Medical Education Resident and Student Describe 'New Normal' of COVID-19

Amid the chaos that COVID-19 has caused in medical education, the siblings talked to each other about how their lives and training have been affected.

APRIL 15, 2020 -- Cherie Fathy is an ophthalmology resident (PGY-3) at the Wills Eye Hospital at Thomas Jefferson University. Her brother, Ramie, is a third-year medical student at the University of Pennsylvania. Amid the chaos that COVID-19 has caused in medical education, the siblings talked to each other about how their lives and training have been affected.

Cherie: Hey, Ramie. How are things on your side of Philadelphia?

Ramie: Hey, sis! Ramzie [our brother] and I miss you over here. It's been a little over 2 weeks since we decided that we probably shouldn't see each other in person.

Cherie: I'm thankful that we have FaceTime to stay connected, especially when it comes to checking in on Baba [our father]. I haven't seen Baba since January. It's just not worth the risk of possibly exposing him. It's definitely ironic just how much the tables have turned, as we're now "scolding" him for going out.

Ramie: I definitely feel that about Dad. I keep thinking it's a little extreme, but I also know I would never forgive myself if I got him sick.

What about your residency training, Cherie? How has COVID changed things? What is your "new normal"?

Cherie: I'm part of a skeleton crew of residents who alternate working days. That way, if one group is exposed to the virus, we still have another set of residents who are ready to see patients. Our eye emergency room serves as a haven for those who can't seek care elsewhere. Wills has one of only three emergency rooms in the country dedicated to eye pathology. It is well recognized in the area as a place where primary doctors, eye care providers, and local emergency rooms can send patients they feel uncomfortable managing. We have also had patients find us and choose to come to an eye emergency room instead of going to an urgent care or local emergency room for their ocular pathology.

Now that several clinics have closed in the area, I'm seeing patients who have waited too long to seek care and now have fulminant ocular infections or advanced macular degeneration from having missed their injections. I think those latter patients have been worried to leave their homes. Many are already older and may be immunocompromised. We are also seeing patients who accidentally injured their eye with new workout equipment or suffered a chemical injury while dyeing their hair because the salons are closed.

Some patients have read about conjunctivitis as a sign of COVID and come in and ask for COVID swabs, which we do not regularly use in the eye emergency room. Per the American Academy of Ophthalmology (AAO), the virus can cause a "mild follicular conjunctivitis that is virtually indistinguishable from other viral causes or conjunctival congestion." Of course, that part is often left out of the news stories.

I now hoard my surgical mask and am trying my best to not lose or soil it. I will be filled with guilt if I have to use another one. Ophthalmology examinations require us to be in close contact with our patients. After every patient interaction, I wonder if that person may have been an asymptomatic spreader or if the virus was transmitted despite my mask, the breath shield, and my copious handwashing and disinfecting.

Honestly, it's not that I'm that worried about myself. I'm worried that I could transmit this virus to my patients, or to you, Ramzie, or Dad. I guess my new normal is anxiety.

'Everything Changed'

Ramie: What did you think in the weeks leading up to the spread here?

Cherie: When the first patient was diagnosed with COVID-19 in Philadelphia, I kept seeing clinic patients without much alteration to my interactions. When the early news came out of Italy, we questioned whether it was safe to host 24 residents in a Prometric testing center; but otherwise, we really did not anticipate a change. Then, of course, everything changed. We heard the news of the doctors in Italy and China giving their all and losing their lives. Stories surfaced of doctors forced to choose who gets a ventilator. Patients were dying alone.Early on, I wondered, Why aren't we doing more? On a local level, the initial response from the different levels of leadership seemed to focus more on "building morale" rather than providing concrete steps to prevent the spread or prepare for a pandemic. In talking to other residents across the country, this wasn't unique to Philadelphia. Obviously, it isn't easy to coordinate a massive shift in practice. But it was frustrating for us as residents because we craved definitive plans and guidance. I do have to commend my institution for their leadership now. We get daily updates on the situation at the main hospital, and at Wills, we follow AAO guidelines regarding scheduling only urgent or emergent patients and only doing emergency surgeries. We're still getting a few nonemergent visits that make me think that a teleophthalmology service could help prevent people from unnecessarily leaving their homes and potentially exposing themselves.

We are looking into telehealth opportunities for our nonurgent patients. However, it is quite new territory for us. In ophthalmology, much of our examination and management depends on a dilated eye examination or a magnified view of the eye using a slit lamp microscope. Televisits will certainly come with new challenges when it comes to definitively diagnosing and treating patients. It's an interesting challenge and one that we will hopefully be able to draw from as we employ teleophthalmology more in the future.

What happened with your rotations?

Ramie: I came back to Philadelphia for my rotations after studying for the USMLE Step 1 for a couple months at home in Tennessee. Ironically, one of the most widely used study resources to prepare for Step 1 started its section on the coronavirus with information about how rare the virus is. It actually stated that it was "not a super high-yield virus," implying that we wouldn't need to be too familiar with it.

