By Inas Abuali, MD, FACP
“These are unprecedented times.” I come across this sentence on an almost hourly basis. It is the opening line of emails I receive, and the phrase thrown in during WebEx team meetings and grand round presentations on COVID-19. We are bombarded every minute by news from media outlets. The phone buzzes incessantly with one email after another, from institutional leadership to Graduate Medical Education organizations to friends checking in. The policies change daily as we attempt to adapt and adjust to the influx of new information. We closely monitor the situation in Italy and China and wonder if our own social distancing has been implemented early enough and to a sufficient degree to make a difference and “flatten the curve.” This new terminology is now part of our daily conversations.
As an international medical graduate and now a hematology/oncology trainee at an academic center, I attempt to make sense of the shifting tides around me and what they mean for my patients, colleagues, and loved ones. So here are a few thoughts from my end, which I typed up in the fellows’ work room while maintaining the appropriate 6 feet of distance away from my co-fellow!
1. This crisis has thrown a spotlight on the significant health care disparities globally and nationally within socioeconomic groups.
My early training was in a low-income country with very limited resources. I remember wearing the same pair of gloves for an entire shift, washing it between patient encounters. I remember patients dying from basic infections due to lack of availability of antibiotics. Now, I see countries united in assisting each other with resources. Will this disastrous pandemic serve as a reminder that we are a global community whose survival is contingent on helping one another? When we come out of this, will patients with cancer in some parts of the world still be dying from lack of access to basic chemotherapeutic drugs? Within high-income nations like the United States, will treatments still be available only to a certain socioeconomic group, while being poor translates into inferior care and occasionally a death sentence?1
2. There is a fine line between quantity and quality of patient encounters.
Going into oncology, I envisioned hour-long discussions with patients about a new diagnosis, goals of care, or various therapy options. The grim reality, however, is that oncologists may be expected to see 30 patients daily to meet the expectations outlined by health care policies and insurance reimbursement regulations. The emphasis is on quantity as we struggle to find the time required to provide the appropriate quality of care. Today, oncology clinics that once were triple-booked and brimming with “6 to 8 weeks’ follow ups” are being stripped down to the essential encounters. Is this time to rethink how often patients need to be seen, to ensure that once they are seen they are receiving the high-quality care we owe them?
3. This is the time to utilize all available technologic resources.
In the current digital era, most of us are still wary of embracing telemedicine, finding comfort in the face-to-face encounters and the reassurance they provide to our patients and ourselves. As we rely on telemedicine in the upcoming weeks to overcome any gaps in care for our patients, it is prudent to think of expanding this utilization in the future to help deliver care for our more frail patients and those with limited geographic accessibility.2
4. We may need to rethink medical education and the role of trainees during the crisis.
Across this country, 90,000 medical students are being trained at more than 150 medical schools. As this crisis escalated, the American Association of Medical Colleges (AAMC) and the Liaison Committee on Medical Education (LCME) issued guidance that a minimum 2-week suspension of medical students’ participation in direct patient care activities is required to appropriately prepare them for return to clinical rotations and to conserve personal protective equipment (PPE).3
Responses regarding the role of residents and fellows have differed across institutions, with a lot of emphasis on creating a reserve of “back-up” residents and fellows who can fill in for others as they get exposed to COVID-19. A re-deployment to general internal medicine wards, intensive care units, and emergency rooms has been adopted by other institutions overwhelmed by the surge of patients and experiencing physician shortages.
As some of us scramble to brush up on skills we have not utilized in a long time, everyone is united in wanting to help during these difficult times.
Interestingly, this also sheds light on what rotations are essential during our medical training and what proportion of our education can be done via e-learning, as a unique redesign of curricula is employed to ensure ongoing learning for those isolating at home.
5. The personal protective equipment (PPE) shortage is a crisis in itself.
As health care providers are hailed as “essential frontline workers” and likened to soldiers on the battlefield, concerning reports of PPE shortages are coming out of areas overwhelmed by COVID-19, such as New York.4 How can we deliver safe care ourselves if we are sick or serving as a focus of contagion? As organizations scramble to find alternative means of rapid mass production of the necessary PPEs, communities are stepping up in donating supplies from various businesses to assist in the current shortage.
6. Our patients with cancer are facing unique struggles and need our vigilance in meeting their needs.
Imagine this: not only are you dealing with a new cancer diagnosis, but you are now expected to come to an appointment alone without your family and trudge hesitantly into a health care facility that screens you for potential COVID-19. The vulnerability of our immunosuppressed patients forces us to improvise and carefully reexamine the guidelines to determine when and whom to treat during those times. Patients want to know if they can defer their chemotherapy and whether their visits can be safely rescheduled. We are holding family meetings virtually over FaceTime as patients’ loved ones are barred from medical ICUs in light of the COVID-19 pandemic. What do we tell patients who look up to us for answers that we may not have? We are all scrambling to keep up to date with the overwhelming emerging volume of new information. (ASCO has compiled a wide range of resources to support clinicians, the cancer care delivery team, and patients with cancer.)
7. Self-care is essential during turbulent times.
A colleague told me the other day that he feels like a leper and is worried about the potential impact he can have on his family if he transmits COVID-19 to them. Other coworkers have been preemptively self-isolating, some going as far as renting an apartment where they can stay alone, away from their families. As physicians, some of us are already isolated due to the demands of work, and our social circles might be limited to other coworkers going through the same stressful experience. Let this be the time where we choose kindness and check in daily with loved ones as we all deal with the anxiety and uncertainty of these times.
Will we come out of this with a new appreciation of our global community, how resources need to be allocated to fund the fundamental infrastructure of our health care system, and how to reach out to one another? Or will this too pass and be forgotten? I am reminded of a line from Haruki Murakami’s Kafka on the Shore: “When you come out of the storm, you won’t be the same person who walked in.”
Be safe and wash your hands—these are unprecedented times!
Dr. Abuali is a hematology/oncology PGY5 fellow at the University of Cincinnati Medical Center and a member of the ASCO Trainee Council.
- Cortes J, Perez-García JM, Llombart-Cussac A, et al. Enhancing global access to cancer medicines. CA Cancer J Clin. Epub ahead of print 2020 Feb 18.
- Sirintrapun SJ, Lopez AM. Telemedicine in cancer care. Am Soc Clin Oncol Educ Book. 2018;38:540-5.
- Association of American Medical Colleges. Interim Guidance on Medical Students’ Participation in Direct Patient Contact Activities: Principles and Guidelines. March 30, 2020.
- Jacobs A, Richtel M, Baker M. ‘At War With No Ammo’: Doctors Say Shortage of Protective Gear Is Dire. New York Times. March 19, 2020.