Hope is around the bend

Casey P. Schukow
Michigan State University College of Osteopathic Medicine

Recently, I saw some images;
I almost couldn’t comprehend;
But then I paused and had a wondrous thought;
That hope is around the bend.

It was of many cheering fans, who filled the stands;
At the PGA Championship, and Indy 500 race;
Over Memorial Day weekend, I realized;
That hope is in a not-so-distant place.

Since March of 2020, COVID-19;
Swept through our nation in a vicious rampage;
Cases and deaths climbed out of control;
Locking hope away in a cage.

Families were torn and masks have been worn;
To slow this virus’s spread;
But as vaccines take effect, I must recollect;
That hope has been brought back from the dead.

It seems we are turning a corner;
In a fight which appeared lost and wizen;
Seeing the faces of those jubilant fans;
Proved to me that hope is on the horizon.

Attending medical school throughout this pandemic;
Has been a unique experience, nonetheless;
As quarantines, and lockdowns, and potential exposures;
Put my sense of hope to the test.

There have been many days, I must admit;
This pandemic left me beaten and bruised;
But staying connected with my peers and loved ones;
Kept hope alive in the news.

While this pandemic is far from over;
Signs are apparent that one day it will end;
So let’s continue to rejoice, fight, and be patient;
Because hope is around the bend.

Please Ignore the Mask—Relearning the Patient Interview in the Age of COVID-19

Peter F. James1
1 Warren Alpert Medical School of Brown University, Providence, RI 02903, USA

ABSTRACT

The COVID-19 pandemic has changed the patient interview. In the context of personal protective equipment and social distancing guidelines, the development of therapeutic alliance proves more difficult than ever. As a new third-year medical student who is experiencing meaningful clinical work for the first time, the challenge of establishing rapport with patients is particularly great. Nonverbal communication is both essential and at risk of being lost in the current clinical environment. It is the author’s concern that the pandemic has rendered body language—both learned and instinctual—at best muffled and at worst impracticable, and that providers must explore unconventional ways to connect with patients. Use of humor and increased time spent at the bedside, amongst other strategies, represent potential solutions to this problem.

Nonverbal communication in the medical setting is a carefully choreographed dance, one in which two partners, physician and patient, exchange meaning through subtle—often imperceptible—physical cues.

As medical students, we learn this dance through direct and explicit instruction from our supervisors. On camera, in simulated clinic rooms with professional patient-actors, we are assessed on our ability to enter a room swiftly but with appropriate warning (a gentle knock, unmistakable but not jarring); wash our hands while facing our patients (to communicate openness); initiate a firm handshake at the right time and with good eye contact; sit down not too close, not too far, all while armed with a wide smile (but not too wide, for fear of appearing inauthentic). Body language is unquestionably instinctive, learned organically through life experience and social development, but the medical school curriculum enhances and reinforces it, thereby making its performance more intentional.

Much of the ‘meat’ of interpersonal communication comes in the space between the words. This third space, unoccupied by either party’s verbal contributions, is populated instead by facial expression, posture, eye contact, arm and hand movement, and physical positioning. These signals are understated and often difficult to identify directly, but through their subconscious interpretation carry great meaning. A nod and unbroken stare say, “I hear you.” An appropriate touch on the arm or shoulder says, “I understand and support you.” Studies have consistently demonstrated that nonverbal communication has a direct effect on patient outcomes. Maintaining eye contact and a respectful closeness in space conveys warmth and attention, and has been shown to increase patient satisfaction [1], [2]. One review of the literature found that nodding, smiling, leaning forward, making respectful contact, and maintaining symmetrical arm position with uncrossed legs were all associated with improved therapeutic alliance between physician and patient [3]. In short, these seemingly trivial acts are anything but—in fact, they play a foundational role in the development of rapport and conveyance of empathy in the medical setting.

I recently finished my first clinical rotation as a third-year medical student: four weeks in a primary care clinic in Pawtucket, Rhode Island. For many medical students like me, the COVID-19 pandemic has provided an opportunity to witness and contribute to a healthcare system stretched to its limits. When I received my ceremonial white coat two years ago, I never considered that my first days of meaningful clinical work would take place in the midst of a global health crisis. The level of flexibility and teamwork on display every day amongst my colleagues is indicative of medicine’s resilience and ethical foundation, the belief that every patient deserves our full effort regardless of the circumstances.

Yet, despite all of our best efforts, it is undeniable that something essential is missing in this new normal. Fresh out of our didactic sessions and simulated patient interviews, students like me are vexed by the challenges of patient interaction in the pandemic. We are painfully aware of how much of our training in nonverbal communication seems impracticable in the current version of clinical practice. White coats and dress clothes are traded for scrubs, gowns, face shields, masks, and gloves. Greetings are offered with nervous waves, muffled words, maybe a mutual bump of the elbow—handshakes are out of the question. Eye contact is made through fogged plastic. Histories are taken, lab results given, good and bad news delivered, all from a safe yet impersonal six-foot distance. Smiles and grimaces stay hidden under blue fabric. That ‘third space’ of communication, once occupied by body language, has been both physically widened and filled with barriers, material and psychological. In short, the nuanced language we learned as preclinical students feels like a forgotten dialect, no longer spoken.

Perhaps this issue is less of a concern for attending physicians, whose experience may allow them to build therapeutic alliance in ways difficult for new students on the wards to replicate. As medical students, we are faced with the task of re-learning the art of the patient interview in a fashion that contradicts both our instruction and our long-held instincts about how to connect with others. It will take time to develop this skill; both patient and provider will need to acknowledge the necessity of learning this new language together, on the fly.

Patients seen in the hospital setting typically experience some level of anxiety associated with their medical condition; these days, that anxiety is often heightened by the concern for potential exposure to the virus while seeking care. Injecting humor, even in the form of a simple joke or quip, into the patient interview may help cut the tension and relieve some of this stress. Acknowledging the strangeness of the situation, laughing about—but not downplaying the importance of—the masks and gowns and shields and gloves, can help minimize the negative effects of those material barriers on caregiver-patient relationships. Studies have suggested that appropriately-used humor can communicate caring and foster interpersonal connection between physician and patient [4]. Across a diversity of different clinical settings including primary care, palliative care, and rehabilitation medicine, humor has been shown to have a positive effect on patient-provider relationships and even health outcomes [5–7]. It is important to recognize, however, that not all patients or situations are equally amenable to humor. Sarcastic or offensive humor have no place in the patient interview and are likely counterproductive to the goal of establishing therapeutic alliance.

When social distancing and layers of personal protective equipment diminish the power of nonverbal communication, the words that are spoken—as well as their tone and volume—attain heightened importance. With kind or compassionate facial expressions obscured by masks, empathy must be conveyed in more explicit fashion through our language. Speaking loudly enough to be heard clearly through face coverings is a simple yet essential component of effective communication in our new clinical reality. Without body language, more words may be required to convey the same meaning; in order to avoid leaving our patients feeling unheard or unsupported, this may mean extending the length of time spent at the bedside. Even the action of chatting for an extra minute about something other than their health—the weather, the news, how they are coping with the pandemic—can help patients feel that they have been given adequate time to express their concerns and have their questions answered. Despite our busy schedules as medical students, we often have more time to spend in direct contact with our patients than the resident or attending physicians. Directing our extra time—a scarce resource in medicine—toward increased patient interaction and improved therapeutic alliance may be the most meaningful way for medical students to contribute to the fight against COVID-19. 

In some hospitals, clinical staff are taking a creative approach toward fostering personal connections with their patients. A burgeoning movement called “Share Your Smile” encourages masked students and healthcare workers to tape large, laminated photos of their cheerful faces to the front of their gowns in an effort to put patients at ease. With limits on visitation, video calls are increasingly being used to combat patient isolation and allow for shared conversation and decision making between patient, family, and physician. Newly designed negative pressure respirator helmets being introduced in some hospitals may look like props from a science fiction movie but allow for full view of one’s face by making traditional masks unnecessary.

Now more than ever, our patients are lonely, scared, and in need of human interaction and support. Whether wrestling with the virus or another medical issue, they are confronted with strict visitor restrictions, a tense clinical environment, and a lack of meaningful contact with others. As medical students during the COVID-19 pandemic, we can play a meaningful role in improving our patients’ experiences with healthcare. We must demonstrate our empathy, even if by strategies at odds with our natural instincts and untaught by our pre-pandemic medical school curricula.

REFERENCE

  1. Mast MS. On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns. Published online 2007. doi:10.1016/j.pec.2007.03.005

  2. Henry SG, Fuhrel-Forbis A, Rogers MAM, Eggly S. Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis. Patient Educ Couns. Published online 2012. doi:10.1016/j.pec.2011.07.006

  3. Pinto RZ, Ferreira PH, Ferreira ML, Maher C, Oliveira VC, Franco MR. Which verbal and nonverbal communication behaviours influence the therapeutic alliance between patients and health practitioners? systematic review of the literature. Physiother (United Kingdom). Published online 2011. doi:10.1016/j.physio.2011.04.002

  4. Bennett HJ. Humor in Medicine. South Med J. Published online 2003. doi:10.1097/01.SMJ.0000066657.70073.14

  5. Schöpf AC, Martin GS, Keating MA. Humor as a Communication Strategy in Provider-Patient Communication in a Chronic Care Setting. Qual Health Res. Published online 2017. doi:10.1177/1049732315620773

  6. Scholl JC, Ragan SL. The use of humor in promoting positive provider-patient interactions in a hospital rehabilitation unit. Health Commun. Published online 2003. doi:10.1207/S15327027HC1503_4

  7. Ridley J, Dance D, Pare D. The acceptability of humor between palliative care patients and health care providers. J Palliat Med. Published online 2014. doi:10.1089/jpm.2013.0354

Shifting Scope, Maintaining Mission: Supporting Community Members Experiencing Homelessness during COVID-19

William Doak1,2 and Neha G. Reddy, MPH1,2
1 The Rhode Island Medical Navigator Partnership, Providence, RI 02903, USA
2 Warren Alpert Medical School of Brown University, Providence, RI 02903, USA

Correspondence concerning this article and requests for reprints should be addressed to William Doak (william_doak@brown.edu)

ABSTRACT

COVID-19 continues to pose a threat to the wellbeing of communities across the country, including communities experiencing homelessness. In an effort to support unhoused and underhoused community members in Rhode Island, the Rhode Island Medical Navigators Partnership (RIMNP), a collaboration of medical students, social workers, healthcare practitioners, and housing-insecure community members, has sought to expand its scope in response to acute needs presented during the pandemic. Since March of 2020, RIMNP has increased collaboration with House of Hope—an organization of advocates working to prevent and end homelessness in Rhode Island, coordinated weekly grocery and meal deliveries to families experiencing food insecurity, helped community members fill out economic impact forms for stimulus checks and to apply for government-subsidized cellular phones, and advocated for a “housing first model” to better support the immediate needs of unhoused communities. The lessons learned during this pandemic highlight the increasing need for national conversations about housing insecurity as a fundamental structural determinant of health.

The Rhode Island Medical Navigator Partnership (RIMNP) is an interdisciplinary program that seeks to address inequities affecting people experiencing homelessness in Rhode Island. Teams of housing-insecure community members, social workers, medical students, and physicians form the core units of the organization, engaging in street outreach, health-systems navigation, and social support [1]. While a majority of RIMNP’s work occurs by way of in-person encounters among team members, COVID-19 physical distancing restrictions have hindered much of this interaction. In an attempt to continue its structurally-informed approach to reducing health inequities associated with homelessness, RIMNP has adjusted its focus towards addressing food and economic insecurity experienced by community members as well as continuing advocacy in support of social housing, a term used in this essay to evoke social justice principles when referring to public measures that attempt to house and support those experiencing housing insecurity. In the era of COVID-19 and physical distancing, RIMNP strives to mitigate the social burden of the current moment on those experiencing homelessness. 

Community members experiencing homelessness continue to encounter challenges arising in part from institutional and governmental attempts to limit the spread of COVID-19. As journalists and social critics have already noted, stay-at-home orders take on a different meaning when stable housing is not in the picture [2-4]. For some folks, housing might look like a nook that fits a mattress behind a barbershop’s back alley, and -- when the weather gets really rough -- the floor of a neighborhood friend; for some, it’s a shelter; for others, it may take the form of an extended-stay motel or “transition housing” in-between benefit applications [5,6]. Even for those in the community with housing, reduced bus schedules and shuttering of state offices have rendered the systems that once helped secure food and other social services inaccessible. Less formal means of support have also evaporated: stay-at-home orders marked the closure of many meal sites, and fewer cars on the road means less money given to people who panhandle to make ends meet.

The depth of the health consequences associated with housing insecurity already indicated a need for interdisciplinary health-system navigation and structural reforms both locally and nationwide; COVID-19 has further confirmed the urgency of this need. While the logistical challenges that come along with physical distancing have certainly shifted the trajectory of RIMNP’s endeavors, these shifts have resulted in more collaboration with agencies outside of RIMNP’s immediate circle of affiliates. Amidst calls to eliminate all face-to-face contact, RIMNP leadership decided that shrinking operations would ultimately counter the organization’s mission and responsibility to the community.

In response, RIMNP began to partner more closely with House of Hope (HoH), a Rhode Island-based organization with a mission to prevent and end homelessness in the state and to end the personal and social trauma of homelessness. HoH’s team of outreach workers and case managers has continued to provide essential services throughout the pandemic. A core aspect of the organization’s work is conducting street outreach, during which outreach workers engage unsheltered persons, offering support and linkage to services. This work continues with COVID-19 modifications like wearing masks and badges to show essential-worker status and disseminating hand sanitizer and other basic needs to members of the community. Furthermore, HoH staff members have played a key role in supporting community members sheltering in hotels during COVID-19 in order to contain the spread of disease and deconcentrate shelters.

In conversations with HoH, folks experiencing homelessness, and those who have been recently housed, it became clear that food insecurity has cast an ever-broadening shadow during this pandemic due to skyrocketing unemployment rates, overburdened food banks and meal sites, and quarantining guidelines that make it challenging for people with chronic medical conditions to purchase food [7]. In partnership with HoH, RIMNP began a project to purchase, organize, and distribute bags of groceries and frozen meals to folks who are currently housed by the state or who have underlying medical conditions and are unable to go grocery shopping. These “weekly meal subscriptions” have been made possible by community donations, and, in total, 18 individuals have found alimentary support through RIMNP.

In addition to food insecurity, accessing government stimulus payments has also proved burdensome. Those who did not file taxes in 2018/2019 or who do not receive SSI or SSDI benefits must fill out a form on the IRS website in order to be eligible to receive a check. This process represents a major barrier for people who have difficulty using or accessing smartphones and computers. Therefore, RIMNP volunteers have been helping fill out economic impact payment forms over the phone; however, the reality that many individuals in the RIMNP network do not have reliable access to a phone constrain simple, tangible efforts to connect community members to resources--a sizeable hurdle given that adherence to physical distancing measures depend heavily on phone communication. In response, a few RIMNP teams purchased government-subsidized phones to facilitate social support or care-coordination. As the pandemic continues to evolve, RIMNP’s role and place as an organization will as well, reflective of the cumbersome landscape unhoused communities must continue to navigate. These changes further reinforce RIMNP’s foundational priority around combating high rates of social isolation through meaningful, longitudinal relationship building.

Certain innovations implemented during COVID-19 give a taste of what life could look like after the worst of this pandemic subsides. By revamping access to alternative shelter options and supplying more sanitary fixtures to individuals living in “tent cities” or other alternative dwellings, cities across the country have demonstrated the capacity to adapt systems to fit the immediate needs and daily realities of the homeless community. Advocates have also noticed advancement towards a “housing-first model” in which housing systems accommodate in-need community members without traditionally requisite “means testing” or other bureaucratic hurdles. Country-wide, there is increasing support for these measures outside of the housing-advocacy community, notably amongst healthcare workers concerned for housing-insecure patients recovering from hospitalization. As governments continue to wrestle with the socio-economic fallout of COVID-19, they have the opportunity to continue the push towards social housing to better address the needs of community members experiencing chronic homelessness beyond the scope of the pandemic [8].