In February, during my first rotation in pediatric dermatology, I could see the signs that something was coming. Patients started coming in with masks on. Hand sanitizer bottles quickly needed to be replaced. National conferences and invited speakers were canceled. Patients started to ask me whether they should stock up on their medications and for how long. Just 2 weeks after I had returned to the hospital, I received an email about the temporary suspension of clinical rotations. Initially the suspension was for 2 weeks. A few days later, it became an indefinite suspension. It may be months before I can safely take part in rotations again. Although I'm disappointed, these decisions make sense in order to protect our patients, staff, faculty members, and others.

Cherie: What are you doing if you're not on rotations?

Ramie: Many of us have left the city and are heading back home to be with family. The school has moved all preclinical courses and small groups online and developed online clerkship and elective modules to continue our education remotely. As you can imagine, it takes time to develop online educational materials to mimic the clinical experiences one has in the hospital. Our instructors are actively creating online, case-based video modules. The school has also been collecting and sharing a long list of research and volunteer opportunities for students to work on.

Frontlines and Sidelines

Cherie: Have you decided to volunteer anywhere?

Ramie: I reached out to a mentor for guidance on how best to use this newly unscheduled time. He motivated me to support the efforts of those combating the virus in the hospital however I could. Initially I set out to volunteer at the hospital, hoping to draw from my clinical experience, as limited as it is. But we are not permitted to get involved in any activities that involved face-to-face, in-person interaction, at least for the time being. This is to help avoid additional spread and to reduce overall use of personal protective equipment (PPE). I keep thinking about how I used to wear masks, gloves, and gowns just to stand near a patient and listen to the doctor. All of that PPE seems like such a waste now when I could have just gotten a debrief after the fact.

I still wanted to find a way to support the community and healthcare workers on the frontlines of the pandemic. I started an organization for health profession students across Philadelphia to coordinate and optimize efforts across the city. With over 2000 members in 2 weeks, the group has begun to support various projects, including calling companies, schools, labs, and museums across the city to locate and donate PPE, as well as collecting and developing informational resources to share with the public. We've also been working on wellness initiatives for medical students and healthcare workers. A team of med students is also working to fight Joel Freedman's recent prevention of the reopening of Hahnemann, which would be an invaluable resource in managing this crisis.

I should mention that all of these efforts are being conducted independently of my medical school.

You're on the frontline more than I am. Have you heard about other ways we can help?Cherie: Any support is truly appreciated. For residents, offers to help with childcare, grocery shopping, and routine errands would be incredibly helpful. On a systems level, donating both blood and PPE are incredibly important. I've also seen community efforts to purchase and provide food from local businesses to feed those who are working overtime in the hospital; this also supports the local businesses that are struggling at the moment.

Have you heard about medical students joining on the frontlines at all?

Ramie: Here in Philadelphia, medical schools are trying to involve their students remotely through activities like helping to reschedule patient appointments, supporting and optimizing telehealth services, monitoring ICU patients, and helping with large-scale quality improvement initiatives to track and quantify COVID cases in the hospital. Students are also helping to collect and deliver much-needed PPE to hospitals at nearby buildings.

That said, the number of positive test results is exponentially rising by the day in Philadelphia; it looks like we have hit the turning point, where cases really start to present themselves. I wouldn't be surprised if our medical students find themselves helping through additional pathways, perhaps even in the hospitals, in the coming weeks or months.

Have you heard of non-internists having to work on the wards at this point? Do you think you'll have to?

Cherie: Not here yet, but the recruitment of residents from specialties other than internal medicine or emergency medicine is definitely in our "disaster plan." We are aware that we may be asked to work in the emergency room, on inpatient floors, and maybe in the ICU if enough residents are out sick with the virus or are put into quarantine. I can't tell you the last time I worked in an ICU, so I'm pretty nervous about this. To prepare for this potential role, I've been keeping up-to-date with the latest guidelines on how to diagnose and manage COVID.

Ramie: How are you and your peers holding up physically and mentally?

Cherie: Many of us are wondering if this is the calm before the storm. We are anxious, but mostly because we're not sure what is coming up ahead. Hopefully, we'll see a positive impact from the quarantine/closure of nonessential businesses in "flattening the curve," and we'll continue to see unified messaging on how to effectively manage this virus and halt its transmission. Hopefully, more information will come out on how we can protect ourselves as well—fewer bandana recommendations and more innovative and validated ideas on PPE.

Ramie: Have you talked to any of your friends on the frontline?

Cherie: I have. They are tired, they are scared, but they are so brave. It is incredible and humbling to see my medical school classmates and friends rise to the challenge, to choose action in the face of paralyzing uncertainty. I am honored to be their colleague.

Cherie A. Fathy, MD, MPH, is a PGY-3 resident in ophthalmology at the Wills Eye Hospital in Philadelphia. She is interested in global health initiatives and disparities research.

Ramie Fathy is a third-year medical student and curriculum representative at the Perelman School of Medicine at the University of Pennsylvania. He is interested in the interaction between medicine, the media, and the public.

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