The Covid-19 pandemic has been extremely hard on everyone in the medical field. Experienced professionals have their hands more than full with sudden patient deaths, hospital overflows and supply shortages, but it’s also been very hard on nursing students, residents, fellows and recent graduates just entering the field, who have been forced to alter the expected trajectories of their training and education, for at least the foreseeable future.
“I got two days of non-Covid orientation,” said a recently-graduated I.C.U. nurse who began her first nursing job in Illinois at the end of February. “Then our first Covid patient rolled in and all the rules got thrown out the window; we had to learn new roles right away.”
As the urgency of the pandemic rose and the number of infected patients grew beyond what many hospitals were equipped to handle, doctors, nurses and trainees alike, from all different fields of medicine, were obligated to abandon their traditional roles — in work and in training — to focus primarily on Covid patients.
“I think the impact of the Covid crisis on residency and fellowship training is a main area of concern for some residents and fellows,” said Dr. Saadia Akhtar, the associate dean for trainee well-being and resilience in the Office of Well-being and Resilience at the Icahn School of Medicine at Mount Sinai in New York in a recent phone interview.
“Many [residents and fellows], depending on the specialty they’re in, were redeployed from their home residency or fellowship program to other areas of the hospital in order to help and assist with taking care of Covid patients. It is an area of concern, both from an educator standpoint, and from a trainee standpoint, because this has impacted what their routine training would have been like. The question then arises — how do we compensate, how do we make sure that [these trainees] continue to have the experiences that they’re supposed to have during normal times?”
Some healthcare workers still in training are worried that they may have to extend their training periods in order to meet the specific requirements of their programs that they have had to forego during this crisis, a harrowing thought. Dr. Akhtar, however, is optimistic that this will not be the case for most.
“I think that there is an opportunity for the educators and for the program directors to alter their schedules,” she said. “For example, if there’s a need for that individual person — whether that’s changing a rotation, implementing a new initiative, or incorporating something within the didactic curriculum — I think in most cases there’ll be an opportunity to make up for that loss to the point where they will not need to extend their training. I think the main concern is making sure that things that should be done get done.”
Required training left incomplete, and job hunting difficulties
Some students, earlier in their training processes, have had to switch to online learning, and have been restricted from hospitals and medical clinics. This is both unsatisfactory and worrisome, especially when taking into account the in-person clinical hours required for certification.
“Before you go on to your clinical rotations we have certain skills we have to do in person,” said a physician assistant (P.A.) student at a Midwestern school that switched to online learning for much of the past semester. “We did a condensed format, and just finished all those skills in one day. Probably only a third of students, including myself, were able to go out for clinical rotations, because so many sites were not letting students back.
“The clinical staff had to literally beg hospitals and clinics to let students in for even just a couple of days so they could get their required [in-person] encounters,” she said in a phone interview.
Some schools have indeed had to postpone graduation as their students were simply unable to complete their required in-person experiences in time. Thus far, the school of this P.A. student has not had to delay graduation, but this will remain dependent on how things pan out in the fall.
The P.A. student also described how her obstetrics and gynecology rotation was cut short because of restrictions and a lack of patients. She will have to pick up missed experiences and encounters in her next rotation, which is surgery. “I do think that this whole experience has significantly affected my decisions to do residency or fellowship program after I graduate so that I can get more education to make up for what I might have missed,” she said.
The pandemic is also affecting future job prospects and creating a great deal of anxiety for students and trainees.
“This is really impeding our learning, and our ability to get out there and get experience,” the P.A. student said. “Everyone I’ve talked to is still enthusiastic about going into care, but we’re nervous about the obstacles that are going to be in our way when we graduate. A lot of people are getting furloughed across the country because of Covid. Things are kind of starting to pick up again, but I wonder where people are going to be in their hiring processes. A lot of hospitals are losing a lot of money right now. I just don’t know where or if we’re going to be able to get jobs next year, or if we’ll be able to get jobs in the fields that we want.”
Another major factor affecting healthcare workers (both trainees and professionals alike) is the psychological trauma brought about by fighting on the front lines of a pandemic. Nurses and physicians can be exposed to many traumatizing experiences under normal circumstances. During a pandemic of this scale, where patient numbers skyrocket and resources are spread thin, the amount and intensity of these traumatic experiences are greatly amplified.
Since the onset of the pandemic, high percentages of physicians and nurses around the world have been experiencing symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD). During other major traumatic events, such as Hurricane Sandy in New York, healthcare workers dealt with one fixed event, and a finite period of fallout afterwards.