These proposed solutions are not without their own share of questions. How can we ensure that folks who may be eligible for social housing maintain their autonomy in the decision-making process? How can we work to decommodify the housing market under the principle of housing as a basic right in an effort to avoid positioning social housing as means of removing the “eyesore” of homelessness? How can we support the economic stability of folks who are housing-insecure? Most fundamentally, how do we rebuild systems to center the voices of those most marginalized as valued and integral members of our communities?

The lessons learned during COVID-19, including the importance of inter-agency collaboration, the willingness to dynamically reimagine organizational scope while staying true to purpose, and the focus on community accessibility, will inform RIMNP’s efforts ahead. Ultimately, COVID-19 has shown the need for an ongoing, robust national conversation about housing insecurity as a structural determinant of health beyond hindering the spread of novel coronavirus. Whether and how these efforts will continue prove among the most pressing questions to come of the current moment’s revitalized emphasis on collectivism.

REFERENCE

  1. Smith M, Sharma PJ, Dressler G. Up from the Streets: The RI Medical Navigator Partnership as a Model of Structurally-Informed Service, Education, and Advocacy. R I Med J. 2019;102(5):33-36.

  2. Stein J, Jan T. Fears mount about impact of coronavirus on homeless. Washington Post. Published March 15, 2020. Accessed April 27, 2020. https://www.washingtonpost.com/business/2020/03/15/fears-mount-about-impact-coronavirus-homeless/

  3. DeParle J. The Coronavirus Class Divide: Space and Privacy. The New York Times. https://www.nytimes.com/2020/04/12/us/politics/coronavirus-poverty-privacy.html. Published April 12, 2020. Accessed April 27, 2020.

  4. Griswold E. How Do You Shelter in Place When You Don’t Have a Home? The New Yorker. Accessed April 28, 2020. https://www.newyorker.com/news/dispatch/how-do-you-shelter-in-place-when-you-dont-have-a-home

  5. Fuller T. Coronavirus Outbreak Has America’s Homeless at Risk of ‘Disaster.’ The New York Times. https://www.nytimes.com/2020/03/10/us/coronavirus-homeless.html. Published March 10, 2020. Accessed April 27, 2020.

  6. Belkin D, King K. Coronavirus Threatens to Overwhelm Cities’ Social Safety Net. Wall Street Journal. https://www.wsj.com/articles/coronavirus-threatens-to-overwhelm-cities-social-safety-net-11585474200. Published March 29, 2020. Accessed April 27, 2020.

  7. Bhatt J. More than a disease, COVID-19 exposes health risk of food insecurity: OPINION. ABC News. Published April 26, 2020. Accessed May 9, 2020. https://abcnews.go.com/Health/disease-covid-19-exposes-health-risk-food-insecurity/story?id=70349076

  8. Kim C. It took a pandemic for cities to finally address homelessness. Vox. Published April 21, 2020. Accessed April 27, 2020. https://www.vox.com/2020/4/21/21227629/coronavirus-homeless-covid-19-las-vegas-san-francisco

Physical Inactivity Crisis & the COVID-19 Pandemic: Time is Now to Implement Exercise as Medicine in Medical School Teaching

Nathan McLaughlin, BS1, Trevor Takami, BS1, and Cindy Lin, MD, FASCM1,2,3
1 University of Washington School of Medicine, Seattle, WA 98195, USA
2 Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA 98195, USA
3 The Sports Institute, University of Washington Medical Center, Seattle, WA 98195, USA

ABSTRACT

Although there is robust evidence that physical activity (PA) is integral in preventing and managing chronic diseases, 80% of American adults do not meet the US Physical Activity Guidelines for exercise and 66% of American children are physically inactive every day. Clinicians are critical in assessing and prescribing PA for patients; however, less than half of patients reported being counselled on PA in a 12-month period. A PA focus is even more crucial due to COVID-19, as it creates new barriers to PA and individuals with chronic medical conditions are most vulnerable. Now is the time to address population health by educating medical students that exercise is medicine. 

We suspect the main issue is the lack of exercise as medicine education in medical training, with more than half of students receiving no formal education on exercise and physicians frequently citing decreased knowledge as a barrier to discussing PA with patients. Evidence suggests education improves provider’s comfort prescribing exercise to their patients. We argue that PA education is imminently needed considering COVID-19 further contributes to sedentary lifestyles (e.g., gym/school closures, working from home). There are both current and downstream effects of the pandemic and with PA education, clinicians can mitigate the physical inactivity crisis.

We propose three recommendations for addressing PA in medicine: 1) implement PA education into required medical school curriculums, 2) create resources for patients who have significant barriers to PA and, 3) promote medical student wellness to increase the likelihood that they discuss PA with patients.

As medical students, many of us are entering back into the clinical setting after months off due to the COVID-19 pandemic. At this point, everyone’s life has been affected by COVID-19 in some way. Upon speaking with patients shortly after returning to clerkships, one of the themes I noticed was how their exercise routines have been interrupted. For example, a patient with abdominal pain, who stated that prior to COVID-19 he was an avid swimmer but has not been able to swim since his community pool has closed. Or another, who was experiencing heart palpitations, said that he would go to the gym daily after work because he enjoys weight training, but now does not exercise because he does not have weights at home. As a student, I had previously felt ill equipped to address exercise plans with patients, and now with life being changed, supporting patients in staying physically active will be even more challenging and important than ever.

Physical activity (PA) is well known to be both effective in the management and prevention of chronic disease and can boost immune function [1,2,3,4]. PA is often considered the “polypill” of disease, improving cardiorespiratory fitness and muscular strength, which are directly related to the function of many other bodily systems [2,5].

In this article, we outline how COVID-19 is disrupting lifestyles and PA, and why this is both an immediate and long-term danger for the general public. Then, we discuss how education on “exercise as medicine” is severely lacking in medical education, and how this translates into physicians lacking confidence to address PA with patients. Finally, we propose long term solutions to better incorporate PA into medical school curriculums, with there being evidence to suggest that this will increase confidence and willingness to promote and prescribe PA routines.

Although it is well known that exercise has countless benefits, 80% of American adults do not meet the US Physical Activity Guidelines for exercise and 66% of American children are physically inactive every day [6]. In terms of healthcare costs, physical inactivity accounts for $117 billion annually of US health care expenditures [7]. Multiple government and public health initiatives have tried to address physical inactivity (e.g., Healthy People 2020, Exercise is Medicine, US National Physical Activity Plan). Exercise guidance and prescription have had a therapeutic role in medical settings such as in cardiac rehabilitation and physical therapy. However, its use in primary care settings to promote well-being and prevention is not universal [8]. A contributing factor is the knowledge deficit among healthcare providers (HCPs) and needing more practice in effective counseling techniques [8,9]. Less than 40% of HCPs report regularly discussing exercise with their patients [10].

Although clinicians recognize PA as an important health intervention, they often do not feel confident in counseling and prescribing PA to patients. Studies show that the lack of confidence often comes from minimal teaching in medical education with only 58% of surveyed deans/directors indicating their medical graduates were competent in conducting a patient evaluation for approving that patient to begin an exercise program, and further only 10% said their students could design an exercise prescription [11]. Only 6% of medical programs reported that their school provided a core course addressing the American College of Sports Medicine Guidelines for Exercise Testing and Prescription [11]. Notably, medical students spend more time on subjects, such as pharmacology, compared to PA, even though drug therapies for chronic diseases have known adverse side effects, whereas PA generally has less [1].

Moreover, COVID-19 has recently become a worldwide public health issue and has presented many challenges for the general population. As of September 19, 2020, the World Health Organization has reported over 28 million cases and 911,000 deaths globally, and approximately 6 million cases and 190,000 deaths in the US [12]. Various public health entities have initiated quarantine and/or stay-at-home orders, which have globally restricted activity. These orders disrupt exercise routines, increase sedentary time, and lead to unhealthy eating habits [3,4,5]. The existing physical inactivity crisis is compounded by the fact that individuals with medical conditions associated with inactive lifestyles, including heart disease, diabetes, and obesity, are more likely to be hospitalized due to COVID-19 and have higher rates of morbidity and mortality [4,13,14].

Lifestyle and PA Changes with COVID-19

COVID-19 has disrupted several aspects of daily life, including how people stay physically active. A study by a company called “Evidation,” shows that PA – measured by step count – is down 48% nationally [15]. These changes likely act as a result of closed gyms, community centers, public parks, and closure of places where many go to walk like malls. COVID-19 has also led to decreased participation in team sports and group exercise programming. Recent articles have mentioned increases in use of streaming services and video games. For example, Twitch, the video game streaming platform, reported video game streaming up 12-24% coinciding with the COVID-19 pandemic, ultimately suggesting an increase in sedentary behavior [16,17].

Unfortunately, COVID-19 has led to increases in unemployment, likely forcing families to experience economic hardship, potentially leading increases in sedentary behavior.  As of June 2020, the national unemployment rate was 11.1% [18]. It is also well known that lower socioeconomic status has been correlated with lower PA upon retirement, further exacerbating rates of physical inactivity among the general public [19,20,21]. 

Increases in sedentary behavior also occur in those who are still working, as working from home is becoming required for many businesses [22]. With more people working from home, commutes are essentially eliminated, and those who can afford it are getting grocery and food deliveries, leading to an overall decreased mobility [23]. Nutritional habits may have also changed because of financial resource limitation, reduced availability of foods, limited access to food caused by restricted store hours, and a switch to more easily accessible, processed and shelf-stable foods [4]. These population level changes may lead to an increase in all-cause mortality, and increased risk of many chronic diseases, including obesity. This is also true for our youth, with school closures and a lack of organized sports during this time. Notably, studies show increased youth weight gain over the summer months, the months commonly associated with being out of school [24].

Further, many people have reported mental health being significantly affected during the COVID-19 pandemic with 1 in 3 Americans reporting that quarantine and social distancing is having a serious impact on their mental health [14]. This is likely due in part to an increase in various stressors including concerns about finances, fear of infection, inadequate supplies, inaccurate information, stigma, and frustration [7,14]. Studies have also shown in older individuals that social isolation is associated with lower PA levels and loneliness in adults has been shown to be an independent risk factor for physical inactivity and increases the likelihood that PA will discontinue over time [25,26]. COVID-19 has indeed created drastic lifestyle changes for an already sedentary population, further compounding the health risk factors of physical inactivity. 

Exercise Prescription and Social Determinants of Health

The COVID-19 pandemic also underscores well known social determinants of health with people of color and minority communities, especially native, black, and Hispanic groups disproportionately affected by COVID-19 [27]. There are various reasons for this, including work environment, front line work, and housing conditions pointing to the issue of systemic racism that exists in our society [28]. Home environment is also important to consider, as physical isolation is a form of protection that may be not possible for many people due to living conditions. Also, certain marginalized groups, such as black and brown communities, may be less likely to hold jobs that permit working from home, such as grocery clerks, transit workers, and hospital staff, among others. Further, communities of Hispanic and black ancestry may have poorer health outcomes and higher COVID-19 death rates likely because these communities receive poorer care through lack of testing and less access to healthcare, as well as facing higher rates of diabetes, hypertension, and heart disease due to systemic racism issues. These trends are also true for children who are Hispanic or black, and these observed disparities might be related to the higher prevalence of underlying conditions among hospitalized Hispanic and black children compared with those among white children [29].

Thus, we feel that improving education around the best known “poly-pill” (i.e., exercise) for healthcare providers is well-timed. More education and confidence around exercise prescription for physicians means improved outcomes for many chronic diseases in the general population, including those experiencing systemic oppression. More individualized exercise and PA as prescribed by physicians may lead to improved cardiorespiratory function and may lessen the severity of COVID-19 infections, further protecting these populations.

Benefits of physical activity during the COVID-19 pandemic

How does PA play a part in benefiting the population during a pandemic? There is a growing amount of research surrounding optimizing immune system function and PA, and some evidence suggests exercise may lessen the severity of COVID-19 symptoms [7]. PA may enhance immune response to prevent upper respiratory tract infections and augment immune competency [30]. PA may also improve antibody production and interact with antioxidant enzymes (such as extracellular superoxide dismutase) and help improve acute respiratory distress syndrome [31,32,33]. Mechanisms behind these pathways are still being discovered. However, this demonstrates the importance of PA to improve physical conditioning to prevent severe COVID-19 infections, and overall, habitual exercise improves immune regulation and generally reduces illness risk [34].

PA also reduces the risk of common chronic medical conditions which, as shown by CDC’s COVID-NET, have been seen in over 90% of hospitalized patients with COVID-19 [1,35,36].  Individuals infected with COVID-19 are much more likely to be hospitalized and have poorer health outcomes if one or more chronic disease diagnoses are present [35]. The evidence linking a significantly increased risk for chronic disease if a person is physically inactive is well established. Cardiovascular (CV) disease had the highest prevalence among diseases that put patients at higher risk of worse COVID-19 disease, and CV disease risk is greatly increased with sedentary behavior [35]. This highlights the importance of PA for reducing the risk of severe COVID-19. 

This introduces the idea of prehabilitation regarding COVID-19 [34]. Prehabilitation is aimed at creating interventions to improve patients’ health before a physiologic stressor, such as coronavirus, so they can better handle the stress if it presents [34]. Prehabilitation may have the greatest positive effect on vulnerable groups (e.g., elderly patients) with multiple medical conditions by supporting overall physiologic function, and therefore immune function [7,34]. Thus, PA becomes especially important for older people during quarantine to improve cardiorespiratory fitness, which is directly related to the function of the respiratory, circulatory, muscular, nervous, and skeletal systems, as well as endocrine and immune systems [5].  

Exercise can also decrease the activity of the nervous system, decreasing the body’s reaction to stress, and may help with anxiety of the pandemic, improving mental health outcomes for those who are stressed [37,38,39]. In fact, exercise may be as effective as antidepressants in reducing symptoms of mild-to-moderate depression [37]. Specifically, evidence suggests that walking, particularly outdoors, can aid in the prevention and treatment of depression and anxiety [40]. Adults 60 years and older with higher PA levels showed a 21% reduction in risk for depression compared to those with lower PA levels [41].  

Medical schools lack education on exercise as medicine

Medical schools continue to graduate the next generation of doctors during COVID-19 and the current physical inactivity crisis. However, education on PA, PA as disease therapeutic and prevention, and exercise prescription is largely missing from medical schools and residency programs. In 2013, more than half of physicians trained in the US in 2013 did not receive formal education in PA and may, therefore, be ill prepared to assist their patients in a manner consistent with current health initiatives [42]. 

There is also a lack of confidence in medical trainees to make effective recommendations [11,43]. In a 2010 survey of 500 trainees and attending physicians at a major teaching hospital, only 13.7% of trainees and 17.3% of attending physicians reported that they had received appropriate training regarding counseling on exercise, and less than 40% of the trainees engaged in any counseling regarding exercise or nutrition with their patients [9].

These trends are not isolated to the United States and are reflected elsewhere in the world. A study of final year UK medical students suggested a substantial portion underestimated the risk of physical inactivity and did not know the physical guidelines. Physical inactivity was incorrectly perceived to be the least important risk factor to global mortality, and only 52% stated they felt adequately trained to give PA advice to the general public [44]. Another study of family medicine residents in Canada felt the need to be better trained in exercise prescription, with 14.9% perceiving their education on exercise prescription to be adequate and 91% desired more training [45].

