At least half of medical education is accomplished in clinical rotations, where medical students learn the practice of medicine from supervising physicians. In recent days, some medical schools have begun canceling rotations in the face of a growing pandemic. The halls of my own school have been abuzz with conversations of deans and students alike about how a medical school must operate during an outbreak.
In addressing some of these concerns, the Association of American Medical Colleges (AAMC) has recognized that students are “members of the heath care team and can provide meaningful care,” but that schools may simply be unable to coordinate clinical experiences.
Like many medical students, I am concerned about COVID-19 and feel strongly that we ought to be on the wards to help out where we can. As the AAMC acknowledges, medical students can contribute to patient care; along those lines, there are good arguments that we ought to be allowed to do our part in combating COVID-19. However, staying home may help decrease the potential spread of COVID-19 through social distancing, helping to “flatten the curve” and keep the number of cases below the health care system’s capacity. Regardless of which argument is more compelling, our effect as potential helpers — or vectors — is limited by the fact that there are relatively few of us compared to the massive numbers of essential or soon-to-be-essential medical personnel that will be needed at work in the coming months.
While we must evaluate the risks and benefits of our options, our decisions about clinical education during a pandemic must be driven by an understanding of what it means to be a medical student. The coming months may culminate in a defining moment for the U.S. health care system; the same may be true for medical education. Are medical students learners, whose duty is to knowledge, or trainees, whose duty is to patients? I firmly believe that as a so-called “student physician,” my ethics ought to err on the side of physician rather than student.
For a physician, there is a clear and historic obligation to care for patients in the face of personal risk. The AMA Code of Medical Ethics states that “individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life.” As students, we do not yet have the power of our physician teachers, and as such, many would argue that such obligations do not pertain to us. It is not just the power of physicians, but rather their calling, that demands such obligation.
Dr. Farr Curlin, a palliative care physician and a mentor of mine, taught me about such a calling. He knows what the practice of medicine looks like when we reach the end of our ability to “fix” our patients. At times, the power of medicine fails. When a physician provides care to the patient who cannot be cured despite the best effort of human technology and biomedical science, this is still medicine, and physicians are still obligated to care. Even still, there are times when a physician is limited in her ability to care, and there is nothing she can do but to be present with the patient in the midst of suffering. Such moments reveal the calling at the heart of medicine — attending to suffering.
I cannot yet care or cure in the way that my teachers can, but I share this calling to attend to suffering. As a student, my attention is often the best thing I can give, and it can even make a critical difference in care when I have the time and energy to discover a patient’s needs that might not otherwise be communicated to my teachers. This call to attention will not disappear in the face of COVID-19. Instead, it will be amplified as a large portion of the population may suffer from the disease and its sequelae. Even though we medical students are not yet physicians, when the health care system operates at its capacity, our calling — and thus our obligation to care — should be even more clear. I only hope that our schools will allow us to step up and respond to it.
After all, this is what I signed up for when I entered medical school. I did not expect to learn medicine under only ideal conditions. On the contrary, as a medical student in Miami, I expected that I would learn medicine from some of the most vulnerable and remarkable patients that might need care in a U.S. hospital, many with tuberculosis, HIV and any number of other communicable diseases that disproportionately affect our population. It will be my duty to care for such patients as a future physician; if I do not learn now, when will I learn?
The AMA Code of Ethics has more to say about obligations during disasters, so that “when providing care in a disaster with its inherent dangers, physicians also have an obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future.” If we also extend this obligation to apply to students, some will see grounds for keeping students off rotations out of concern for their safety and ability to provide future care. Instead, I see it as an obligation to continue our clinical education for the safety of our future patients.
We who enter the field of medicine do so knowing that we may need to care for patients at the risk of our own personal health. We do not deny care to a patient with HIV or hepatitis C whose virus might be transmitted in the event of a needlestick. We do not shy away from the care of patients who have the flu or other infections that might lead to our own morbidity or mortality.
Regardless, based on the current evidence for the disease epidemiology, my classmates and I are at comparatively low risk. According to the AAMC, the average age of U.S. medical students upon matriculation is 24 years old, and most students complete their program within four years. Looking at Chinese data on COVID-19 epidemiology, only 8% of cases occurred in patients aged 20-29, and only 3.8% of cases occurred in health care personnel. Looking further into the data, the case fatality rate was 0.2% in 20-29 and 30-39 year old patients, and 0.3% in health care workers.
If these disease trends hold true in the United States, the results may be disastrous to be sure, but as a healthy 28-year-old, I am not fearful for my own life and health but fear more for the many patients who are at increased risk, namely those who are older or who have underlying health conditions. These patients will experience lasting effects of the disease, as will many others who may be triaged away from care as hospitals fill up. Today’s acute problems will become chronic, and chronic problems left unattended will eventually become acute.
Such fallout of a global pandemic may last for years and will be compounded by looming physician shortages. Next year’s medical interns need to be ready for an overloaded system, to be prepared by a medical education that is adapted but not compromised. We will need the grit that comes from attending to our patients’ suffering in the face of a pandemic.
Ultimately, this is the best argument for why medical students must be allowed to participate in clinical care: we must be ready for whatever comes next. Canceling rotations or restricting patient contact now will not suffice, because the threat of COVID-19 will not pass within weeks. We have already seen the disease affect China for months, and some reasonable calculations suggest hospitals could reach capacity in May or that a peak of new cases might only be reached in August. If we do not continue training now, how will next year’s physicians be adequately prepared to provide care in the future?
One of my professors, Dr. Jeff Brosco, likes to tell students that we have signed up for a profession that demands we run toward a fire, and not away from it. We might just be students, but the direction we run matters.