The Covid pandemic, however, is not finite, and stretches on into an uncertain future. “I think the issue with Covid,” Dr. Akhtar said, “is that we need to adjust to living in the new world. This is not easy to do.”
In an article for The Conversation, Dr. Karen J. Foli, author and associate professor at the Purdue University School of Nursing, described some of the different types of traumas that healthcare professionals can experience during their regular work. The article focused primarily on nurses, but these types of traumas can be experienced by any in the healthcare field.
These traumas include insufficient resource trauma, which “occurs when [healthcare workers] don’t have the staff, supplies, knowledge or access to other professionals to fulfill ethical or professional responsibilities,” and secondary or vicarious trauma, which occurs when a healthcare worker “fully engages with the patient and co-experiences suffering.”
Insufficient resource trauma has certainly been occurring on a mass scale, as hospitals and health clinics across the country have been facing staffing shortages and extreme lack of equipment and resources since the very beginning of the pandemic; some still are to this day.
Numerous healthcare workers were initially given inadequate personal protective equipment (P.P.E.)., leading to outbreaks of Covid and even deaths amongst hospital staff. Many healthcare workers feared going to work every day, and then feared returning home because they might be jeopardizing the safety of their families.
Which patient has the best chance to survive?
Resource shortages have also put healthcare providers in extremely difficult situations of having to limit resources to patients deemed most likely to survive, and to stretch themselves thin caring for multiple unstable patients at a time with insufficient numbers of staff.
“It’s honestly doing a disservice to the patients,” a young New York emergency room nurse said in a recent phone interview. “It is so unsafe. But we had no choice.” She went on to describe a harrowing night in the E.R. where a staff of 15 nurses were faced with 155 (primarily Covid) patients, and where doctors had to choose which patients they thought had the best chance of survival to receive further care because the hospital did not have the resources to provide high flow oxygen to everyone. You can read more about this nurse’s experiences here.
Situations like this go against the very nature of the medical profession, which strives to provide the highest quality of care to all patients, and Dr. Foli wrote that she believes that such experiences can damage a healthcare worker’s sense of morality. Studies have shown that a damaged sense of morality can lead to increased rates of depression and P.T.S.D. symptoms.
Ways that hospitals can help
Fortunately, it does seem that some hospitals across the country are taking into account the difficult experiences healthcare professionals and students are undergoing. The Icahn School of Medicine at Mount Sinai has created the Mount Sinai Center for Stress, Resilience, and Personal Growth as a direct response to the psychological toll of the pandemic on its healthcare workers and students.
“We know that our staff has been working at an intensity level so stressful that many will likely suffer mental health consequences,” the center’s website says. “Previous studies of disaster responders indicate that they are at elevated risk for developing post-traumatic stress disorder (PTSD), depression, alcohol misuse, anxiety, and burnout. The goal of the Center for Stress, Resilience, and Personal Growth is to help our workers recover and even become more resilient, helping to ensure the future of our healthcare system.” The center focuses on clinical care — including mental health screening, resilience training, and referrals for mental health care — as well as outreach, education and research.
Despite the horror of this time, there are some small silver linings. For example, a switch to online learning has made it more possible for students to take part in lectures and conferences with nationally known speakers, who would otherwise have been constrained by travel times and arrangements.
Restricted hiring processes and a need for specific roles to be filled have led some healthcare workers to take on new positions and learn new skills that they never otherwise would have tried – in some cases to a positive effect. (Read our story here about an occupational therapist who, due to Covid-related hiring restrictions, was forced to take a job at a nursing home, and learned to love it.)
There is not yet data on how the trauma and uncertainty of the pandemic will affect individuals just starting out in their careers, but it can be assumed that this experience is largely damaging.
Happily, a great many students and young medical professionals are focusing on resilience and learning to take things in stride, and they have not yet been deterred from continuing work in the medical field. If hospitals and people across the country can adopt this attitude and focus on supporting and promoting the long-term well-being of healthcare workers during this difficult time, negative psychological effects may in some way be mitigated.
One freshly graduated Midwestern I.C.U. nurse said she and her co-workers have been staying motivated by exploring new and relevant interests, including an excited interest in infectious diseases and research since the pandemic’s inception. She also mentioned that she and her co-workers have been learning to prioritize mental and personal health, as well as setting personal boundaries with their work where they can; after weeks of working four or five 12-hour shifts a week, she is now limiting the number of shifts she takes a week in order to avoid burnout and negative psychological effects.
“We are exhausted,” she says, “but most of us are definitely inspired.”