Education on exercise as medicine may give confidence to providers

This section was meant to offer a perspective that education on “exercise as medicine” may give providers the confidence they need to discuss and prescribe exercise. However, the research available is rather sparse, which speaks to the relative lack of focus on exercise as medicine during medical training. The few studies found, however, were telling. A study in 2017, involving a 4.5 week course in geriatric medicine with exposure to therapy programs including visits to a community-based exercise class where medical students interview older adults, there was a significant increase in the students’ perception of the importance of exercise for elderly people. Perceived competence in prescribing exercise also increased significantly after this geriatric course [46]. Other preliminary data from a University of Massachusetts Medical School exercise medicine elective showed an increased level of confidence after completing coursework [47]. A 2004 study at Harvard Medical School showed a significant increase in self-reported confidence advising family and friends about exercise, assessing patient exercise, and changing patient exercise after students took a preventative medicine and nutrition course which included one week on exercise [48].  

Future Directions

The combination of COVID-19 and the current physical inactivity crisis has forced us to think about how we can best prioritize the health of the public, and here we outline recommendations to promote PA in the clinical setting. 

(1) We must increase or institute education on “exercise as medicine” in required medical school curriculums. One way this could be accomplished is by building on resources that already exist, such as the Exercise is Medicine (EIM) global health initiative through by American College of Sports Medicine (ACSM), which aims to make PA assessment and promotion a standard in clinical care. EIM encourages physicians to include PA when designing treatment plans and to refer patients to evidence-based exercise programs and qualified exercise professionals [49]. There are several guidelines for providers on how to work with your patients and exercise prescription. The Action Guide includes motivational interviewing tactics and examples of exercise prescription. However, this organization does not have content targeted specifically toward medical students. EIM could expand programming/coursework into all medical schools, drastically increasing the amount of education provided for students. Education could also be facilitated through musculoskeletal teaching blocks taught by sports medicine/exercise specialists to offer expertise on exercise prescription for common chronic conditions. This dissemination of knowledge could also be addressed through training modules in the didactic or clinical phase of medical school and include case scenarios or simulation training.  By further enhancing the education of our new medical practitioners on exercise prescription, patients are more likely to incorporate regular PA into their daily lives.

(2) We must improve PA awareness and the accessibility of resources in the community. Awareness around PA can be improved in the outpatient clinical setting by establishing PA and fitness as a vital sign and may improve the issue that PA is sub-optimally addressed in most clinical encounters [50].  This is currently done at the University of Washington (UW), led by Cindy Lin, MD, FACSM, by integrating a standardized and simple two question “exercise as vital sign screener” in the EPIC electronic medical record [51].  UW medical assistants are now asking these questions as part of the usual heart rate and blood pressure vital sign intake. The American Heart Association states that routine PA assessment in clinical settings is imperative for prevention and management of chronic disease, including CV disease. Best practices involve assessing PA at patient check-ins when vital signs are administered, or as part of the rooming process [52].  Another study showed that systematically collecting exercise information during outpatient settings in the form of a vital sign may be associated with significant changes in exercise related clinical outcomes [53]. We can also improve the accessibility of local resources for our patients, an example of this being Exercise Rx. Exercise Rx through The Sports Institute at UW Medicine offers clinicians and patients alike the ability to view and access a variety of low cost, free, and local programs, parks, websites, and online workout plans [54]. 

(3) We must continue to promote individual wellness and PA for students in medical schools and physicians across the globe. The reason for this is not only to support the mental health and well-being of students while journeying through a challenging educational experience, but also because there is evidence that health care providers who are more physically active are more likely to educate patients on PA [55]. If the medical community fosters an environment of PA promotion and movement for its HCPs, it is likely such principles may be dispersed to the physicians’ patients. 

CONCLUSION

The COVID-19 pandemic has created concerns regarding social isolation, stay-at-home orders, and the closures of gyms and other recreational areas, exacerbating population level sedentary behaviors. Prior to COVID-19, most of the world was already not meeting activity recommendations, even though exercise is known for its countless preventative and therapeutic benefits for a multitude of diseases. Regular PA and exercise may help improve outcomes for COVID-19 patients and prepare us for future pandemics. With the future unknowns of continued isolation and stay-at-home orders, this calls for changes in medical education such as those proposed in this paper. New clinicians need to build expertise on PA and exercise as an individualized medical therapy and have access to the tools and resources to help patients be successful.

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The Implications of Online Preclinical Medical Education: Voicing Student Concerns

Tarika Srinivasan1 and Bethany Brumbaugh1
1 Harvard Medical School, Boston, MA 02115, USA

ABSTRACT

Due to the COVID-19 pandemic, several medical schools have opted to reformat preclinical instruction for online delivery to reduce the risk of transmission among faculty and students in classrooms. However, enthusiasm for adaptation has preceded current necessity, as some scholars’ have foretold an eventual “reimagining” of entirely online, open-access preclinical curricula. We, two first-year medical students, express concerns about the compromise of the student experience in service of this goal. Unexamined implementation of an online preclinical curriculum may threaten student satisfaction, class interconnectedness, professional development, student diversity, and overall attrition – potentially countering the efforts of recent decades of medical education reform. We ask the academic medical community to refrain from viewing interim online adaptations as a test-run for a supposed inevitability in preclinical medical instruction.

In an article published before COVID-19 began ravaging the United States, physician and bioethicist Ezekiel Emanuel almost prophetically wrote about a time in the not-so-distant future in which preclinical medical education would be transitioned to an online format [1]. He articulates that “reconfiguration of medical education seems inevitable, fueled by online educational technology and the need to transform clinical training to more outpatient settings with promotion based on competency, not time.” When writing this article, Emanuel likely did not imagine how serious consideration of this vision would soon be accelerated. As incoming first-year students at Harvard Medical School, we are grappling with the fact that our first semester will be delivered entirely online due to concerns related to the pandemic’s trajectory. There is no doubt that significant adjustments to preclinical education stand to be made in light of present circumstances. However, we are concerned an online preclerkship phase may counteract the improvements that medical educators have sought over the several years preceding this pandemic. Such improvements include integrating basic science knowledge for applicability, better facilitating the formation of medical professionalism, and attracting a diversity of students into the traditionally homogeneous medical profession [2-7]. We worry that an online preclinical curriculum may relegate these ideals in favor of economizing medical education.

Before critiquing the implementation of an online preclinical education, it is important to acknowledge the merits of this immediate transition. At first glance, medical schools appear to be in a prime position to embark on preclerkship education online. Several schools have adopted shortened basic science curriculum, from the traditional 2 years to 12-18 months. Most medical students at institutions without the requirement of attendance at lectures instead opt for streaming them in the comfort of their apartments, a practice bearing striking resemblance to those changes necessitated by pandemic’s closure of schools. However, outside of the context of COVID-19, Emanuel describes these changes as necessary steps in quality improvement and efficiency to quickly mold future physicians who are eager to enter into patient care. Against the backdrop of the COVID-19 pandemic, the risk-averse would naturally conclude that the scales weigh in favor of transitioning the majority of in-person instruction to a virtual format. Indeed, institutions (including Harvard Medical School) have made laudable steps to push through barriers to shift lectures and case-based group learning entirely online. Yet, it is unclear just how much will be lost on behalf of the student during this time.

Even though we are neophytes with respect to physical exams, life support skills, and medical procedures, even first year medical students perceive an overwhelming responsibility--whether self-derived or socially thrust--to be active in the face of the pandemic. That perceived responsibility is manifested in the acquisition of knowledge, but this has increasingly come from much more than conveniently streamed or pre-recorded lectures. Recently reformed curricula typically integrate longitudinal clinical preceptorships and clinical skill simulation over the course of the preclinical phase. Basic science knowledge is increasingly delivered in a “flipped,” case-based format, demanding that students learn foundational concepts independently and participate heavily in small group sessions that apply this information to familiar clinical cases [8]. Through major systemic overhaul, the first few graduating classes of medical students have appeared to have performed substantially secondary to this educational format [9-11]. However, given that this success cannot easily be attributed to a discernible variable, virtual transition may compromise this curricular format. Medical educators might appraise whether they can faithfully recreate the case-based learning experience online. Might we be undoing the great strides that have been made in streamlining and modernizing medical curricula? The potential compromise of quality for these first few classes of students receiving virtual preclinical education should be addressed as a research priority rather than an accepted next step for improvement.

Second, whether the medium be lectures or more applied early clinical endeavors, the preclinical experience encompasses far more than the absorption of discrete medical knowledge. Preclinical students are encouraged to be involved in research, specialty exploration, and community service, as they are viewed as effective facilitators of professional identity formation. With recent pressure on physicians to be more engaged in advocacy activities and be able to address systemic issues that impact health, the narrowing of preclinical exposure seems a detriment to the development of future holistically-minded physicians. This then brings up the question of the implicit messages given by those with seniority and received by preclinical students, those necessarily at the bottom of the physician hierarchy. The “hidden curriculum” is a parallel educational experience that involves the swath of learning that occurs outside of the explicit, endorsed curriculum [12,13]. Even more than in previous years, preclinical medical students like ourselves are grappling with mixed messages regarding our roles and responsibilities as budding medical professionals. Although preclinical students spend little to no time in clinical settings during the basic science curriculum anyway, the risk of bringing them to learn in-person is still deemed too great by some institutions. However, there is no signed agreement distinguishing the preclinical and clinical phases to accommodate for the increased risk of exposure to illness (such as COVID-19) in clinical settings. To the incoming preclinical medical student, the subtext of this relegation of our education may appear to be a reinforcement of the sense of entrenched hierarchy within medical education, a trend that institutions have sought to eradicate for the past several years [14-16].

Preclinical students occupy a unique liminal stage of their medical education. They have passed the gauntlet of competitive medical admissions to gain coveted spots within a medical institution. Even with an online virtual semester, medical students will still be initiated into the fraternity of medicine virtually by taking some form of a modern Hippocratic Oath and receiving a white coat [17,18]. Yet, medical students have largely been kept out of the loop in the decision-making that will formulate their medical education experience. In the hard years leading up to our matriculation, we have looked forward to the preclinical phase as a dedicated time for forming deep, interpersonal bonds among classmates and faculty. Without the benefit of an interconnected class, students may fail to cultivate the innate virtues of collaboration and teamwork that have been increasingly emphasized along all stages of medical education [19,20]. In addition, role modeling and mentorship have been demonstrated as a cornerstone of professional development [21,22]. Students may lose the sense of motivation and expectation that comes through deep relationships with mentors. The erosion of these bonds may subvert efforts to reform the hidden curriculum of medical school from traditionally entrenched hierarchical structures to humanistic, ethical patient care and relationship-building among healthcare teams.

Finally, those who foretell a permanent shift to online preclinical education might consider how the effects of this transition might reverberate through the physician workforce. Research suggests that the flexibility and convenience conferred by online courses may not lead to better educational outcomes, especially for those starting out on unequal footing with peers [23,24]. Overall failed retention rates for online education programs, even with the promise of course credit, range from 20 to 50% [1,25]. It is possible that transition would erect even more barriers for students from underrepresented, disadvantaged groups to overcome, especially those for whom a secure Wi-Fi connection, continual course access, and a safe, suitable learning environment is not a given. Emanuel optimistically describes a massive open online course (MOOC) -like system in which every preclinical student would have access to the same world-renowned set of lectures. But the capitalization of the medical school application process--as evidenced by the exorbitant cost of private advising, MCAT preparation courses, and application feeds--might influence preclerkship education to reward the privilege of those in the highest echelons of our society with the deepest pockets. In fact, these courses have struggled to lift retention rates and expand their user base beyond affluent students [26]. Shifting preclinical medical education entirely into an open, online format may reify medical practice as an elite profession that easily advances those with means and further disadvantages those without, unraveling the goals of equitable professional opportunities among racial and socioeconomic subgroups.

Medical institutions might consider the classes of students that they will create due to this temporary shift of the preclinical medical curriculum to a virtual format. While idealists might consider that the COVID-19 pandemic is exactly the impetus to kickstart a virtual overhaul of preclinical education, educators should beware of unbridled enthusiasm when appraising its implementation. We implore medical educators to consider: are world changers, medical researchers, and public health leaders born at home, or in the context of a rich, diverse community that is physically present throughout the entirety of the medical education experience? As institutions have worked for years to maintain the ambition and optimism of incoming students and diversify identities and skills through which they are able to contribute, virtual transitions that might reverse those efforts should not be taken lightly. Though we, as first-year medical students, accept the necessity of this accommodation under the circumstances of today, we caveat those who might herald virtual preclinical education as the irrefutable model of tomorrow.

Disclosures: None.

Funding: None.

Acknowledgements: The authors would like to express their gratitude to the faculty of the Mayo Clinic Biomedical Ethics Research Program, the Hastings Center, and Yale’s Interdisciplinary Center for Bioethics for facilitating our development as ethical thinkers. They also thank the faculty and administrators of the Harvard Medical School Pathways curriculum for enthusiastically involving students in the COVID-19 adaptation process. Special thanks to Drs. Randall King, MD, PhD, Henrike Besche, PhD, Fidencio Saldaña, MD, MPH, and Edward Hundert, MD.

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NYCOVID Connect: Supporting a city through online information and resources

Aaron Troy, MPH, Nina Singh, Anya Krok, MPhil, Drew Adler, Paxton Voigt, Emma Lang, Ally Covello, and Jenna Reich
New York University Grossman School of Medicine

New York City has been an epicenter of the COVID-19 pandemic, with more than 200,000 confirmed cases and 17,000 confirmed deaths.  The city’s institutions and organizations have mounted a response as rapidly evolving as the challenge, and as multifaceted as the NYC population.  Early in the surge, as NYC medical students, we struggled to keep track of the daily deluge of policies, logistics, and resources coming from disparate sources and written in technical language. We sought to solve this problem with NYCOVID Connect, a comprehensive, up-to-date, and accessible online guide that connects NYC residents with COVID-19 community resources, policy updates, health information, and, most importantly, each other.

The NYU Grossman School of Medicine COVID-19 Task Force launched this project as the NYC COVID-19 Information and Resource Sheet, based on similar efforts in San Francisco and Los Angeles.  In a Google Doc, we collated NYC-specific information and resources categories including: “Policy Updates,” “Facility Closures and Public Transport,” “Food and Housing,” “Mental Health and Domestic Violence,” and more.  Volunteer editors were recruited from the Task Force to update each section weekly, and translators were recruited from the broader community of the Task Force members’ contacts.

In late March, the COVID-19 Task Force was restructured, and a formal project team was created.  The team included our Communications Head, a Content Lead, Dissemination Leads, Web Leads, and a Translation Lead.  Each Lead managed a team of NYC student volunteers who served as editors, designers, or translators.

This team took three key steps to broaden our reach: created a website (www.NYCOVIDConnect.com), created an Instagram page (@nycovidconnect), and rebranded as NYCOVID Connect.  The team also created a daily workflow: first content editors write their updates, then the content lead adds them to our internal Google Doc and Slack, then the dissemination team updates the website and creates Instagram posts. At the end of every week, all changes are translated into Spanish, Chinese, French, Italian, Portuguese, Russian, Bengali, Korean, and Yiddish.

In the months since its founding, NYCOVID Connect has grown to include forty-two pages of up-to-date, organized information and resources. The Instagram page has released over one-hundred-and-twenty unique posts in content areas including Daily Updates, Scientific Research, Public Health, and Community Resources. We also ran a question-and-answer service using Instagram stories, in which a team of medical students answered over 50 questions sent in from our followers. 

