Liberty Loan Parade at Philadelphia, Pennsylvania, 28 September 1918. Naval Aircraft Factory float, featuring the hull of a F5L patrol seaplane, going south on Broad Street, escorted by Sailors with rifles. This parade, with its associated dense gatherings of people, contributed significantly to the massive outbreak of influenza which struck Philadelphia a few days later.
What are pandemics? Can they be stopped?
02:55 - Source: CNN

Editor’s Note: Dr. Mark Lieber is a former CNN Health contributor and rising first-year internal medicine resident physician at Johns Hopkins Bayview Medical Center in Baltimore, Maryland. He recently graduated from the University of California, Irvine School of Medicine and plans to focus his medical career on HIV and LGBTQ primary care.

CNN  — 

Earlier this month, I – along with 38,000 or so other medical school graduates – officially began medical residency training here in the United States.

We represent only the tip of the iceberg. In addition to first-year residents – otherwise known as “interns” – there are also thousands of other health care workers who will be joining the medical workforce this summer, including nurses, physician assistants, social workers, technicians and other indispensable members of the medical team.

Residents are physicians in the sense that we have completed medical school and obtained an M.D. or D.O. degree, but we still have not finished our training in a specific area of medicine, such as surgery, internal medicine, pediatrics or psychiatry. I once had a professor in medical school who compared new residents to stem cells: We start off as undifferentiated doctors and, through a three- to seven-year residency program, evolve into a particular type of physician with specific tools and ways of looking at our patients and the world.

Residency is a milestone that I and the rest of my colleagues have been working toward for years, or even decades. But none of us expected that we would be starting off during a pandemic.

To prepare, I reached out to a few residency program directors and other national leaders in graduate medical education. All of them stressed the fact that, even during normal times, residency is tough.

Dr. Patrick Cocks, director of the internal medicine residency program at NYU Langone Health, said the Covid-19 pandemic reminds him of his own experience as a new resident in New York City, where he began his training in July 2001.

“I was an intern at NYU during September 11th. That was a formative experience in my life as a physician and a health care worker in New York City,” Cocks said.

“But that was nowhere near the scope and scale of the Covid pandemic, the depths of which have touched our communities and impacted our training sites. [Covid] is something we cannot see, we cannot feel, and we didn’t know anything about.”

How do I make sure I’m not a burden?

While most new residents, including myself, started on or around July 1, we are actually not the first cohort to begin our training during the Covid pandemic. In at least a half dozen states, some medical schools allowed medical students to graduate early in order to join the Covid-19 response in April and May, according to the American Medical Association.

At NYU’s Grossman School of Medicine, for example, 52 medical students volunteered to graduate early in order to help their colleagues in New York’s overburdened hospitals. One of these brave volunteers is Dr. Frank Chung, who will be staying at NYU to begin his residency training in radiology.

“I trained at NYU for five years, including a research year, and I’ve really grown to love the people I work with and the community that’s here. These are the faculty and the residents who have mentored me, who have helped shape the person I am today,” Chung said. “So seeing them in distress and knowing that I could do something potentially to help them was a really big factor in terms of me wanting to help them out and contribute something.”

To provide a preview of what my life might look like, Chung described his experiences back in April.

“One of my biggest concerns was: How do I make sure that I am not a burden? How do I make sure I’m not just taking up extra PPE unnecessarily?” Chung said, referring to the personal protective equipment that keeps workers safe from infection. “I was also worried about the potential effects of getting Covid because many of us have seen people who are young and otherwise fairly healthy who have gotten very sick. So I think we all thought that there is a very real risk opting into this.”

Personally, I am frightened by the idea of having to watch someone die alone in the hospital due to the current Covid precautions, as hospitals limit visitors. Nobody should have to die alone, and I find this unfortunate likelihood to be one of the most disturbing aspects of the pandemic.

Chung echoed this fear.

“It’s challenging because a lot of these people, when they last saw their family members, they were doing okay,” Chung said. “So it’s a shock to them when you start telling them that we’re worried about your mother’s lungs or her kidneys.”

We all have different ways of dealing with death, anxiety and uncertainty. According to Chung, focusing on one positive thing each day helped him get through his first few weeks of training during the Covid pandemic.

“As silly as that sounds, I think sometimes we always just get bogged down by the things that we could improve upon,” Chung said. “But by focusing on the things that you actually did, even if it’s just having a great conversation with a family about goals of care, is something to kind of ground yourself.”

For me, meditation and mindfulness have been key to getting through tough times. But for this next challenge, I have also identified a new source of strength: remembering why I decided to go into medicine in the first place.

Remembering why we went into medicine

Unlike many of my fellow incoming residents, I jumped on the medicine bandwagon relatively late in life. When I was in my early 30s, I took a job working for the global health organization, Partners In Health, in Malawi – a country that continues to be hit hard by the HIV epidemic.

