July Is Coming: Medical Education and Physician Trainee Turnover in 2020

Worldwide, physicians are at the center of the fight against COVID-19. Throughout the United States, academic medical professionals are addressing staffing and supply shortages in the midst of this pandemic. What’s more, July is fast approaching, and it will soon be time to pass the baton along to the next generation of physician trainees, which poses serious challenges to the academic medical community.

The healthcare calendar year is set to change over in the middle of this pandemic, and industry professionals have been unable to address the problems this switch poses.¹ The July transition this year has the potential to go poorly, which would have damaging implications for all of academic medicine. This year, the National Resident Matching Program^® (NRMP^®) filled most of its 37,256 positions.² Residents makes up 20% of the physician workforce in some areas of the U.S.³ Public health desperately needs more physicians, but physicians-in-training require supportive and educational resources  in order to maximize their potential to care for patients. During this period of time, when many supervisors are finding themselves completely overwhelmed by having to care for an increased number of patients, innovation and ethical programming is needed to supplement this exceptionally challenging period in academic medicine.

If tradition is followed, each physician-in-training will move up a level in the ranks of medical responsibility in July. If the pandemic is no longer causing a state of emergency, the workforce will not be managing fires anymore but will be exhausted. If it remains within a state of emergency, the workforce will be both managing fires and over-tired. Either way, this environment will only make things more difficult for trainees and supervisors, as they work to care for patients and themselves while educating the next generation of highly skilled specialists.

Importantly, there is very little time to evaluate what has changed, what stayed the same and what is needed to move forward. It might seem too early to spend intellectual resources thinking about July, when currently healthcare workers are currently sleeping in their garages to remain isolated from their families and making personal protective equipment (PPE) out of office supplies.⁴ But we must be ready.

Three groups of physicians and trainees are at risk during the July transition, each presented with unique challenges:

1) Attendings transitioning institutions;

2) Graduating residents becoming attendings and changing institutions; and

3) New interns changing institutions and excepting significantly increased levels of responsibility

What’s changing

There are already significant changes occurring to the medical training landscape. Even more significant is what they portend. Worldwide, medical schools are modifying testing and graduation requirements for medical students in an effort to get as many doctors into the workforce as quickly as possible. ⁵ In late March, the York University School of Medicine  released plans to graduate their fourth-year medical students early in an effort to fill the need for physicians in New York.⁶ Another change by the State Department has temporarily halted the issuance of J-1 work visas, which are necessary for over 4,200 newly matched international medical graduates.⁷ U.S. physicians-in-training are raising concerns about inadequate COVID-19 training, despite such training being mandated by the ACGME. ³ 

Time and resources

Even the most seasoned attendings can require lot of time and employee resources to become functional in a new hospital and adequately supervise trainees. It is not an issue of skill but of orientation to new electronic medical records, knowledge of equipment location and access to support resources. In a normal environment, they may simply ask the person next to them where a medical supply is located. In July, there will be no time to spare—or the answer may be too complicated to answer quickly

Issues of computers, copiers, and seemingly small tasks are notorious for taking hours of physicians’ time in the current system. This type of waste simply cannot be tolerated in a time of great need. Hospitals must acquire adequate support staff so that physicians can devote 100% of their unique skills to the moment’s unique needs, not fighting with a copy machine.

Legal obligations and guidance

The reality of changing institutions during the coming months may prove to be too much, and attendings may find themselves unable to transition as planned. It is important to seek legal advice early to avoid making a mistake with contractual or other legal obligations. A physician may find themselves choosing between leaving a hospital so short-staffed that patients are in danger or breaching a contract with a new assignment. With any legal or ethical problem, it is important to bear in mind that a hospital’s legal counsel is not that of the individual physician. But it still might be convenient and budget-friendly to ask the hospital attorney for advice.

It is critical to know that the hospital’s counsel has a professional duty of loyalty to the hospital and not the individuals who work there. If an attorney violates the duty of loyalty to the corporation by advising a physician who interests are contrary to the hospital’s, the lawyer is subject to discipline by their state bar associations. For physicians to get legal advice with their best interests in mind, they must independently hire an attorney. Funding can come from a third party, as long as it is clear that the physician is the client from the onset of representation. More on this can be found in the American Bar Associations Model Rules for Professional Conduct.⁸

State medical associations play a large role in professional guidance, as they are the final authority on issues regarding the practice of medicine. For example, the situation may require special definitions for patient abandonment when there is inadequate staff and supplies. The guidance from that particular state’s medical association will carry legal significance a physician’s actions under its jurisdiction. Professional societies need to consider the unique challenges that their members are facing and make every effort to offer them support and guidance in real time. It is challenging for large organizations to move quickly, but physicians on the ground are being forced to move quickly, so the organizations that support them must issue timely guidance.

Graduating residents

Within many teaching hospitals, senior residents carry find themselves in a uniquely trying position. Usually the spring of their final year is the time for them to polish their craft while negotiating job contracts that they have dreamed of since their pre-med days. For many specialists, this is not the current state of affairs. July is a hard deadline in a situation where all estimations and information is soft. Will these senior residents have a job to go to in July? Are there resources to transition their essential skills from one institution to another? Will they feel like they’re transporting a too-fragile patient, except this time, it is the system that is too fragile?