The website has averaged 200 visits per week, with half of visitors reaching the website through the URL and the other half referred from Facebook, Instagram, or Google. 65% of visitors are in New York City, and 50% are accessing our mobile-friendly site using a cell phone or tablet. The ‘Getting Tested’ page has garnered the most attention followed by ‘Policy Updates.’ Instagram posts directing people to the website successfully increase traffic to the relevant pages, in one case tripling the weekly views of our ‘Getting Tested’ page.

Our Instagram account has more than 1,600 followers, predominantly New Yorkers (~60%) aged 24-35 (~60%). Preliminary data suggests that Public Health, Scientific Research and Daily Update posts attract the most likes and shares. Daily Update and Public Health posts have generated the most traffic to the account and website. Lastly, hashtags significantly increases the number of times the post is seen.

Going forward, we will adapt this platform to fit the unpredictable challenges COVID-19 will pose to New Yorkers.  We will also take advantage of newly available in-person opportunities to disseminate this resource, including paper flyers and discussions with patients.

NYCOVID Connect harnessed medical students’ dedication, knowledge, and collaborative spirit to create a product with the power to improve the lives of millions.  We hope our process will serve as a model for those aiming to support cities’ responses to large-scale challenges and movements now and in the future.

NYCOVID CONNECT.png

Readability of Selected Domestic Public Health Communications during the COVID-19 Pandemic

Anjali Om, BA1, Amna Nawaz, BS2, and Namita Mathew, BS1
1 Emory University School of Medicine, Atlanta, GA 30322, USA
2 Georgetown University School of Medicine, Washington, DC 20007, USA

Correspondence concerning this article and requests for reprints should be addressed to Anjali Om (anjali.om@emory.edu)

ABSTRACT

Background: Since the outbreak of the novel coronavirus pandemic, public health Internet platforms have been inundated with constantly updating information. Despite American Medical Association and National Institutes of Health recommendations that patient education be no greater than a sixth grade reading level, health documents often exceed this. To our knowledge, the readability of public health education material related to COVID-19 has not been reported.

Aims: To analyze the readability of public health communications regarding COVID-19.

Methods: We searched CDC.gov and five state Department of Public Health sites (New York, New Jersey, Illinois, California, and Massachusetts) for COVID-19 educational material and obtained six readability indices by uploading article text into an online tool.

Results: Across 623 articles, mean Flesch Kincaid Reading Ease was 41.7, corresponding to a “difficult” reading level. Mean scores indicating grade levels appropriate for understanding were: Flesch Kincaid Grade Level 12.8, Gunning Fog Index 14.6, SMOG Index 11.4, Coleman Liau Index 13.8, and Automated Readability Index 12.7. Only 0.006% (n=4) of articles had readability scores within recommended levels.

Conclusion: Our study shows that public health communications regarding COVID-19 are well above recommended grade levels.

INTRODUCTION

Since the beginning of the novel coronavirus outbreak in December 2019, public health organizations have inundated Internet platforms by constantly updating information. Studies have repeatedly demonstrated that Americans are increasingly using the Internet for health care information; it is estimated that between 63-80% of Internet users have looked for online health information [1,2]. While the sheer quantity of information available to the public may seem conducive to broad-reaching education, this information often requires a high level of reading comprehension to be adequately received. 

Health literacy is defined by the National Academy of Medicine as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [3]. Health literacy may play an important role in health outcomes, as patients with lower health literacy reportedly have worse health status and higher rates of hospitalization [4-6]. The only national data published on American literacy estimated that in 2003, 14% of Americans had below basic health literacy, defined as no more than the most simple and concrete literary skills [7-9].   For example, those with below basic health literacy might be able to locate the time and date of a medical appointment on a form but would be unable to read a pamphlet on hypertension and identify two features of the disease [8]. Advocates for improving health literacy argue that it encompasses a balance between the skills and abilities of the target audience and the demands and complexity of the materials delivered [10]. In other words, health literacy is dependent on both the skill of the user and the level of difficulty at which the information is presented. Health literacy, is well correlated to education and overall literacy [11,12]. Studies have shown that the average reading level of American adults is around eighth grade, while the average reading level of Medicaid enrollees is about fifth grade [13]. In addition, average reading level is three to five grades below the highest level of education completed [14].

Because health literacy seems to be an important indicator of health outcomes, the American Medical Association (AMA) and National Institutes of Health (NIH) have recommended that all patient education material be no greater than a sixth grade reading level [15].  Despite these guidelines, previous studies have shown that many medical subspecialties publish material well above the recommended reading level [14-17]. After the Ebola epidemic, a similar study showed difficult readability of public health material published on the Ebola virus disease [18]. However, the readability of public health education material related to COVID-19 has not been reported. The purpose of this study is to analyze the readability of communication resources distributed by the Centers for Disease Control and Prevention (CDC) and state Departments of Public Health (DPH) regarding COVID-19 using six readability indices.

METHODS

Study Design

On May 29, 2020, a list of educational materials published by the CDC regarding COVID-19 was populated by searching CDC.gov for “Communication Resources” filed under “Coronavirus Disease 2019 (COVID-19)” [19]. All articles published on or before the date of search were collected.

A list of states with the highest number of confirmed COVID-19 cases as of May 29, 2020 was also populated [20].  For the five states with the highest case numbers (New York, New Jersey, Illinois, California, and Massachusetts) DPH sites were searched [21-25]. The first 100 unique results when sorted by relevance for two independent search criteria, “COVID” and “coronavirus,” were collected.

Inclusion and Exclusion Criteria

Figure 1 illustrates the selection process used to identify qualifying articles. Content of each search result was evaluated and filtered to include only articles relevant to COVID-19. Results not classified as delivering public health information regarding COVID-19, presumed to be populated due to imprecise website algorithms, were excluded. Similarly, the target audience of each article was evaluated and classified as either “healthcare providers,” encompassing those responsible for diagnosing, processing collection specimens, or treating COVID-19, or “non-providers,” any member of a non-healthcare related field receiving COVID-19 related information. Articles targeted towards “healthcare providers” were not considered public health education material and were therefore excluded. Pages not in English, pages with fewer than 100 words of text, and pages exclusively composed of resource links, graphics, figures, or search tools were also excluded.  Broken URL links were also excluded. 

Readability Assessment

Readability assessment was then performed by uploading text from each qualifying article into a free online tool (https://www.webfx.com/tools/read-able/check.php) [26]. Website identifiers, internal webpage navigation links, advertisements, graphs, pictures, videos, tables, figures, figure legends, captions, additional resource URLs, references, legal disclaimers, content sources, and copyright notices were removed from the assessment to prevent altered results. From the online tool, six different numerical readability indicators were obtained: Flesch Kincaid Reading Ease (FRE), Flesch Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG) Index, Coleman Liau Index (CLI), and Automated Readability Index (ARI). Table 1 lists the formulas by which each readability index is calculated.

RESULTS

445 unique communication articles published by the CDC, and 782 unique articles by five state DPH sites (133 from NY, 130 from NJ, 187 from IL, 181 from CA, and 151 from MA) were collected through search criteria. Of these, a total of 50.8% (n=623) were included based on inclusion and exclusion criteria (271 from CDC, 53 from NY DPH, 47 from NJ DPH, 111 from IL DPH, 51 from CA DPH, and 90 from MA DPH).

Mean readability statistics are listed in Table 2. FRE scores indicate readability on a scale from 0-100, with higher scores corresponding to greater reading ease; scores 0-30 indicate very difficult reading at or above a college graduate level, while scores 90-100 indicate very easy reading at an estimated fifth grade level [27]. Overall mean FRE for all 623 included articles was 41.7 (SD 14.8; 95% CI 40.5-42.8), corresponding to “difficult to read.” Mean word count was 883 (SD 891; 95% CI 813-953) and mean percentage of complex words, defined as words containing three or more syllables, was 18.8 (SD 5.3; 95% CI 18.3-19.2). Mean readability statistics for each public health organization are listed in Table 2.

The remaining indices (FKGL, GFI, SMOG, CLI, and ARI) produced scores corresponding to a grade level deemed appropriate for understanding [27]. For all included articles, the overall mean FKGL was 12.8 (SD 3.8; 95% CI 12.4-13.0), mean GFI 14.6 (SD 3.2; 95% CI 14.3-14.8), mean SMOG index 11.4 (SD 4.3; 95% CI 11.1-11.7), mean CLI 13.8 (SD 3.1; 95% CI 13.5-14.0), and mean ARI 12.7 (SD 4.2, 95% CI 12.3-13.0). Mean readability index scores for each individual public health organization analyzed are depicted in Figure 2. For included articles, average grade level of readability was calculated by averaging the five indices that produced recommended grade levels for understanding. Of the 623 total included articles, 0.006% (n=4), 1 from IL DPH and 3 from NJ DPH, had average readability scores within the AMA/NIH guidelines for patient education materials (at or below a sixth grade reading level).

DISCUSSION

In the era of the COVID-19 pandemic, online education is becoming increasingly essential to stay updated on changing guidelines [28]. For a communicable disease, especially one for which containment depends on individual preparedness, it is especially important to be able to understand and follow public health policies that limit physical contact [29]. At the time of data collection, New York state had more than 368,000 confirmed cases, New Jersey had 157,000, Illinois had 115,000, California had 101,000 and Massachusetts nearly 95,000 [17]. Four of the five states also had at least partial lockdowns still in place, as Massachusetts began a plan to reopen on May 18 while New Jersey still had a statewide stay-at-home order set to expire June 5 [30].  For these states especially, online public health communication may represent a major source of information.

Our analysis is consistent with previously published material showing that medical information is often distributed at reading levels well above both the average and recommended levels.  It is important to note that states have individual variation in literacy. For example, 10% of Massachusetts’ population has below basic literacy skills, while for New York this number is 22% [8]. Regardless, the AMA/NIH recommendation for readability remains the same nationwide. In addition to readability, article length may also influence patient understanding.  Our study found an average word length between 622 and 1139 words. Based on a calculated average reading speed of 200-330 words per minute and not accounting for readability scores beyond level of average understanding, these articles would require a mean reading time of 1.9-5.7 minutes [31].  It is worth noting that a sixth grade reading level corresponds to a reading speed of about 170 words per minute, increasing the mean reading time for articles in this study to 3.7-6.7 minutes [32].

The mean FRE score of the included articles in this study ranges from 36-53. Texts with FRE scores between 30-50 are considered “difficult to read,” examples of which include academic or scholarly magazines [33]. Texts with FRE scores between 50-60 are considered “fairly difficult to read,” likened to magazines like The Atlantic [34,35]. For reference, the AMA/NIH guidelines roughly correspond to a FRE between 80-90, equivalent to a popular fiction novel [32]. The FKGL assessment inputs the same variables as the FRE put provides a grade level of education required to easily understand the material; for example, a FKGL score of 12.8 corresponds to a reading level between the 12th and 13th grades [36]. Like the FKGL, the GFI, SMOG, CLI, and ARI all provide a grade level at which the text can be easily understood and use higher scores to indicate more difficult texts. The GFI and SMOG tests use sentence length, defined as number of words per sentences, and the number of complex words, defined as words containing three or more syllables, to calculate readability [14,37]. The CLI takes into consideration word length, defined as number of letters per 100 words, and sentence length, defined as number of sentences per 100 words, rather than syllables [14,38].

This study has certain notable limitations. First, it included only public health information distributed by the CDC and five state DPHs.  Because our web tool was limited to analyzing text entries, many organizations that publish predominately graphical information, including but not limited to WHO, UN, and UNICEF, were not analyzed.  While the CDC and DPH are major and reputable sources of public health communication, they are not representative of all outlets, particularly international sources, that may distribute information regarding COVID-19 [39].  Second, this study relied on search criteria to populate lists of public health communications on each site studied. Despite secondarily verifying that articles collected were related to COVID-19, this methodology could only exclude superfluous articles, not include content beyond that which each website algorithm generated.  Third, despite using six different numerical indices, this study did not include all available metrics that may assess readability [40]. Fourth, despite being widely used, readability indices may present a biased and incomplete characterization of understanding.  For example, indices that correlate syllables with complexity (FRE, FKGL, GFI, and SMOG) may naively assume that words like educational are more difficult to understand than tropism [41]. Finally, readability may be influenced by factors not considered by readability indices, such as website organization, inclusion of substantiating images and graphs, and graphic design.

CONCLUSION

Our study shows that public health communications distributed by the CDC and state DPH regarding COVID-19 are at grade levels well above the AMA/NIH recommendations and substantiates a similar trend demonstrated by other analyses of published health information.  While the Internet exposes users to a vast quantity of information, the quality of information that is outside of a comprehensible level remains uncertain, even at trusted public sources for information. Along with work to ensure health literate documents, further studies that explore methods of increasing readability may help decrease health disparities and improve health outcomes.

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The Other COVID-19 Crisis: Confronting Anti-Asian/AAPI Microaggressions in Clinical Settings

Jade Connor, MSc1 , Azfar Hossain 1 , Maahika Srinivasan, MS 1
1 Harvard Medical School, Boston, MA 02115, USA

Correspondence concerning this article and requests for reprints should be addressed to Maahika Srinivasan (maahika_srinivasan@hms.harvard.edu)

ABSTRACT

Since the beginning of the COVID-19 pandemic, there has been an alarming rise of racist incidents targeting patients and healthcare workers identifying as Asian, Asian American, and/or Pacific Islander (Asian/AAPI). This is part of a larger wave of anti-Asian/AAPI discrimination spreading across the country. Ongoing COVID-19-related bias in healthcare settings has the potential to engender immediate and long-term consequences, from delays in seeking care among patients to increased rates of burnout among frontline providers. Microaggressions and other acts of discrimination against Asian/AAPI individuals do not occur in a vacuum but are manifestations of historical and structural forces, including stereotypes, systems, and institutions. Unfortunately, due to gaps in medical education and training, many clinicians are ill-equipped to respond to anti-Asian/AAPI bias or understand this underlying context.

Based on the “Stop, Talk, Roll” and 4 R’s frameworks on addressing microaggressions and discrimination in clinical settings, an approach for non-Asian/AAPI providers to support patients and colleagues experiencing COVID-19-related harassment is presented. Allyship, an ever-evolving process of standing in solidarity with marginalized communities, is central to this approach. Although these strategies can help mitigate discrimination during the current pandemic, anti-racism work does not end with the end of COVID-19.

“You’re not welcome here.”

In Boston, a woman in labor refuses care from a concerned resident. In rural South Carolina, a patient shouts down another patient in an urgent care waiting room. In Los Angeles, a family bars a hospice nurse from entering their home, leaving the patient without pain medication for hours.

Though these incidents occurred several days and thousands of miles apart, a through line unites them. First, each event happened in the context of healthcare. Second, all of the subjects of attack identify as Asian, Asian American, and/or Pacific Islander (Asian/AAPI). Lastly, this is the age of the COVID-19 pandemic.

These incidents — examples of microassaults, a subset of racial microaggressions defined as “racial derogations that are verbal, nonverbal, or environmental attacks meant to hurt the person of color” — are manifestations of a larger trend of racism that has infected our society as rapidly as COVID-19 itself [1]. The FBI warns that the pandemic threatens to trigger a “surge” of verbal and physical attacks against Asian/AAPI people; there were over 1,100 incidents recently reported in just two weeks [2,3]. Hospitals and clinics are hotspots for these events given high stress around COVID-19 in these settings, which are among the few places still open to the public.

As the current crisis highlights, however, derogations against Asian/AAPI folks also manifest more insidiously. In the early stages of the pandemic, comments like “This is America, we don’t wear masks here” directed towards Asian American individuals wearing masks represent microinsults — another form of microaggression intended by the perpetrator to reflect a worldview in which racial and ethnic minorities are aliens within their own country [1]. In addition, Asian/AAPI communities experienced microinvalidations when they were told to be “overreacting” to politicians’ repeated use of “Chinese virus,” as their feelings and lived realities were negated [1,4]. Whether intentional or inadvertent, these slights indicate systemic perpetuation of Eurocentric/white supremacy, designating Asian/AAPI folks as inferior. 

