ‘Am I safe? Is my patient
safe? Is this care adequate? Am I
doing all I can?’ All of this takes
a serious toll on the psyche of
trainees, and it’s an impact that
will likely be felt for a long time.”
Safety concerns among resi-
dents and fellows are complicated
by the recognition that their deci-
sions have implications for their
loved ones and others outside the
hospital. Some worry about trans-
mitting infection to others in their
homes. Feelings of vulnerability
are exacerbated by rapidly chang-
ing conditions and recommenda-
tions. Fear of potential PPE short-
ages was prominent.
Covid-19 has brought forward
new ethical dilemmas for trainees,
some of whom are considering the
implications of intubating certain
patients when ventilators are in
short supply or wondering wheth-
er they should join an attending
for procedures that would help
them fulfill criteria to sit for board
exams but would require the use
of additional PPE. Many students
reported moral distress associated
with watching patients be isolated
from loved ones and described
feeling distant from patients while
wearing PPE. Trainees not provid-
ing Covid-19 care because of per-
sonal health issues expressed guilt
that colleagues had to step in. Stu-
dents frequently reported disap-
pointment and frustration about
not being able to help. Many peo-
ple faced challenges that were
largely practical, such as needing
child care.
Especially for fourth-year stu-
dents, apprehension about “being
rusty” and maintaining skills that
will be required when they begin
their internships shortly loomed
large. Students also expressed
other practical concerns, such as
whether they would graduate on
time or maintain financial aid.
Students’ desire to help has driven
them to volunteer to support the
school’s clinical mission and com-
munity, by preparing home care
kits for patients with Covid-19,
for example, or by providing child
care for health care workers.
Feelings of anxiety and vulner-
ability among students and train-
ees compete internally with a de-
sire and commitment to serve the
sick. Many have done more than
has been required of them for pa-
tient care and within the com-
munity, despite risks and chal-
lenges. When one program called
on residents to fill extra shifts
through the end of April, all slots
were filled by volunteers within
10 minutes.
Moving forward, leaders in
medical education can communi-
cate frequently with students and
trainees to maximize the informa-
tion and emotional support they
receive. Students and trainees are
Survey Responses from University of Washington and UW Medicine Medical
Students, Residents, and Fellows.*
Students and trainees were asked to describe what — if any — unique or challenging
ethical or practical challenges they have experienced as a result of the Covid-19 pan-
demic and how they have responded. They were also asked whether there was anything
they would like to tell us about their experience during the Covid-19 pandemic.
“I’m excited to be able to make a difference, but I’m just as scared as everyone
else.” (IM resident)
“How do I respond when my housemates…are uncomfortable with me being in the
house because I might bring Covid home?” (IM resident)
“Going in patient rooms less due to exposure. Not wanting to touch patients as
much. New teams. New coverage. New workflow. New PPE training and usage.
New triage system…. This is endless and ongoing.” (IM resident)
“Masks were taken from precaution carts, hidden away in huddle spaces or work-
rooms. Patients were stealing them from the hospital. And we were running
short. The team started to prioritize who would go into a room, based on how
much gear was being used.” (student)
“Is it ethical to keep the N95s my mother sent to me, with the strict warning to not
share them, to myself?” (IM resident)
“Considering the cost of intubating a sick elderly patient with multiple comorbidi-
ties who may use a ventilator for weeks while they are in dwindling supply.”
(EM resident)
“When the Covid epidemic hit, I was on my anesthesia rotation. I dealt with the
ethical dilemma of going in to get my intubation numbers higher while know-
ing I was still nonessential personnel.” (EM resident)
“Lack of visitors, especially the limited number for patients who are dying…. This
has put us in the place of looking toward public health goals more so than our
own individual patients.” (PCC fellow)
“I feel underutilized…. It’s so hard to be a student and not help when you feel mor-
ally and ethically inclined to do so.” (student)
“As 4th year comes to a close and internship looms, being away from patient care
for so long is deeply concerning…. Not an ideal time to be rusty.” (student)
“As strange as it sounds, I feel lucky to be working during this time.” (IM intern)
* EM denotes emergency medicine, IM internal medicine, PCC pulmonary and
critical care, and PPE personal protective equipment.
