For some doctors-in-training, it’s become all COVID all the time

When Dr. Clare Prohaska started her pulmonary and critical care fellowship training at Indiana University, she had big plans. She wanted to shore up her clinical knowledge about lung diseases and had just received a research grant to explore the molecular underpinnings of high blood pressure that affects the lungs and heart.

But just a few months into her fellowship in 2020, the pandemic hit and her plans were upended. Two out of her three years as a fellow have been consumed by caring for COVID patients in the intensive care unit.

“We've all become experts at telling people their loved ones are gonna die,” she said.

At the start of the pandemic, Prohaska kept a tally of how many families she had to tell their loved ones died. Now, she has lost count and that scares her.

It takes years for anyone to become an independent physician. After medical school, doctors get hands-on, specialized training during their residencies. Many go on to complete a subspecialized fellowship before they are certified to practice medicine without supervision.

Across the U.S., many graduate medical education program supervisors are concerned about disruptions to the training their residents and fellows are receiving, according to the Accreditation Council for Graduate Medical Education, which sets the training standards for U.S. residency and fellowship programs.

“We're not really being trained to be pulmonary and critical care physicians,” Prohaska said. “We're being trained to be COVID physicians.”

The greatest ICU doctors of all time, but at what cost?

Hospitals across the country have been slammed with a rise in COVID-related hospitalizations for weeks.

Prohaska works at IU Health’s Methodist Hospital, where 100 percent of the hospital’s 890 inpatient beds and 238 ICU beds are in use as of Jan. 24. Indiana hospitalization rates are at 47 cases per 100,000 people, compared to 46 nationally, according to the latest data from the U.S. Centers for Disease Control and Prevention.

Statewide, 32 percent of ICU beds are in use for COVID patients in Indiana, compared to a little over a quarter of ICU beds nationally.

Death rates in Indiana are 1.6 times the national average. The state trails the national vaccination rate with only 56 percent of the eligible population fully vaccinated compared to 63 percent nationally.

Residents and fellows often bear the brunt of a hospital’s clinical work — and for good reason. It’s how they get hands-on clinical experience on a variety of cases, under the supervision of more experienced physicians.

But because of the onslaught of COVID cases, Prohaska and her colleagues have had far less time than residents during pre-pandemic times to focus on gaining important clinical and research experiences.

Dr. Gabriel Bosslet, the director of the pulmonary and critical care fellowship at IU and Prohaska’s mentor, said the experiences of young medical trainees the past two years are ones for the history books.

“The current generation of intensive care unit trainees will be some of the best trained in advanced, severe acute lung disease than we've ever had,” Bosslet said. “Is that good in a way? Yes. But I'll be honest, the return on investment for the amount of additional knowledge they're gaining with every additional COVID-19 patient they're seeing at this point is very, very minimal.”

In other words, there are only so many new skills you can gain when it’s all COVID, all the time.

Bosslet said pulmonary and critical care trainees are fulfilling the requirements of the Accreditation Council for Graduate Medical Education — the body that certifies residency and fellowship programs. But he still worries about what they’re missing out on: providing outpatient care for people with lung conditions, lung cancer screenings and other procedures that have been canceled every time COVID cases have surged.

Lately, close to 60 percent of the ICU patients at Methodist Hospital are COVID, said Bosslet.

With canceled elective procedures and more telemedicine, residents miss out

Not all medical specialties have been pulled into COVID wards. In fact, only 6 percent of trainees at the IU School of Medicine have had to be pulled away from their specialty to cover for COVID patients, according to the IU graduate medical education office.

While 6 percent seems small, the concern over how this affects doctors’ training grows the longer the pandemic drags on.

The situation inside hospitals in Indiana is the worst it’s ever been, Bosslet said.

Lately, more general surgery residents at IU have been deployed to help care for COVID patients than at any point during the pandemic, according to Dr. Jennifer Choi, the program director of IU’s general surgery residency.

On top of that, hospitals around the globe have canceled non-emergency, elective surgeries to make room for COVID cases. It’s terrible news for patients who have to wait indefinitely to address their health concerns — and it also means there are fewer surgeries for residents to attend and learn from.