Mark Lieber and his friend and co-worker Arthur in Malawi.

About nine months into my post at Partners In Health, one of my closest local friends and co-workers – a Malawian man named Arthur – died from an HIV-related co-infection. News of his passing forced me to contemplate the many inequalities that separated his fate from mine. That easily could have been me, I thought, had I been born in a different country or at a different time.

This ultimately led to my decision to pursue a career in medicine – to work toward closing the inequalities in health care that exist both internationally and here at home.

On the surface, the HIV and coronavirus epidemics may seem very different, but the two actually share many similarities. For example, both disproportionately impact the most vulnerable among us. For HIV, it was the gay community. For Covid-19, it has been the elderly and African Americans. Reminding myself of those parallels has been an important motivating force entering residency.

Earlier this year, Dr. Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, commented how the coronavirus outbreak’s disproportionate death toll among Black Americans reminded him of HIV/AIDS largely impacting gay people.

“It was only when the world realized how the gay community responded to this outbreak with incredible courage and dignity and strength and activism – I think that really changed some of the stigma against the gay community,” Fauci said at a White House press conference in April.

“I see a similarity here because health disparities have always existed for the African American community,” Fauci added. “Yet again, when you have a situation like the coronavirus, they are suffering disproportionately.”

As someone who was still in diapers in the mid-1980s, I will never know what it was like to fight HIV/AIDS during its peak in the United States. But Fauci’s words remind me that, even with Covid, we are still engaged in a similar fight – a fight against health inequality that goes much deeper than either of these two viruses alone.

A pandemic of well-being issues

In addition to identifying our own personal sources of strength, there are many things that hospitals and training programs can also do to help new trainees transition to this next phase of their career.

We’ll be learning how to navigate a new hospital and electronic medical record system – and now, there’s more emphasis on protecting ourselves, our patients and our loved ones from the coronavirus.

According to Cocks, learning how to properly put on and take off personal protective equipment – otherwise known as “donning and doffing” – should be a top priority for new residents. It’s not as easy as washing hands and slipping on a mask.

“From the clinical perspective, we want to ensure the safety of our incoming residents in the potential care of Covid patients. So ensuring that they are competent in donning and doffing, ensuring that there is a structure of supervision around that so that they all have donning and doffing buddies and are comfortable with that process, and ultimately demonstrate competence before they’re doing it individually,” Cocks said.

The challenges brought on by Covid are not only unexpected, they are unprecedented. The last time we saw a global pandemic of this magnitude was in 1918 – long before most residency programs were even established in the United States. And the case numbers in the United States are continuing to rise, breaking records for cases and hospitalizations in some parts of the country.

So to all the other health care workers who are joining the ranks of hospital staff this month: If you are feeling a little anxious right now, rest assured that you are not alone.

“I think for any new resident, the beginning presents sort of a daunting challenge for them. But then to add to it the learning environment in the middle of a pandemic, I think it really heightens that sense of anxiety,” says Dr. John Combes, Accreditation Council for Graduate Medical Education chief communications and public policy officer.

“We are encouraging programs to pay very close attention to the well-being of these resident physicians,” he added.

Combes warned that another kind of pandemic could follow if we aren’t proactively caring for health care workers now.

“There’s going to be a pandemic of well-being issues in health care workers, including residents and fellows, that will parallel the [Covid] pandemic unless we begin to address it now and into the future, even after the pandemic is over,” Combes said.

“We feel it’s very important that residents receive adequate rest, particularly in an area when they need to be paying close attention to infection control practices and the use of personal protective equipment. So that’s our number one concern.”

Some residency programs have been granted a status that allows them more flexibility with residents during the pandemic. It means different schedules and moving physicians to high-needs areas, such as the ICU.

Chung, the rising first-year resident physician at NYU, says that these changes helped him transition to his first few weeks of residency life.

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“Even though things can be kind of busy, they’ve invested in seeing me grow as a physician and that has been a tremendously helpful experience,” Chung said.

“Now that it’s in the rearview mirror, I’m just super happy that I got this experience because, you know, I got my feet wet. I now have this whole list of things that I want to review before (the official start of residency),” Chung added. “And I know that once I actually hit the floors, I will be better prepared.”

Years ago, when we all first started on this journey towards becoming a health care provider, the medical landscape looked much different than it does today. Now, as the Covid pandemic continues to unfold, it is more important than ever that we remember why we were drawn to medicine.

As residency gets underway, I keep reminding myself that, despite these new challenges, we are still engaged in an older and much larger fight – a fight to provide adequate health care to all regardless of age, gender, race, ethnicity, sexual orientation, disability status, socioeconomic status, political party or any other factor that makes us different.

That – and the hope for a better tomorrow – should help us get through these difficult and unprecedented times.