What will training look like in the post-pandemic era?

I remember my first week of internship very clearly – I was a part of my first code blue as a physician. Later that week, I had to have a goals of care discussion with a patient who had been in the hospital for 3 weeks (longer than I had been a doctor at that point). These were new experiences that I was eager for, but I was fortunate to have my routine that maintained a sense of normalcy for me, very much like naptime to my toddler. I was diligent in pre-rounding and seeing all my patients before my attending showed up, and would have formed a plan for their care before 8 AM.

Once the COVID-19 pandemic was in full swing here in the US, a lot of these things that were part of my routine as an intern suddenly went to the wayside. At my institution, interns were instructed not to pre-round on patients such as to minimize contact and potential infection transmission. Family meetings could only be conducted via telephone, or in some cases, video conference. Code blues were no longer a mad dash to the patient’s room, but rather, different hospital wards had different teams, such that a provider taking care of COVID+ patients does not go to a code blue for non-COVID patients and vice versa.

Rounding on these revamped inpatient teams has been…interesting to say the least. I can’t tell you the amount of times I or an attending will ask the patient a question about the patient and the response is “I don’t know, I haven’t seen them.” It’s great that interns are more comfortable admitting they don’t know something rather than lie about it, but at the same time, I can’t help but feel a sense of lack of ownership on their behalf.

Everybody will tell you that intern year sucks, and it’s rough, and they would hate to go back and do it again. But many people will also admit that they are impressed with how much they have learned and managed to push themselves beyond their perceived level of comfort during that time frame. I didn’t particularly enjoy coming to the hospital early each day I was on an inpatient service just to see my patients and review their charts, or going to the patient’s room for the umpteenth time in a day, but there have been a number of times where something meaningful was gleaned, and my ability to think critically and manage patients independently grew a little that day.

The thing that bothers me the most about these precautions is the huge change to goals of care discussions and family meetings. The logic behind it – minimizing spread of infection and exposures – makes sense and I agree with it completely. But it’s hard to develop good rapport with an individual only over the phone, and similarly, it’s difficult to comfort another human being digitally. There’s something about the physical presence of another person, the eye contact, and even the slightest gestures, that can help make the worst day of someone’s life a little less painful.

It’s quite fortunate that these protocol changes came more than halfway through the academic year, when interns at least have a handle on what things to look out for and have developed their own sense of alarm from glancing at the chart. I can’t imagine starting intern year where I only physically interact with “my” patients during rounds with my attending, or via telephone, unless there is some kind of emergency.

On the other hand, this is accelerating our embrace of telemedicine on the outpatient side, which is good for both patients and providers in many cases, and from my anecdotal experience, has resulted in a lot fewer “no-shows.” Interns are afforded more sleep, and arguably learning to pay more attention to vital signs changes and lab value changes – or at least they’re getting a better sense of when they should actually get up and go see the patient (sometimes at the urging of their senior 😊). This could simply be an inevitable step in the evolution of medical education that was accelerated by the pandemic, but I can’t say I feel that all these changes should be here to stay.

Whether it was fumbling through morning rounds and trying to formulate a new plan based on overnight events, or developing my emotional intelligence and flexing that empathy muscle, these were formative experiences for me during my intern year that have significantly contributed to my development as a clinician. These could just be the ramblings of a dinosaur, much akin to the older physicians talking about their paper charts, fibrinolytics and 48 hour calls, but I do hope some of these changes can be undone soon, for the sake of our trainees as well as our patients and their families.

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How Does An Intern Become Burnt-Out In Residency?

The transition from medical school to residency is abrupt, yet exciting. We begin the year so eager and enthusiastic. The rush of adrenaline as you place your first order… the validation you feel as the attending physicians agree with your plan… the first time you make the correct diagnosis in the ever-elusive morning report cases… all of it is new and challenging.  The patients refer to you as doctor and ask you questions about their care. The nurses ask if you can evaluate a sick patient because they want your opinion. You spend hours after sign-out making sure your notes are perfect, which your academic mind considers a daily writing assignment that you MUST ace every time. You try your best to read that article on UpToDate before you fall asleep. You are the first one to get to the hospital, and last to leave.

You have been given trust and responsibilities. You want to meet these expectations.

The first few months pass and you find a rhythm. The feelings of excitement fade and you begin to feel efficient. You start to recognize what you need to do to keep your attending physicians and the upper levels happy.  You are finishing your work faster than before.

You start to feel more comfortable, but little day to day things happen that change you without you even realizing it. A patient passing away, a picture of your family together for dinner without you, a burnt-out consultant yelling at you over an improper consult. When these things occur, you ignore them and try to move forward. You feel as though you have easily brushed them away, but in reality, they affect you.

January and February become the hardest months of the year. Burnout can present in many different ways. It can present itself subtly like having difficulty getting up in the morning to go to work. You may think to yourself, “this is normal, tons of people have a difficult time getting up in the morning.” Yet, it is like a stepping stone. Your lack of sleep turns into you finding nursing calls annoying. All of the time spent on documentation, hours spent in front of computers taking away from patient care begin to change how you view your work. The combination of working twelve hours a day and trying to learn more about the pathology you see becomes difficult. You may even find your work uninteresting. And yet, with all of that said, even though you are fully aware of burnout and have heard the term multiple times, you believe that what you are experiencing is normal.

The first step to tackling burnout is to recognize it. Self-reflection is an important aspect of residency, but at times, it is your friends and family that point out the subtleties of burn out. Once you have recognized it, then it is easier to track and find what exactly is causing you to feel stressed.

Have you experienced burnout? If so, how has your experience of burnout affected you?