COVID-19-related bias in healthcare settings may have enduring repercussions on both individual and population levels. Asian/AAPI patients may forgo care to avoid harassment in hospitals and clinics, a trend well-documented among other groups facing discrimination including Black American, Latinx and transgender individuals [5-7]. Studies also reported correlations between microaggressions and poorer health outcomes, including increased rates of heart attack and hospitalization [8]. At a time demanding more resilience than ever from health workers, racist incidents contribute to burnout, stress and mental illness among providers on the front lines [1,9].

There’s no question this moment calls for solidarity with targeted patients and providers; however, we worry that many clinicians are underprepared to address anti-Asian/AAPI bias. One recent study reported that most medical and dental students found knowing how to respond to clinical microaggressions “very challenging or extremely challenging,” while many others have described the common failure of providers to understand “how racism potentially infects the delivery of services to clients of color” [10,11]. In our own training, we have seen multiple instances of health workers across all specialties ignoring, downplaying or excusing identity-based discrimination on the wards. Whether due to lack of awareness or uncertainty around how to react, not addressing anti-Asian/AAPI discrimination during the pandemic is a choice that threatens to leave many behind.

We are moved by the work already being done by Asian/AAPI activists across the country in response to racism against their communities [12]. For those of us who do not identify as Asian/AAPI: what steps can we take to support those experiencing COVID-19-fueled bias in clinical settings? Based on our experiences researching clinical microaggressions and leading anti-bias workshops with Harvard Medical School’s Racial Justice Coalition, we offer several suggestions.

First, providers and trainees across all specialties must respond to interpersonal incidents, recognizing that Asian/AAPI individuals are at risk of COVID-19-related harassment. Georgetown University School of Medicine’s “Stop, Talk, Roll” tool (Table 1), which we have adapted for allies, provides a three-part approach: stopping the interaction, talking with the person targeted and ultimately “rolling out” an appropriate response [13]. In the case of the Asian/AAPI patient being harassed in the waiting room, this could take the form of stopping the encounter by having the perpetrator removed by security and communicating no tolerance for harassment; talking with the targeted patient to ask how they are feeling; and “rolling out” next steps, such as connecting that person to social work or reporting the incident through institutional channels.

Another approach shared by the University of Washington involves the 4 R’s: Recognize, Reason, Responsibility and Respond (Table 2) [14]. In the case of a patient refusing care from an Asian/AAPI provider, a colleague witnessing the encounter could recognize the refusal as a microaggression; reason through possible impacts of the refusal (could this comment make the provider feel unwelcome?); decide that one has a professional responsibility to take action; and then respond by telling the patient that prejudiced refusals of minority providers are unacceptable, or by checking in with the targeted individual after the encounter. In this response, Paul-Emile et al.’s framework on race-based refusals — which considers patient stability, decision-making capacity and reasoning — could also inform next steps [9].

Regardless of the framework used, it is critical we let those who are most affected by these incidents guide our responses, rather than making assumptions about how we can help. We must avoid speaking on behalf of those we are trying to support, which can silence or undermine others. Rather than stating, “Your comments make my colleague uncomfortable,” one could instead say, “I feel uncomfortable right now” in response to a racist incident. These responses can also involve microaffirmations: simple acts ranging from giving credit to others to actively listening [15].

While these real-time responses to microaggressions are crucial, allyship is not a static concept but rather an intentional and continuous process of checking one’s biases; challenging one’s assumptions; re-examining one’s understanding of the systems that disempower others; and revising one’s approach to the world accordingly. As such, intervention as an ally is meaningless without interrogating the intersecting structural and historical contexts propagating the marginalization of racial minorities. 

Xenophobia and racism did not originate with COVID-19; they have a deeply rooted history in the United States. From this country’s founding, those deemed “non-white” — particularly the poor and immigrants — have been scapegoated as spreading infectious disease, leading to policies that systematically oppressed these groups. During the 1900 bubonic plague outbreak in the western US, people of Chinese descent were labeled as disease vectors and subjected to mandatory quarantines (notably, after all white community members were relocated from the affected area) [16]. During the 2003 SARS epidemic, Asian/AAPI individuals were denigrated in the media [17]. These communities have simultaneously faced other forms of disempowerment outside of disease outbreaks, from imprisonment in internment camps to policies denying citizenship and land ownership [18].

Despite this history, there has been a systemic disregard of racism targeting Asian/AAPI folks due to the model minority myth. Asian/AAPI communities are frequently perceived as “model minorities” who have “made it” in American society due to stereotyped work ethic and intellectual capabilities. They are believed to be inherently immune to the impacts of racism and classism, since they are assumed to have capitalized on the American “meritocracy” [19]. This concept is codified when Asian/AAPI communities are neglected in policy interventions — including in healthcare [20]. By understanding this context, we can improve our ability to identify bias and respond in ways that account for the lived experiences of patients and peers.

While the physiological toll of this pandemic will eventually dwindle, the interpersonal and structural tensions that it underscores will not fade without action. We acknowledge that institutions also play a significant role in dismantling racism and xenophobia through policy and messaging. Healthcare institutions and medical schools should mandate rigorous anti-bias and allyship training for all stakeholders including providers, faculty, staff, and trainees — an intervention called for by many others [21,22]. Furthermore, institutions should implement accountability measures to ensure this training is translated into action. Our focus in this piece, however, is to emphasize how individuals may combat inequities when they take the form of microaggressions — ranging from bigoted and prejudicial comments to overt discriminatory acts.

 Just as we have undertaken the uncomfortable task of social distancing for the health of our communities, we must engage in the process of allyship in solidarity with our Asian/AAPI patients and peers. An effective ally is tasked with complex responsibilities: intentional listening; embracing discomfort; constant self-educating; amplifying the voices of oppressed peoples. Allyship is not confined to a specific time, situation, or group: it is a lifelong approach to engaging with the people around us, constantly striving to improve the ways in which we walk with those who are marginalized. It’s on all of us to engage in this process in support of communities facing discrimination, knowing that our responsibility doesn’t end with COVID-19.

ACKNOWLEDGEMENTS

We would like to express our gratitude to Avik Chatterjee MD, MPH for his continued mentorship in addition to the following faculty and peers who developed the medical education workshop from which many of these themes were drawn: Tamina Kienka, Raquel Sofia Sandoval, Titilayo Afolabi, Jordan Said, and Daniele Ölveczky, MD, MS.

REFERENEC

  1. Sue DW, Bucceri J, Lin AI, Nadal KL, Torino GC. Racial microaggressions and the Asian American experience. Cultur Divers Ethnic Minor Psychol. 2007;13(1):72-81. doi:10.1037/1099-9809.13.1.72

  2. Margolin J. FBI warns of potential surge in hate crimes against Asian Americans amid coronavirus. ABC News. March 27, 2020. https://abcnews.go.com/US/fbi-warns-potential-surge-hate-crimes-asian-americans/story?id=69831920. Accessed April 18, 2020.

  3. Jeung R. Incidents of coronavirus discrimination: March 26 - April 1, 2020. Asian Pacific Policy & Planning Council and Chinese for Affirmative Action. April 3, 2020. http://www.asianpacificpolicyandplanningcouncil.org/wp-content/uploads/Stop_AAPI_Hate_Weekly_Report_4_3_20.pdf. Accessed April 18, 2020.

  4. Wulfsohn JA. Bill Maher blasts ‘PC’ uproar over ‘Chinese virus’ label: ‘We SHOULD blame China.’ Fox News. https://www.foxnews.com/entertainment/bill-maher-blasts-pc-uproar-over-calling-coronavirus-chinese-virus-we-should-blame-china. Accessed April 18, 2020.

  5. Alsan M, Wanamaker M. Tuskegee and the health of black men. Q J Econ. 2018;133(1):407-455. doi:10.1093/qje/qjx029

  6. Sheppard VB, Williams KP, Wang J, Shavers V, Mandelblatt JS. An examination of factors associated with healthcare discrimination in Latina immigrants: the role of healthcare relationships and language. J Natl Med Assoc. 2014;106(1):15–22. doi: 10.1016/S0027-9684(15)30066-3

  7. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.

  8. Walls ML, Gonzalez J, Gladney T, Onello E. Unconscious biases: racial microaggressions in American Indian health care. J Am Board Fam Med. 2015;28(2):231-239. doi:10.3122/jabfm.2015.02.140194

  9. Paul-Emile K, Smith AK, Lo B, Fernández A. Dealing with racist patients. N Engl J Med. 2016;374:708-711. doi:10.1056/NEJMp1514939

  10. Sandoval RS, Afolabi T, Said J, Dunleavy S, Chatterjee A, Ölveczky D. Building a Tool kit for medical and dental students: Addressing microaggressions and discrimination on the wards. MedEdPORTAL. 2020;16. doi:10.15766/mep_2374-8265.10893

  11. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: Implications for clinical practice. Am Psychol. 2007; 62(4):271–286. https://doi.org/10.1037/0003-066X.62.4.271

  12. Asian Americans Advancing Justice. Coronavirus/COVID-19 resources to stand against racism. https://advancingjustice-aajc.org/covid19. Accessed April 18, 2020.

  13. Georgetown University School of Medicine. Stop, talk, roll. https://som.georgetown.edu/diversityandinclusion/studentorganizations/stoptalkroll/#c_d161c6cce833. Accessed April 18, 2020.

  14. University of Washington School of Medicine. Recognizing and addressing microaggressions in the learning environment. https://www.uwmedicine.org/education/Documents/wwami/faculty-development-workshop/Recognizing-and-Addressing-Microaggressions-in-the-Learning-Environment.pptx. Accessed April 18, 2020.

  15. Rowe M. Micro-affirmations & micro-inequities. https://cpb-us-w2.wpmucdn.com/sites.udel.edu/dist/0/674/files/2015/12/rowe_microaffirmations-2jhcuc9.pdf. Accessed April 18, 2020.

  16. Kalisch PA. The Black Death in Chinatown: Plague and politics in San Francisco 1900-1904. Ariz West. 1972;14(2):113-136. https://www.jstor.org/stable/40168068?seq=1

  17. Person B, Sy F, Holton K, et al. Fear and stigma: The epidemic within the SARS outbreak. Emerg Infect Dis. 2004;10(2):358-363. doi:10.3201/eid1002.030750

  18. Nagata DK, Kim JHJ, Wu K. The Japanese American wartime incarceration: Examining the scope of racial trauma. Am Psychol. 2019;74(1):36-48. doi:10.1037/amp0000303

  19. Wing JY. Beyond black and white: The model minority myth and the invisibility of Asian American students. Urban Rev. 2007;39(4):455-487. doi:10.1007/s11256-007-0058-6

  20. Hall GCN, Yee AH. U.S. mental health policy: Addressing the neglect of Asian Americans. Asian Am J Psychol. 2012;3(3):181-193. doi:10.1037/a0029950

  21. Ahmad NJ, Shi M. The need for anti-racism training in medical school curricula. Acad Med. 2017;92(8):1073. doi:10.1097/ACM.0000000000001806

  22. Acosta D, Ackerman-Barger K. Breaking the silence: Time to talk about race and racism. Acad Med. 2017;92(3):285–288. doi:10.1097/ACM.0000000000001416

Struggles from the COVID-19 Epicenter and Rim

Ali Mahfuz, MBA and Sujata Ojha
Texas Christian University and University of North Texas Health Science Center School of Medicine

During a time of great uncertainty, two medical students illustrate shared concerns and values in contrasting environments. We share our reflections to provide solace to those who are in relatable situations during these isolating times.

Epicenter- Ali 

Just as everyone thought that cable news was on the verge of disappearing, New Yorkers everywhere huddled together in front of their televisions for a daily COVID-19 briefing from Gov. Andrew Cuomo. As he prepared to deliver an update, I reflected on how almost two months have gone by since I flew back home from medical school in Texas. I came back to uphold my familial responsibility of taking care of my elderly immunocompromised parents. I know, in the back of my mind, that if my dad catches the virus, he will not survive. He is still fighting lung cancer and receiving regular treatment. Fortunately, my medical school shifted temporarily to a virtual modality, allowing me the opportunity to substantially decrease their exposure to this imminent threat. Without me, there is no one else there to pick up groceries, medications, daily necessities, laundry, and so much more.

On May 15th, Gov. Cuomo signed an executive order extending stay-at-home orders a second time for parts of New York. The “New York on PAUSE” order would remain in effect until at least June 13 and I am inundated by dichotomous emotions [1]. On one hand, my family’s health is better protected, but on the other hand, I continue to sacrifice my sanity being trapped at home all day.   

The struggle with social isolation is natural. It impacts our psychological well-being. My understanding of infectious disease makes me several times more aware than the general public of the societal benefits from sheltering-in-place. But I remain envious of those ignorant to the risks of exposure. The ability to grab meals and socialize alleviates the mundane day-to-day life we have all been thrusted into. It provides an escape from the built-up tension that occurs in some households with everyone stuck together. The temptation to compromise my principles are there, lurking in the background, waiting for a chance to overtake me. However, the health and well-being of my parents help reinforce my conviction.

Living through the COVID-19 crisis in New York, I am constantly reminded how fortunate my family is right now. As of June 22nd, there are 389,085 confirmed cases [2]. The deaths and hospitalizations of close friends and family is not a foreign concept. Immigrant families like mine tend to live in small apartments, making social distancing impossible. Most of them are also essential workers who end up bringing the disease back home. As of right now, the number of people I personally know who have passed away from COVID-19 surpasses the fingers on my hand. I pray for their souls and the families they left behind. Social distancing is sadly easier when you have emotional scars to remind you. While we all continue to endure some tough turbulent times, I hope that our concerns for our families can overcome our temptation. 

Rim - Suju

The Friday before spring break, March 6th, was the last time I saw my classmates. I left my apartment to commute back to my parent’s home with only a week’s worth of clothes. Little did I know that the rest of my first year of classes would shift to an online modality. What I thought was a temporary shift rapidly became a new permanent challenge I had to adjust to. We all had to. I never imagined that COVID-19 was brewing an ominous storm, wreaking havoc on both my personal life and education.

Prior to COVID-19, I was determined to maintain strong relationships with my family and undergraduate friends. Luckily for me, I could commute home during the weekends. Having a weekly dinner with my family became my reprieve for pent up anxiety of medical school. Oddly, this transition to online classes from home felt reminiscent of studying through an extended weekend. In reality, I was trapped at home social distancing. Unable to participate in extracurriculars, I indulged in swiping through my phone. The first thing I see is: “Social Distancing Infringes on my Constitutional Rights!”

I gasped in silence as I saw this sentiment circulating on Twitter and Facebook. After only three weeks into quarantine, friends and former high school classmates felt more threatened by our government than the imminent threat of COVID-19. I could not fathom how tensions were rising in my suburban Texas neighborhood.

On May 1st, Texas Gov. Abbott officially opened the state. This meant my mother would have to return back to work at the grocery store. She would be forced to interact with thousands of customers. Knowing how exposed she would be, I felt it was almost inevitable for her to contract the virus. As of June 23rd, the Lone Star state has a total of 119,888 cases with 2,215 deaths [3]. After lifting the stay-at-home orders, Texas went from ranging about 500 to 4,760 new cases per day [3]. How could my heart not ache for all the people who are about to suffer?