The New England Journal of Medicine
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3. PERSPECTIVE
3
“We Signed Up for This!”
n engl j med nejm.org 
experiencing intense anxiety, un-
certainty, and anticipatory loss.
Leaders should create safe spaces
for them to share their concerns,
acknowledge and validate their
emotions, and collaborate on in-
novative ways to contribute. Lead-
ers can provide trainees who are
unable to participate in Covid-19
care because of personal health
issues with other options for help-
ing, such as caring for outpatients
through telemedicine. Through-
out the pandemic, leaders should
maximize students’ and trainees’
control over their involvement in
Covid-19 care where possible.
The Covid-19 crisis is a teach-
able moment. Chaos and uncer-
tainty demand an unyielding focus
on core medical principles and
consistent modeling of profession-
alism, altruism, quality, and safe-
ty. Bioethical issues that previ-
ously seemed theoretical, such as
rationing and futility of care, are
being brought to life during this
crisis. Educators can proactively
teach students and trainees about
strategies for improving end-of-life
care, allocating scarce resources,
and caring for patients who are
noncompliant with self-quarantine
recommendations. Leaders should
also anticipate pointed questions
from students and trainees about
Covid-19 policies and procedures
and respond with respect and
openness.
As the health care system be-
comes more adept at providing
Covid-19 care, there will be inno-
vative ways to assimilate students
into care processes. Several schools
are allowing fourth-year medical
students to graduate early or re-
turn to the clinical environment
to help address impending staff
shortages. The efficacy of this
approach will hinge on the abili-
ty to safely deploy these young
clinicians in ways that don’t re-
quire time-consuming supervision,
as well as on the response of ac-
crediting bodies. Medical schools
should ensure that their fourth-
year students arrive at their intern-
ships ready to be effective mem-
bers of Covid-19 teams.
Down the road, disruptions
such as Covid-19 will prompt us
to revisit routines and traditions.
Which of the new practices that
are being developed during the
Covid-19 pandemic can be adopt-
ed more broadly to enhance edu-
cational and clinical experiences?
How do we simultaneously pro-
vide the safest care and the safest
education? What is the role of
new technology and other inno-
vations in the future of medical
care and clinical learning?3
Medicine and medical educa-
tion are based on a strong tradi-
tion of partnership and of one
generation passing down knowl-
edge to the next. Students and
trainees have experienced consid-
erable loss — loss of routines and
traditions, expertise, educational
opportunities, and social connec-
tions — and many are witnessing
frequent loss of life. Most are wor-
ried about more losses yet to come
in all these areas.
But amid loss, there is hope.
In their seminal paper on AIDS
and occupational risk for physi-
cians, Zuger and Miles wrote,
“Medicine is an inherently moral
enterprise, the success and future
of which depend to a great extent
on the integrity of individual pro-
fessionals as they face the duties
the calling of healer entails.”4
Watching our students and train-
ees step up during the Covid-19
pandemic despite their fears gives
us hope that the profession’s fu-
ture is in good hands.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Departments of Medicine (T.H.G.,
A.M.S.) and Bioethics (T.H.G.), University
of Washington School of Medicine, and UW
Medicine (A.M.S.) — both in Seattle.
This article was published on April 8, 2020,
at NEJM.org.
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2. Association of American Medical Col-
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dents’ participation in direct patient contact
activities:​principles and guidelines. March
30, 2020 (https://www​.aamc​.org/​system/​
files/​2020​-­03/​Guidance%20on%20
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.17​.20%20Final​.pdf).
3. Emanuel EJ. The inevitable reimagining
of medical education. JAMA 2020;​323:​1127-8.
4. Zuger A, Miles SH. Physicians, AIDS,
and occupational risk: historic traditions and
ethical obligations. JAMA 1987;​258:​1924-8.
DOI: 10.1056/NEJMp2005234
Copyright © 2020 Massachusetts Medical Society.“We Signed Up for This!”
The New England Journal of Medicine
Downloaded from nejm.org by ROD STER on April 8, 2020. For personal use only. No other uses without permission.
Copyright © 2020 Massachusetts Medical Society. All rights reserved.