“Our senior residents are still getting the experience they need,” because they started their training before the pandemic hit, Choi said. “But our more junior level residents … are being pretty negatively impacted by the pandemic.”

Choi expects the impact of the pandemic on medical residency training won’t be fully seen for at least a few years. General surgery residency is a five-year training program. This means that those who are halfway through their training now have spent most of their training during the pandemic with all the disruptions it brought.

That’s not to say that pandemic-era medical trainees will be less competent doctors and surgeons. But Choi said there is merit to the concern that some of the junior residents may not be able to fulfill the national residency graduation requirements.

Her residency program has employed strategies to ensure this does not happen. For example, they carry out “skills labs,” using human cadavers instead of patients.

But operating on a cadaver is not like operating on a real patient with a warm beating heart whose family is waiting for them to come back home.

“I think it's affecting graduate confidence, perhaps more than graduate competence,” Choi said. “But they do go hand in hand with someone's ability to function at a high level once they leave training.”

Senior resident Dr. Mirian Okoye, who is in a three-year family medicine program, is dealing with the tradeoffs of training mostly during the pandemic. She went into family medicine because she values the relationships she can build with patients.

“I like seeing kids, I like seeing people my age, I like seeing older patients and being able to have that established relationship with them from birth all the way up to getting older, and kind of being super familiar with the family dynamic,” Okoye said.

Since the pandemic hit, most of the patient encounters have turned virtual and national licensing agencies don’t count virtual visits as part of the required “continuation of care” caseload. So, while Dr. Okoye and her co-residents saw many patients virtually throughout the pandemic, this work will not count toward their required residency work.

“It was frustrating, for sure. But these patients needed to be seen anyway,” Okoye said.

Because IU Health hospitals are the only hospitals in the state associated with a medical school, the number of cases trainees get to see is huge compared to many others across the country. In fact, IU surgical residency graduates typically exceed the required number of cases by a margin of up to 25 percent, Choi said, which makes her and other program directors more assured that IU residents will manage to catch up.

Pandemic politics contribute to compassion fatigue 

At the start of the pandemic doctors and health care workers were put on a pedestal and praised as heroes. As the pandemic has dragged on, public sentiment has shifted, and patient encounters have become more adversarial than before, according to Dr. Brock McMillen, the family medicine residency program director at IU.

In 2020, the attitude was: “you’re heroes, thank you for your service,” he said. And now, it’s more like: “Why’s my food cold? Work harder.”

It’s particularly hard for young trainees who are doing work they did not sign up for when they embarked on their training, McMillen said.

Prohaska said fighting to save patients’ lives isn’t even the hardest part.

One patient, who Prohaska said doctors tried “every trick in the book” to save, was put on ECMO, a machine that bypasses the heart and lungs to deliver oxygen to the blood directly, for days. The doctors knew he would not survive but the family refused to take him off the machines, which are in high demand. That meant other critically ill patients could not use them.

“The patient died. But his wife was just like, ‘it wasn't from COVID’. And I was like, ‘Excuse me? This is 100 percent COVID that did this.’ And she just didn't believe it,” Prohaska said.

The family was upset with her and her colleagues, which Prohaska said she understands to be misplaced grief.

“I do not expect them to thank me,” she said. “But I do get upset when they try arguing with me about vaccines, or, you know, asking for ivermectin when the person is maxed out on the ventilator, and we're doing everything we possibly can. Things like that insult me.”

Bosslet said lately, the ICU at IU Health Methodist Hospital has been operating at more than twice the usual capacity, and he estimates that nine out of 10 aren’t vaccinated.

It’s “to the point where we don't even ask anymore whether they're vaccinated,” Bosslet said. “And there is a level of difficulty that comes from knowing that these people didn't have to be here. So that creates a level of compassion fatigue that is very powerful.”

This story comes from a reporting collaboration that includes the Indianapolis Recorder and Side Effects Public Media — a public health news initiative based at WFYI. Follow Farah on Twitter: @Farah_Yousrym.

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