Following the return of “freedom,” I observed restaurants and bars filled with crowds of people without masks championing that their life is “normal” again. While the media advocated social distancing and the government trusted us to comply, I felt that so much of society remained ignorant to the risks. I wonder, if I did not attend medical school, how would I react? Would I succumb to the peer pressure to participate? I contemplated if my judgement was coming from a place of envy because I, too, was initially weary of a quarantine. However, envy was the wrong emotion. I truly empathized with those who have and will be affected by COVID-19. The stories of respiratory failure from faculty on the frontline make me more innately aware of the consequences. I just wish society as a whole could share this feeling. I just want everyone around me to realize we live in a time of true antithesis, by doing nothing (staying home), we do the most.

REFERENCE

  1. “No. 202.31: Continuing Temporary Suspension and Modification of Laws Relating to the Disaster Emergency.” Governor Andrew M. Cuomo, 15 May 2020, www.governor.ny.gov/news/no-20231-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency

  2. DD  “Workbook: NYS-COVID19-Tracker.” COVID19, 22 June 2020, covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Map?%3Aembed=yes&amp;%3Atoolbar=no&amp;%3Atabs=n

  3. “Texas Coronavirus Map and Case Count.” The New York Times, The New York Times, 23 June. 2020, www.nytimes.com/interactive/2020/us/texas-coronavirus-cases.html.

Ophthalmology in times of epidemic and pandemic: Past and present

Nishanth S. Iyengar, BS1
1 New York University Grossman School of Medicine, New York, NY 10016, USA

Correspondence concerning this article and requests for reprints should be addressed to Nishanth S. Iyengar (nishanth.iyengar@nyulangone.org)

Epidemics and pandemics in the era of modern medicine have consistently—and rightly—catapulted infectious disease experts into the forefront of public awareness. The ongoing coronavirus disease 2019 (COVID-19) pandemic is no exception: Dr. Anthony S. Fauci, longtime head of the National Institute of Allergy and Infectious Diseases in the United States, has become a fixture of American television and a celebrity in his own right.

Less well-known are the critical roles that ophthalmologists have played in identifying, understanding, and battling catastrophic infectious disease outbreaks. The late Dr. Li Wenliang of Wuhan, China, who sounded the alarm near the beginning of the current COVID-19 pandemic, is perhaps the most salient contemporary example. Dr. Li had worked since 2014 as an ophthalmologist at Wuhan Central Hospital; in late December 2019, Dr. Li grew concerned by what he was seeing in his hospital and alerted colleagues to the potential emergence of a severe acute respiratory syndrome–like disease [1]. Despite being a qualified physician wholly invested in patient care, Dr. Li was promptly “summoned to the Public Security Bureau in Wuhan and made to sign a statement in which he was accused of making false statements that disturbed the public order” [1]. Dr. Li tragically died of COVID-19 about a month later, and hundreds of thousands of others worldwide have also lost their lives during the ongoing pandemic.

Long before COVID-19, numerous epidemics of yellow fever afflicted societies across the centuries and around the world. Yet again, an ophthalmologist played a critical role in the history of the disease and our understanding of its pathophysiology. In 1881, Dr. Carlos Finlay, a Cuban-born ophthalmologist of Scottish and French extraction, publicly posited that Aedes aegypti mosquitoes may have been responsible for outbreaks of yellow fever among human populations [2]. This was the first time that anyone had suggested that yellow fever was not transmitted directly from human to human [3]. In striking similarity to Dr. Li’s original COVID-19 tip-off, Dr. Finlay’s conjecture fell upon deaf ears [3]. Only in 1900 did the United States Army’s Yellow Fever Commission, led by the famed Dr. Walter Reed, corroborate Dr. Finlay’s groundbreaking hypothesis on the transmission of the disease [3]. General Leonard Wood, himself a physician, proclaimed that “the confirmation of Dr. Finlay’s doctrine is the greatest step forward made in medical science since [Edward] Jenner’s discovery of vaccination” [3].

The role of ophthalmologists in addressing outbreaks of infectious disease is not limited to the whistleblowing and epidemiological conjecture heretofore described. Ophthalmologists have provided—and continue to provide—vital care to individuals suffering from debilitating ocular consequences of epidemic and pandemic diseases. Perhaps the most fascinating instance of a purely ophthalmic disease that rose to epidemic proportions is trachoma. Dr. Robert M. Feibel of Washington University School of Medicine wrote in 2011 that “no ocular disease was considered more stubborn and difficult to eradicate than trachoma” [4]. Trachoma had ravaged humanity for millennia because the only therapeutic interventions were ineffective, nonspecific, and had hardly evolved since ancient times until the early 1900s, when an alarming trachoma epidemic was identified within Native American reservations [4]. This eventually spurred Dr. Fred Loe, a self-trained ophthalmologist and longtime employee of the Indian Medical Service, to make the revolutionary discovery that sulfanilamide could definitively cure trachoma [4]. Thanks to Dr. Loe’s pioneering work, by the 1970s trachoma was eliminated from Native American reservations [4].

Infectious diseases seemingly unrelated to the eye have been found to have ophthalmic complications and sequelae. The Ebola virus disease (EVD) epidemic of the mid-2010s, which wrought havoc on several countries in West Africa, is a more recent example of an infectious disease outbreak in which ophthalmologists continue to play a crucial therapeutic role. In 2017, Dr. Jessica G. Shantha of the Emory Eye Center and her colleagues described how “thousands of survivors are at-risk of systemic and ophthalmic sequelae termed the ‘post-Ebola virus disease syndrome’ [PEVDS].” Uveitis, a key component of PEVDS, affects up to one third of survivors of EVD and can lead to devastating loss of vision in the absence of necessary ophthalmic care [5,6]. Yet another example, HIV/AIDS remains an infectious disease with pandemic status, and ophthalmologists are crucial in the diagnosis and management of a critical ophthalmic sequela: cytomegalovirus retinitis [7].

In the same vein as EVD and HIV/AIDS, the present COVID-19 pandemic has spurred ophthalmologists to investigate the possible ocular implications of the disease. In March 2020, a retrospective analysis of 38 clinically-confirmed COVID-19 patients from China’s Hubei province showed that approximately one-third had ophthalmic findings consistent with conjunctivitis [8]. However, another recent study of 121 COVID-19 patients in Wuhan found that only eight patients—fewer than 10%—demonstrated ocular symptoms, including itching, redness, tearing, discharge, and foreign body sensation [9]. Indeed, this is a highly active, ongoing area of research that highlights the important contributions of ophthalmologists during outbreaks of infectious disease.

Finally, I would be remiss if I did not call attention to the extraordinary work done by ophthalmology residents and attending ophthalmologists at my own institution during the current pandemic. Residents were redeployed to medicine wards and joined forces with clinicians from a spectrum of specialties to care for COVID-19 patients. Attending ophthalmologists—including the department chairman—resurrected their knowledge of internal medicine and selflessly volunteered their time and energy to support their colleagues on the inpatient wards during this hugely challenging time. They, along with ophthalmologists around the world who have delivered exceptional care to patients battling COVID-19 and its complications, are true heroes.

REFERENCE

  1. Green A. Li Wenliang. The Lancet. 2020;395(10225):682.

  2. Haas LF. Carlos Juan Finlay y Barres (1833-1915). Journal of neurology, neurosurgery, and psychiatry. 1998;65(2):268.

  3. Finlay, Carlos. Truhlsen-Marmor Museum of the Eye, American Academy of Ophthalmology. https://www.aao.org/biographies-detail/carlos-finlay-md. Accessed May 5, 2020.

  4. Feibel RM. Fred Loe, MD, and the History of Trachoma. Archives of Ophthalmology. 2011;129(4):503-508.

  5. Shantha JG, Crozier I, Yeh S. An update on ocular complications of Ebola virus disease. Curr Opin Ophthalmol. 2017;28(6):600-606.

  6. Eye care for Ebola survivors. World Health Organization. https://www.who.int/news-room/feature-stories/detail/eye-care-for-ebola-survivors. Published 2019. Accessed.

  7. Holland GN. AIDS and ophthalmology: the first quarter century. Am J Ophthalmol. 2008;145(3):397-408.

  8. Wu P, Duan F, Luo C, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmology. 2020;138(5):575-578.

  9. Zhou Y, Duan C, Zeng Y, et al. Ocular Findings and Proportion with Conjunctival SARS-COV-2 in COVID-19 Patients. Ophthalmology. 2020, in press.

Physicians’ Duty to Treat in a Pandemic: A Code of Ethics Approach

Sophia Yin, BS1
1 Harvard Medical School, Boston, MA 02116, USA

Correspondence concerning this article and requests for reprints should be addressed to Sophia Yin (sophia_yin@hms.harvard.edu)

ABSTRACT

In the wake of the COVID-19 pandemic, physicians around the world have faced dire personal protective equipment shortages, leading to questions of what the duty to treat is, particularly in the face of such personal risk. Some have called on physicians’ codes of ethics as a basis for their duty regardless of this risk. In this essay, I present a historical perspective of physicians’ codes of ethics in the United States. I discuss the nuances of physicians’ duty to treat as outlined by their codes of ethics, present limitations to these duties, and argue that there exists a reciprocal relationship between physicians and society.

The current COVID-19 pandemic has been devastating. Of great concern to healthcare providers around the world has been the lack of personal protective equipment (PPE), which has placed many healthcare providers at substantial risk. In the U.S., the CDC’s PPE guidelines allow using facemasks “beyond the manufacturer-designated shelf life during patient care activities” and even using bandanas and scarves as a last resort [1]. As many healthcare workers on the frontlines have begun speaking out about their fears, some have received criticism. Do physicians have a duty to treat despite personal risk, particularly in situations with limited PPE? Many call on codified ethical obligations as support. However, these notions of duty are nuanced.

The duty to care for the sick is embedded in physicians’ codes of ethics. This can be found in the 1847 Code of Ethics of the American Medical Association (AMA), the first national code of medical ethics in the United States, which stated “when pestilence prevails, it is their duty to face the danger, and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives” [2]. However, codes of ethics are dynamic and change throughout time. Through the early half of the 20th century, the duty to treat became less strict. By 1957, the AMA’s code stated that physicians should “render service to the best of [their] ability” during emergencies [3]. Even this was removed by 1977 [3]. However, as a result of the HIV pandemic in the 1980s, the duty to treat was restored in many ethics standards [3]. This was bolstered with legal support in Bragdon v. Abbott (1998), when the Supreme Court ruled that persons with HIV/AIDS are considered persons with disabilities and thus are protected by the American with Disabilities Act (ADA) [4]. However, the Court also ruled that it does not force caregivers to treat an "individual [who] poses a direct threat to the health or safety of others," defined as "a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures or by the provision of auxiliary aids or services” [4].

HIV, however, is not a readily transmissible virus.  A report by the Centers of Disease Control and Prevention (CDC) from November 2016 reported that the cumulative total number of cases of confirmed occupational transmission of HIV to healthcare workers in the United States was 58 cases, and the risk of infection by needlestick injury involving HIV-infected blood is less than 1% [3]. Even before the advent of anti-HIV drugs, the risk to healthcare providers was not high. Thus, much of these refusals to treat may have been rooted in bias towards groups of people considered high risk for infection rather than legitimate concerns about risk. The strengthening of these duties to treat thus served an important role in combatting these biases. However, more recent threats of serious infectious diseases, including COVID-19, provide a characteristically different threat than the HIV pandemic because of their ability to spread with a speed and potential to overwhelm a healthcare system [5]. With potentially greater risk of transmission, these have created new questions surrounding the duty to treat.

Currently, according to the American College of Physicians Ethics Manual: “Physicians take an oath to serve the sick. Traditionally, the ethical imperative for physicians to provide care has overridden the risk to the treating physician, even during epidemics…The social contract between medicine and society also requires physicians to treat all in need of care” [6]. The AMA “social contract with humanity” oath adopted in 2001, states “We, the members of the world community of physicians, solemnly commit ourselves to… apply our knowledge and skills when needed, though doing so may put us at risk” [5]. The current AMA Code of Medical Ethics’ Opinion on Physician Duty to Treat states: “Because of their commitment to care for the sick and injured, 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” [7].

Though codes espouse an ethical obligation to treat, they themselves provide limits to this duty. Like other “special positive duties,” the ethical obligation to treat is considered a prima facie obligation, which has ethically justified limits. The person providing aid is not obligated to take on any and all risks and can even be obligated to not to take on certain risks, depending on the source of the duty and presence of conflicting duties [8]. These limits “originate in the professional virtue of self-sacrifice, which creates the ethical obligation to accept only reasonable risks to oneself in order to fulfill beneficence-based ethical obligations to patients” [2]. While physicians duties often center on self-sacrifice, “self-sacrifice does not create an ethical obligation to accept unreasonable risks in patient care and organizational policy should make this clear” [2]. The AMA code acknowledges this, stating: “The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future” [2]. It is unclear specifically where this balance lies, and who should be making this decision.

The current ethics manuals also reference a social contract between medicine and society. This would imply that if doctors have a duty towards society, conversely, society must also have an obligation to physicians. For example, the ACP Ethics manual also states: “Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous infection-control methods” [6]. As we have seen in the COVID-19 epidemic, this has not necessarily been held true in the case of massive PPE shortages in some places.  Current evidence shows that with effective infection control, the risk of infection with COVID-19 from patients is low and should thus not be feared, however, “the risk of infection without effective infection control does not minimize risk” and “in such clinical circumstances, medical faculty and learners are justified to fear infection” [2]. This scope of this risk also is not limited to the individual, but rather extends to “others whom medical faculty and learners have an ethical obligation to protect, such as family members, friends, and neighbors” [2].

Updated April 14, 2020, the AMA Code of Medical Ethics began a series specific to COVID-19 medical ethics guidance. In it, they addressed whether physicians can “ethically decline” to provide care in the case of unavailable PPE. They justify that some circumstances, such as an underlying health condition that put them at “extremely high risk for a poor outcome should they become infected” is justified [6]. It is not explicit, however, which conditions this includes, whether this factors in duties that this risk might extend to (e.g., family, friends, neighbors), and who would make that ultimate decision. In addition, permitting some physicians but not others to opt out of a duty to treat could be problematic. If some opt out, this thereby increases the risks to their colleagues, which “would encourage more physicians to opt out, increasing the risks even further and leading even more physicians to opt out,” potentially triggering a self-reinforcing cycle of physician withdrawal that ultimately would defeat the duty [3].

Physicians’ oaths and codes of ethics have been historically and currently used as evidence of physicians’ duty to treat in the case of pandemic. However, the extent to which physicians are obligated by their codes is unclear. The duty to treat is a prima facie obligation, and both limits to this duty and the ability to ethically decline is outlined in the codes. However, what has resulted is that many physicians have volunteered from a private, personal sense of obligation. As Danielle Ofrie wrote in a recent op-ed, “For most doctors and nurses, it is unthinkable to walk away without completing your work because dropping the ball could endanger your patients” but continuing the historical practice of “counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine” [9]. Volunteering in the face of this increased risk is “a superogatory—and hence particularly praiseworthy—act” [10]. However, this cannot be an act that comes with praise and little else. Physicians must have access to gowns, masks, and other personal protective equipment; we must take steps to strengthen public health infrastructure; and we should ensure financial benefits to providers and their families in the event of disability or death [3]. If there exists a social relationship in which physicians willingly assume risks to treat, there must be an expectation by society to reduce the risk.

REFERENCE

  1. Strategies for Optimizing the Supply of Facemasks. U.S. Department of Health and Human Services Centers for Disease Control and Prevention.

  2. McCullough L, Coverdale J, Chervenak FA. Teaching Professional Formation in Response to the COVID-19 Pandemic. Academic Medicine.

  3. Orentlicher D. The Physician’s Duty to Treat During Pandemics. American Journal of Public Health 2018;108:1459-61.

  4. Bragdon v. Abbott. Oyez; 1998.

  5. Malm H, May T, Francis LP, Omer SB, Salmon DA, Hood R. Ethics, Pandemics, and the Duty to Treat. The American Journal of Bioethics 2008;8:4-19.