Anecdotally, most rising attendings require a week to move from their hospital of residency to their new institution, if that institution is within the same state (naturally longer if it is out of state). Currently, many workers are working continuously.⁹ For many, the thought of a week off to move is unthinkable and possibly unbearable from a logistical perspective. If the system is too fragile, will these rising attendings be expected to stay over at their existing institutions? This, too, seems unthinkable. If this does come to bear, what can the physician community do to balance the individual sacrifice that these early career professionals will be bearing? Again, legal advice is essential. It is unlikely that these early career professionals can afford the financial burden of adequate legal advice. This is an opportunity for the physician community to offer real support via funding for independent legal counsel. Some options include lobbying the government for relief packages, funding through specialty organizations or private donations, etc.

Rising residents

Students in various positions and levels of responsibility in the medical hierarchy will be asked to rise up to the next level. This transition of responsibility is always difficult and fragile; however, the strain on the system is largely unprecedented. The AIDS crisis did occur in the setting of our modern training system (post-Flexner Report, post-ACGME). However, it was more geographically specific, and we therefore had the ability to bring in new healthcare workers.^10,11  Still, those who supervised and trained during this time, may have experience and advice that can help us with upcoming challenges.

Modern technology is an advantage that today’s trainees have while facing this pandemic. How can they best use it to transition in July? This question is largely specialty-specific, but some answers include specialty organizations offering free board review resources to medical students who will be asked to hit the ground running on July 1^st while their supervisors are extremely busy in the field and left with little time to teach. For various reasons, those entering the field in July may not be in the clinical arena now and they can prepare for the physical strain via pre-habilitation.¹²Additionally, retired physicians have been asked by some states to consider coming back to work. Some state attorney generals are setting up legal hotlines, but state and local governments aren’t agreeing on what actions to take.

July is coming. That much is certain. Whatever it holds, American physicians and trainees will assuredly rise to the challenge. Through innovation, leadership and community collaboration, we can support each other and pragmatically address the challenges facing academic medicine. Academic physicians have always and will always answer the call of public while training the physicians of tomorrow.

References

1.         ACGME. ACGME Resident/Fellow Education and Training Considerations related to Coronavirus (COVID-19). https://www.acgme.org/Newsroom/Newsroom-Details/ArticleID/10085/ACGME-Resident-Fellow-Education-and-Training-Considerations-related-to-Coronavirus-COVID-19. Accessed March 22, 2020.
2.         NRMP. Press Release: Thousands of Medical Students and Graduates Celebrate NRMP Match Results. National Resident Matching Program Press Release. 2020. http://www.nrmp.org/2020-press-release-thousands-resident-physician-applicants-celebrate-nrmp-match-results/.
3.         Smith R. UW Medical Residents Hit With a Demoralizing Contract in the Midst of Coronavirus Outbreak – Slog – The Stranger. https://www.thestranger.com/slog/2020/03/23/43226553/uw-medical-residents-hit-with-a-demoralizing-contract-in-the-midst-of-coronavirus-outbreak. Accessed March 25, 2020.
4.         O’KANE C. Doctor who moved into his garage to protect newborn and family receives praise from Obama. CBS NEWS. https://www.cbsnews.com/news/coronavirus-doctor-moved-into-garage-protect-newborn-family-president-barack-obama-praises-health-care-workers/. Accessed March 22, 2020.
5.         Kottasová I. Thousands of medical students are being fast-tracked into doctors to help fight the coronavirus – CNN. https://www.cnn.com/2020/03/19/europe/medical-students-coronavirus-intl/index.html. Accessed March 25, 2020.
6.         Annese J. NYU med school class to graduate early to fight coronavirus – New York Daily News. https://www.nydailynews.com/coronavirus/ny-coronavirus-nyu-med-school-early-graduation-20200325-jdjsjzqpjrfolklpmsu3peolye-story.html. Accessed March 24, 2020.
7.         Branswell H. Amid coronavirus, thousands of foreign doctors could be blocked from U.S. https://www.statnews.com/2020/03/23/as-coronavirus-spreads-thousands-of-foreign-doctors-could-be-blocked-from-u-s-entry-group-warns/. Accessed March 24, 2020.
8.         Glenza SKJ. Medical staff can keep working after coronavirus exposure, New York City says | US news | The Guardian. https://www.theguardian.com/us-news/2020/mar/19/new-york-health-workers-raise-concern-over-advice-to-work-after-virus-exposure. Accessed March 22, 2020.
9.         Cooke M, Irby DM, Sullivan W, Ludmerer KM. American Medical Education 100 Years after the Flexner Report. Cox M, Irby DM, eds. New England Journal of Medicine. 2006;355(13):1339-1344. doi:10.1056/NEJMra055445
10.        Silver JK. Prehabilitation could save lives in a pandemic – The BMJ. https://blogs.bmj.com/bmj/2020/03/19/julie-k-silver-prehabilitation-could-save-lives-in-a-pandemic/. Accessed March 22, 2020.
11.        Silver JK, Baima J. Cancer prehabilitation: An opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American Journal of Physical Medicine and Rehabilitation. 2013;92(8):715-727. doi:10.1097/PHM.0b013e31829b4afe
12.        WIFR Newsroom. Pritzker asks retired physicians, doctors and nurses to come back to work during the COVID-19 oubreak. https://www.wifr.com/content/news/Pritzker-asks-retired-physicians-doctors-and-nurses-to-come-back-to-work-during-the-COVID-1o-oubreak-568997121.html. Accessed March 22, 2020.