  6. Sulmasy LS, Bledsoe TA, for the ACP Ethics P, Committee HR. American College of Physicians Ethics Manual: Seventh Edition. Annals of Internal Medicine 2019;170:S1-S32.

  7. Affairs ACoEaJ. AMA Code of Medical Ethics’ Opinion on Physician Duty to Treat: Opinion 9.067 - Physician Obligation in Disaster Preparedness and Response. AMA Journal of Ethics June 2010.

  8. In Memoriam: Healthcare Workers Who Have Died of COVID-19. WebMD LLC.

  9. Ofri D. The Business of Health Care Depends on Exploiting Doctors and Nurses. The New York Times June 8, 2019.

  10. Threats IoMUFoM. 4. Ethical Issues in Pandemic Planning and Response.  Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary. Washington DC 2007.

Medical Student Experience During the COVID-19 Pandemic: A Qualitative Study

Madeline Paton, MS1, Gavriel Roda, BS1, and Emily Gottenborg, MD1
1University of Colorado School of Medicine, Aurora, CO 80045, USA

Correspondence concerning this article and requests for reprints should be addressed to Madeline Paton (madeline.paton@cuanschutz.edu)

ABSTRACT

Purpose: As a result of the coronavirus disease 2019 (COVID-19) pandemic, medical education has experienced an unprecedented interruption, with a significant impact on clinical phase medical students, who were considered non-essential healthcare workers and removed from clinical settings.  We sought to better understand the challenges experienced by third and fourth-year medical students to inform future decisions around medical education during global crises.

Methods: We conducted a qualitative descriptive study including eleven interviews of clinical phase medical students from a single institution. Interview guides were based on the following domains: 1) experience during the COVID-19 pandemic, 2) fears and challenges faced, and 3) recommendations for the future. Interviews were recorded, transcribed verbatim, and analyzed using a general inductive approach until thematic saturation was achieved, using the Dedoose web application, Version 8.3.17 (2008).

Results: The following themes emerged regarding the participants’ experience during the COVID-19 pandemic: they reported feeling 1) capable of doing more, 2) a burden to the healthcare system, and 3) loss of control, but they also reported achieving a better understanding of healthcare systems and inequities in healthcare delivery. Finally, they offered recommendations for educational leaders to consider for similar circumstances in the future.

Conclusion: Medical students experienced many challenges as a result of the COVID-19 pandemic, but they were able to offer recommendations and solutions to ameliorate these challenges in future similar circumstances.

INTRODUCTION

Medical education has experienced an unprecedented interruption as a result of the coronavirus disease 2019 (COVID-19) pandemic, with a significant impact on clinical phase medical students who were removed from clinical settings.  In response to the declaration of the COVID-19 pandemic in March 2020, the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recommended a strategy of social distancing to prevent ongoing spread of the disease [1]. Additionally, the CDC offered recommendations to institutions of higher education that included consideration of suspension of classes and group events [2]. On March 17, the Association of American Medical Colleges (AAMC) called for a halt of all student clinical duties for two weeks in order to comply with social distancing and remove unnecessary individuals from the clinical space [3]. On March 30, the AAMC requested removal of students from participation in direct patient care, barring a critical health care workforce need, as students were deemed non-essential healthcare workers [4].

The COVID-19 pandemic raises questions regarding the impact of this interruption on medical education and the appropriate response of medical educators in the event of a national or global crisis in order to protect the safety of medical students, while also utilizing them in the response effort. The decision to remove students from clinical facilities has precedence, which occurred during the 2003 SARS epidemic in Toronto, Canada [5]. Yet medical students have a wide breadth of clinical knowledge and skills, and have been called upon to serve during national crises in the past. During the 1918 Spanish flu pandemic, medical students acted as both intern physicians and nursing staff at the University of Pennsylvania School of Medicine [6]. In the current COVID-19 pandemic, final year medical students were fast-tracked to graduation in Britain, Italy, and American medical schools such as Grossman School of Medicine at New York University and Tufts University in order to expand the medical work force [7]. However, current medical students have expressed opposing opinions regarding desired to be involved in COVID 19 response in the clinical setting [8,9].

The goal of this investigation was to learn the perspectives of medical students at a single institution regarding the impact on their education, identify common challenges that they faced, and gather recommendations to approach medical education during similar national or global crises in the future. 

METHODS

Study Design

Using grounded theory methodology, we conducted a qualitative study of clinical phase, third and fourth-year medical students at the University of Colorado School of Medicine [10]. Semi-structured interviews were conducted from March 30, 2020 to April 8, 2020. We recruited participants through an invitation to participate posted on class-specific social media pages. Informed consent was performed prior to each interview through email. An interview guide was used to assess the following domains: 1) experience and impact on education, 2) fears and challenges, and 3) recommendations (Supplemental Digital Appendix 1). Telephone interviews were recorded and transcribed verbatim. Interviews were conducted until thematic saturation was achieved, which occurred after 11 interviews. Similar protocols have been established in prior publications [11]. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado. 

Analysis

Codes were inductively developed from the interview data by a team of one internal medicine doctor (E.G.), who had prior experience in qualitative methodology, and two medical students (M.P. and G.R.). Code disparities were reconciled by team consensus. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using the Dedoose web application, Version 8.3.17 (2018, Los Angeles, CA, www.dedoose.com). 

RESULTS

Demographics of the participants are shown in Table 1 and represent a diversity of future specialty choice. The major themes generated by the participants focused on the challenges they experienced, and the tension between wanting to participate to a greater extent to support the healthcare system while also feeling like a burden. This tension resulted in a sense of loss of control over their educational experience. However, the participants gained a meaningful understanding of the healthcare system and associated inequities, allowing them to offer actionable recommendations for educational leaders to consider regarding medical student involvement in global crises in the future.

Table 1: Demographic Information of the 11 participants, 2020, Aurora, CO

Medical Student COVID Experience_demographics.png

Capable of Doing More

“We’re a resource that is not being fully tapped,” was a sentiment that was echoed by all of the participants. In response to removing students from the clinical setting, various volunteer opportunities were created, such as hospital mask distribution, phone correspondence with patients with negative viral testing, virtual rounding with inpatients, and coffee delivery to frontline workers. However, some students expressed that there were not enough opportunities for everyone to participate, leaving many sitting idly at home. 

“I’ve wanted to do so much more, but there have been so many volunteers and so many people who have wanted to step up, that there’s not always room for everybody.”

Most students felt that their training thus far had prepared them to assist in the clinical setting and that they were not being used to their fullest potential. 

“We are all going through this extensive training to become these very specialized tools, and the second that this erupted we got put on the back shelf in the work room. . . I could be doing infinitely more than I am now from a clinical perspective.”

All of the fourth-year participants expressed that they felt prepared work on the front lines. Collectively, they believed that they would contribute more to frontline clinical care now rather than waiting for the official start of their internship year.

“I’d argue that I’ll probably know a little bit less in two months than I do now. . . if I can learn now when we’re still on the upswing, rather than in two months when potentially we’re hitting the peak, I feel like I could be a much more valuable asset.”

The tension created by having invested much of their lives training for a medical career and suddenly being pulled from their roles created an identity crisis for many of the students.

“I have never felt closer with the medical system, but also, I think it’s one of the times I’ve felt the farthest from it and the most removed.”

Burden to Healthcare System

“The overwhelming sense that I’ve gotten from classmates, that I would agree with, is that people want to help if we can [but] also don’t want to be a burden on the system.” Nearly every student referred to themselves as a “burden” to the healthcare team or system and was especially prominent in interviews with the third-year students.  

“The idea of being sent to the front lines stresses me out a lot. I think part of that has to do with the theme that I brought up earlier of feeling like I am burdening a team as a medical student.”

Participants described that hospital staff were already working under high levels of stress, and the presence of a medical student could be detrimental to workflow. 

“The mental load that it would take to also be aware of a medical student and supervise what they are doing would perhaps detract from patient care overall.”

Many students stated specifically that their use of personal protective equipment (PPE) would burden the healthcare system and that the decision to remove students was justified by efforts to reduce its use. Interestingly, many of these same students expressed ways in which they could be in service without creating a burden.

Loss of Control

“It’s a lot of control that I have to let go ... I can’t control my schedule. I can’t control my rotations. I can’t control away rotations.”Much of a medical student’s life is under the control of scheduling lotteries and algorithms, but the interruption due to COVID-19 created a sense of a more devastating loss of control, especially among the third-year medical students. Third-year students expressed deep concern for loss of sub-internship rotations, visiting student rotations, letters of recommendation, Step 2 cancellations and the associated impact on their residency match, and future career success.

“I think that has been the hardest thing: Recognizing that the application that I dreamt up for myself isn’t going to be the application I am going to be turning in anymore. [There is] a lot of uncertainty about whether or not I am going to [be] as competitive of an applicant as I anticipated that I would be, and to what extent other students are going to be affected by this and whether that is going to change how I appear relative to them.”

Students expressed experiencing high levels of distress and anxiety due to their “projected medical school path [being] radically changed.”

“It’s been pretty anxiety provoking to feel like the answers to a lot of big questions about direction that our careers are changing from day to day.”

Educational Impact and Healthcare Systems

“I really wish we could be in clinic right now because, I was really excited about wrapping up all of my clinical experiences this year… it was gonna bring everything together and provide a nice conclusion to 3rd year.” Overall, most students stated that the interruption in clinical rotations negatively affected their education due to the loss of hands-on clinical training, access to preceptors, career planning, and ‘missing out’ on critical clinical electives and opportunities. A fourth-year student entering emergency medicine had planned to participate in an ultrasound elective before the pandemic hit. He described the online adaptation of this hands-on elective:

“[it is] hard to do ultrasound if you don’t have a patient... Definitely the online version of it was less than ideal.”

Third-year medical students lost “non-essential” rotations, and one student felt they were missing key pieces of their education. 

“I’m not going to get an emergency medicine experience. I’m not going to get an orthopedic experience. It’s kind of weird that those are considered expendable rotations.”

One fourth-year medical student expressed concern about beginning internship in a chaotic environment.

“I wonder how this affects our residency training when you’re about to enter an environment where doctors will have been, for the preceding three or four months, just inundated with this pandemic and stressed and overworked. Now we’re these new people going in, who usually can use a little more handholding. I just wonder, will people be able to do that? And will we feel safe going into this environment if we don’t have as much oversight as month-one interns would [usually] get?”

However, many students highlighted that this experience served as a crash course in the inner-workings of the healthcare system and “laid bare the issues …  in terms of equity and health care access and how [the healthcare system] prioritizes individuals.” Students emphasized that this impacted their perspective of the system they are entering. 

“I think I have been disappointed, but not hugely surprised, to see the way our country is handling this and the way that our health care system is set up to handle [the pandemic.] It confirmed for me that I am entering a career in a broken system.”

Although health inequities are a topic of discussion throughout the medical curriculum, some believed they would have benefited from a more robust curriculum on healthcare systems, vulnerable populations, and advocacy.

“My hope would be that our evidence based medicine curriculum and the public health thread that we have throughout the four years of medical education would be beefed up with a bit of additional training in epidemiology and how to control infection and manage large scale crisis … in a way that would make us a more empowered and a less confused if this were to happen again.”

Importantly, this experience confirmed some students calling to serve and advocate for vulnerable populations. 

“I really want to work marginalized, underserved, and under-privileged populations. If anything, this experience has just furthered my desired to do that.”

Although this negatively affected students’ medical education, they largely found that they were learning critical aspects of the form and function of the healthcare system that could not otherwise be taught in a classroom setting.  

RECOMMENDATIONS FOR THE FUTURE

“I am hopeful that because we have lived through this now, that medical education will evolve... to include some sort of training about what we do if this happens again.” Most students echoed this hope and were able to provide recommendations for how they believed they could be best utilized during the current and future crises. The overwhelming sentiment was that students could be used to support frontline clinical staff in various meaningful ways, acknowledging that this may require ample PPE.

“It hinges on having enough personal protective equipment to be useful and not a burden. If there were enough masks and gowns for us to be in the hospital we could function as support staff in a variety of ways, we write the notes. We have been doing it several years.”

“Allowing us to... take histories, talk to patients, explain plans, and take some of the load off the attendings and residents. We have enough capacity to do those sorts of things and be helpful.”

Students offered ideas for how they could continue to function within specific specialties less burdened by the pandemic, which would also offer them meaningful experiences in their future specialty choice.

“The decision to pull students from the clinical spaces policy was applied too broadly perhaps and we should have thought more specialty specific about what needs were going to look like in the clinical space. Women are still giving birth right now, and in a lot of places they are having to labor by themselves because of the policies that have been applied with regards to visitors. So, because I know that I know how to coach somebody through labor and I also know that it is bad for woman and babies to have to labor totally alone. I wish I had the ability to go into the hospital and just be with woman that is pretty formative in their own life experiences.

 One fourth-year student suggested working with palliative care teams to be with patients who were alone as a result of visitor restriction policy. 

“We are just dealing with something that is devastating and sudden for people. A lot of us have an interest in palliative care or just we have the time... we could be there for families.”

In addition to contributing as support staff, students recommended using their skills to support and advocate for their community in times of need, which could strengthen their commitment to advocating for change in the future.

"Advocacy -- which we can do. . .  and take these lessons and be like, ‘hey I was there, I saw how it affected these populations,’ and when I’m an attending physician I can say, ‘I’m gonna work to try and get things changed so that,  maybe policies are different next time something like this happens.”

DISCUSSION

This study described the impact that the COVID-19 pandemic is having on clinical phase medical students, and highlights the tension between their desire and ability to contribute and feeling like a burden. Medical students spend a significant portion of their training rotating through various clinical specialties and transitioning across healthcare teams, where adapting to new roles and environments is critical to their success. The students in our study felt they could use this flexibility to provide meaningful clinical support to participate in COVID-19 efforts. Two solutions were proposed to better incorporate medical students clinically, in the event of future infectious outbreaks or clinical crises: (1) recruit students to serve as support staff with the main objective to reduce the workload faced by attending and resident doctors, and (2) allow students to continue seeing patients in specialties that were affected to a lesser extent. Overall, the adaptability of medical students makes them uniquely equipped to participate in clinical efforts, and by providing them with clinical opportunities it both supports their educational development and creates a qualified work force.  

Though students expressed their desire to participate in clinical support roles, they were hesitant to share their disappointment upon removal from clinical settings. Nearly all interviewees prefaced negative emotions by rationalizing the justification cited by educational leadership, largely centered around preservation of PPE. Surprisingly, they did not perceive that decisions were made in order to protect their health and safety, a sentiment noted by trainees at other institutions during this and historical crises.11,12 In the context of limited PPE, nearly every student considered the broader implications of the pandemic as it related to the functionality of the health care system and its associated inequities and disparities, causing students to call for increased curricular offerings on advocacy, public health, infection control and epidemiology. While most graduating medical students have a shared sense of duty and wanting to help people, there was overwhelming report that this confirmed, or in some cases ignited, a calling for working with marginalized populations. Due to the significance impact of this pandemic, we hypothesize that we will see a change in this generation of physicians’ ability and desire to advocate for systematic change.

Perhaps the most concerning finding was the overwhelming sense that students believe they are a burden to healthcare teams and systems, and we are concerned about the long-term consequences of this sentiment. Medical students are encouraged by their colleagues and mentors to function as an integral part of the health care team. They are told to act as their patients’ primary provider and were included in all aspects of care. Yet during the pandemic, this sense of ownership and inclusion dissipated rapidly to feelings of unimportance and being burdensome. We hypothesize that the language used to describe PPE conservation efforts contributed, based on the overlapping thematic analysis between “burden” and “PPE.” Preserving PPE as a vital resource is a necessary strategy, however, the messaging communicated to students that they are not critical to delivery of patient care. We uncovered an emerging “identity crisis,” where students felt the tension between undergoing years of training to serve an integral role in society, and being told to “take a backseat” during a crisis.

CONCLUSION

Medical students experienced many challenges as a result of the COVID-19 pandemic, but they were able to provide solutions and ways in which the medical education community can grow from this experience.  As an educational community we need to support students to return to their previous level of autonomy and ownership, and acknowledge that the sense of burden could have lasting psychological consequences following them into residency, and preventing their development into confident physicians.  In the ongoing efforts to combat the COVID-19 pandemic, we can incorporate some of the valuable recommendations shared in this manuscript to embed medical students as essential members of the clinical healthcare team.

Acknowledgements: None

Funding/Support: None

Other Disclosures: None

Ethics Approval: This study was deemed exempt by the Colorado Multiple Institutional Review Board (COMIRB)

Disclaimers: None

Previous Presentations: None

REFERENCE

  1. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf. Updated March 12, 2020. Accessed March 22, 2020.

  2. Interim Guidance for Administrators of US Institutions of Higher Education. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-ihe-response.html. Updated March 18, 2020. Accessed March 22, 2020.

  3. Guidance on Medical Students’ Clinical Participation Effective Immediately [press release]. Association of American Medical Colleges, March 17, 2020.

  4. Interim Guidance on Medical Students’ Participation in Direct Patient Contact Activities: Principles and Guidelines [press release]. Association of American Medical Colleges, March 30, 2020.

  5. Clark J. Fear of SARS thwarts medical education in Toronto. Bmj. 2003;326(7393):784.

  6. Starr I. Influenza in 1918: recollections of the epidemic in Philadelphia. 1976. Ann Intern Med. 2006;145(2):138-140.

  7. Goldberg E. Early Graduation Could Send Medical Students to Virus Front Lines. The New York Times. March 26, 2020.

  8. Aldag E. I’m a fourth-year medical student. I don’t want to graduate early. Association of American Medical Colleges. American Web site. https://www.aamc.org/news-insights/i-m-fourth-year-medical-student-i-don-t-want-graduate-early. Updated April 14, 2020. Accessed April 14, 2020.

  9. Miller DG, Pierson L, Doernberg S. The Role of Medical Students During the COVID-19 Pandemic. Ann Intern Med. 2020.

  10. Strauss A, Corbin J. Grounded theory methodology. Handbook of qualitative research. 1994;17:273-285.

  11. Rambaldini G, Wilson K, Rath D, et al. The impact of severe acute respiratory syndrome on medical house staff: a qualitative study. J Gen Intern Med. 2005;20(5):381-385. 

  12. Gallagher TH, Schleyer AM. “We Signed Up for This!” — Student and Trainee Responses to the Covid-19 Pandemic. New England Journal of Medicine. 2020.



Hospital Delirium and the Long Tail of COVID-19

Benjamin Oseroff, MA, MPhil1
1 Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA

Correspondence concerning this article and requests for reprints should be addressed to Benjamin Oseroff (boseroff@gmail.com)

ABSTRACT

The COVID-19 pandemic promises to increase the incidence of delirium among hospitalized, older patients. This viewpoint explores the challenges in treating delirium during COVID-19 and how an increase in delirium might extend the impact of the pandemic. As we move past the early phase of the outbreak, hospitals and postacute care facilities should prioritize adapting existing best practices to treat delirium and manage its long-term effects. Virtual technologies may have a role to play as part of a temporary solution but are unlikely to be sufficient long-term. This perspective is informed by my experiences as a Hospital Delirium Program volunteer at Mount Sinai Morningside in New York City.

The COVID-19 pandemic is disproportionately hospitalizing older patients, promising a marked increase in cases of hospital delirium. Delirium is an acute confusion caused by a medical condition and one of the most common complications for patients over 65, estimated to occur in 29-64% of hospital admissions [1]. The total health care costs associated with delirium in the United States are estimated to be more than $181 billion (2020 dollars) per year [2].

Delirious patients can present as agitated, lethargic, or alternate between the two. Often undiagnosed, delirium is associated with increased morbidity, longer hospitalization, and higher mortality up to 12 months post-hospitalization [3]. Advanced age, visual impairment, poor mobility, and depression are all risk factors associated with delirium, though the underlying mechanism varies from patient to patient [4].

The risk of developing delirium is exacerbated for patients on ventilators, many of whom are prescribed medications for sedation that can increase a patient’s chance of developing delirium. Previous estimates put the incidence of delirium at 60-85% for patients receiving mechanical ventilation [5]. There may also be additional risks specific to this coronavirus. A recent study from Wuhan, China found that nearly 40% of hospitalized patients with COVID-19 developed neurological symptoms, including a smaller subset who experienced consciousness changes consistent with delirium [6]. Delirium may be a key presenting symptom of COVID-19 among older patients who do not exhibit the same symptoms as younger adults [7]. This is consistent with evidence that delirium was common among those infected during the acute stages of the MERS and SARS outbreaks [8].

While common and serious, hospital delirium is not inevitable. Multicomponent interventions, like the Hospital Elder Life Program (HELP), have shown significant promise in treating and preventing delirium. At more than 200 HELP sites worldwide, interdisciplinary health teams screen patients and volunteers provide nonpharmacological interventions to maintain physical and cognitive functioning during hospitalization and through the transition home. A systematic review and meta-analysis of evaluations of HELP showed the program reduced delirium incidence by 53% and achieved average cost savings of $2700 per patient per hospitalization [9]. At Mount Sinai Morningside Hospital in New York City, I am part of a cadre of dedicated volunteers who deliver nonpharmacological interventions, such as therapeutic conversation, music, and sensory supports to promote cognitive stimulation, reorient patients to their environments, and increase mobility.

My experiences as a volunteer lend a personal anecdote to the evidence on treating and preventing delirium. Over the past 12 months, I have seen how nonpharmacologic interventions are key to managing delirium, particularly for patients who may not have consistent visitors to engage with them throughout lengthy hospital stays. Often alone for much of the day, elderly hospitalized patients can quickly lose hold of their normal rhythm. I frequently walk into a room to find a patient asleep in the middle of the day with the lights off. Other times, patients are awake and yet newly unable to communicate. Apparently simple interventions, such as opening the blinds, playing a favorite song, or asking about a patient’s childhood, can have dramatic effects on patients’ orientation and comfort. I remember one patient this past fall who, upon hearing a favorite song from his childhood, went in minutes from being non-verbal to singing along. The gratitude many patients express for returning to their normal selves has made volunteering in the Hospital Delirium Program one of my most meaningful clinical experiences.

As the number of COVID-19 cases continues to rise, shortages of beds, staff, and protective equipment have pushed hospitals to cancel elective procedures and restrict patient visitors. At many hospitals, this also understandably includes suspending volunteer programs like the Hospital Delirium Program at Mount Sinai Morningside. In combination, these steps promise to isolate vulnerable patients at a time of profound need.

The COVID-19 outbreak and the necessary response may undo much of the progress hospitals have made in recent years to reduce hospital delirium. In addition to limiting visitors, clinical best practices such as waking patients and mobilizing them for exercise have been abandoned in some cases for fear of promoting spread of the virus [10]. Drugs that are low-risk for delirium that are used for sedation for ventilation such as dexmedetomidine and propofol are in short supply, leading critical care physicians to switch to delirium-inducing drugs such as benzodiazepines [11]. A recent report from France detailed the neurological findings from 58 COVID-19 patients admitted to the ICU with acute respiratory distress syndrome (ARDS). More than 85% of the patients received a benzodiazepine (midazolam) as part of their ventilation and 65% of patients were positive on the Confusion Assessment Method-ICU (CAM-ICU) assessment, indicating delirium [12].     

While the toll of the pandemic is currently measured on a daily or weekly basis, delirium, left untreated, could extend the tail of COVID-19 for several months. Those who develop delirium in the hospital often suffer from long-lasting cognitive deficits. Symptoms are often similar to mild Alzheimer’s disease or moderate traumatic brain injury. This will pose an additional strain on those tasked with caring for patients when they leave the hospital, such as skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, and home health agencies. These facilities normally operate with high occupancy rates, and already there are calls to build a surge capacity in postacute care facilities in anticipation of increased demand [13]. Once inundated with COVID-19 patients, postacute care facilities may then face the same pressure as hospitals to isolate patients from family and visitors for infection control. This may further limit the ability of patients with delirium to return to baseline.

Hospitals and postacute care facilities should consider how to develop new strategies to mitigate the delirium-related impact of COVID-19 in a way that is safe for health care workers, volunteers, families, and patients. Supply allowing, hospitals should prioritize the reduced use of delirium-inducing benzodiazepines for the elderly patients at highest risk for developing delirium such as those poor mobility, advanced age, and visual impairment. Elderly patients should be universally screened for delirium using validated tools such as the CAM, which can be performed by non-mental health professionals. Allowing limited family and caregivers to visit would be an important step to reduce patient isolation and manage delirium. However, required personal protective equipment may limit the quality of in-person interactions and will likely contribute to further sensory impairment and disorientation for patients.

When in-person visiting is not possible, facilities should also consider using digital technologies to connect patients to family members, who are relied upon in best practice to help diagnosis delirium by identifying cognitive changes from baseline. A similar protocol using phone calls was already standard practice at Mount Sinai Morningside pre-COVID-19 for patients who did not have caregivers present. At sites with established programs, volunteer patient visitors could also virtually continue to converse with patients, play music, and deliver other effective preventive interventions. While best practices are emerging for using telemedicine to reach elderly patients at home, this modality has not been studied for treating hospital delirium specifically [14]. Virtual visiting is likely to present an extra challenge for elderly patients with delirium who may be less adept at engaging with technology and may require additional supervision to use virtual devices. Not being in-person will also limit the ability of volunteers and family members to encourage mobility and make environmental adjustments. I have also found through my own experiences that simple physical touches, such as squeezing a hand, can be key to forming personal connection with patients and helping them return to their usual selves. For these reasons, virtual visiting should only be a temporary substitute.

The spread of COVID-19 and the challenges of treating patients during the pandemic mean there is almost certain to be a rise in the cases of delirium. Focusing on preventing and treating delirium, however, is essential to ensure the burden of COVID-19 does not extend unnecessarily long. At its core, delirium management is about treating the patient as person. While we may have to modify our approach, this ideal should remain at the center of health care, in times of crisis and not.

REFERENCE

  1. Inouye, S. K., Westendorp, R. G. & Saczynski, J. S. Delirium in elderly people. The Lancet 383, 911–922 (2014).

  2. Leslie, D. L. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch. Intern. Med. 168, 27 (2008).

  3. Kiely, D. K. et al. Persistent Delirium Predicts Greater Mortality. J. Am. Geriatr. Soc. 57, 55–61 (2009).

  4. Vasilevskis, E. E., Han, J. H., Hughes, C. G. & Ely, E. W. Epidemiology and risk factors for delirium across hospital settings. Best Pract. Res. Clin. Anaesthesiol. 26, 277–287 (2012).

  5. Pun, B. T. & Ely, E. W. The Importance of Diagnosing and Managing ICU Delirium. Chest 132, 624–636 (2007).

  6. Mao, L. et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. (2020) doi:10.1001/jamaneurol.2020.1127.

  7. O’Hanlon, S. & Inouye, S. K. Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing afaa094 (2020) doi:10.1093/ageing/afaa094.

  8. Rogers, J. P. et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry S2215036620302030 (2020) doi:10.1016/S2215-0366(20)30203-0.

  9. Hshieh, T. T., Yang, T., Gartaganis, S. L., Yue, J. & Inouye, S. K. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am. J. Geriatr. Psychiatry 26, 1015–1033 (2018).

  10. Inouye, S. K. The Epidemic Within the Pandemic: Delirium. The New York Times (2020).

  11. Buckley, B. COVID-19 Triggers Spike in ICU Delirium. Pharmacy Practice News (2020).

  12. Helms, J. et al. Neurologic Features in Severe SARS-CoV-2 Infection. N. Engl. J. Med. NEJMc2008597 (2020) doi:10.1056/NEJMc2008597.

  13. Arora, V. S. & Fried, J. E. How Will We Care For Coronavirus Patients After They Leave The Hospital? By Building Postacute Care Surge Capacity. Health Affairs Blog https://www.healthaffairs.org/do/10.1377/hblog20200408.641535/full/ (2020).

  14. Solberg, L. The Keys to Effective Telemedicine for Older Adults. Improvement Blog http://www.ihi.org/communities/blogs/the-keys-to-effective-telemedicine-for-older-adults (2020).

The Latino Medical Student Association COVID-19 Response

Zach Jaeger, B.S.1,4, José G. Grajales-Reyes, B.S.1,4, Richard Ferro, MSc.2,4, and Donald Rodríguez, B.S.3,4

1Washington University School of Medicine, St. Louis, MO 63110, USA
2Quinnipiac University, Frank H. Netter MD School of Medicine, Hamden, CT 06518, USA
3University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
4Latino Medical Student Association, Tallahassee, FL 32301, USA

Correspondence concerning this article and for further communications should be addressed to Zach Jaeger (service@lmsa.net)

Abstract

The Latino Medical Student Association (LMSA) is a national non-profit organization with the mission to unite and empower medical students through service, mentorship, education, and advocacy for the health of the Latinx community. In response to the COVID-19 pandemic that has magnified health inequities, our group of nearly 150 active chapters has unified to meet community needs. At a local and regional level, many have provided services and created resource archives to support frontline providers and other essential workers. To address the language barrier for many Latinxs, some chapters have developed and distributed video series and infographics in Spanish to dispel myths and educate the public on the coronavirus and public health. At a national level, the LMSA supports its members through wellness initiatives and webinars, pre-medical student mentorship, continuing medical Spanish curricula, and promoting research. As an organization of future physicians, we admire and appreciate our role models risking their lives on the front lines. To fulfill our duties to each other and to the community, we aim to answer the needs of our community during this difficult time with a unified, robust response.

Disclosures

All of the authors hold a position on the National Executive Board of the LMSA. Zach Jaeger is the National Service Chair of the LMSA. José G Grajales-Reyes is the Vice-Chair of Internal Affairs of the LMSA. Richard Ferro is the Vice-Chair of External Affairs of the LMSA. Donald Rodríguez is the National President of the LMSA.

In the wake of the COVID-19 crisis in the United States, members of the Latino Medical Student Association (LMSA) have grappled with both their innate desire to help others in times of need and their duty to advocate for the health of underserved communities. As a national, student- run, 501(c)(3) non-profit organization with nearly 150 active chapters, LMSA exists to unite and empower medical students through service, education, and mentorship to advocate for the health of the U.S. Latinx population. In this vein, we have developed and supported grassroots efforts to promote the well-being of our patients and peers. These efforts include the creation of a national archive of COVID-19 resources in Spanish and English, the dissemination of service opportunities to aid healthcare workers at the frontlines of COVID-19 care, and the expansion of mentorship initiatives to support trainees from backgrounds historically underrepresented in medicine (URiM).

In several U.S. metropolitan areas, COVID-19 has disproportionately affected communities of color, with Hispanic patients experiencing higher infection and mortality rates compared to non-Hispanic whites. To address this disparity, LMSA has sought to provide Spanish-speaking patients with culturally and linguistically relevant resources for them to better protect themselves against SARS-CoV-2. At a chapter level, members at various medical schools have recorded informational videos in Spanish to educate the public and dispel myths that recur in Latinx social media. Accompanying infographics highlight these videos’ major points in an accessible manner, and Spanish-speaking physicians participate in and review these productions to ensure medical accuracy before distribution. At a regional level, our students have published comprehensive summaries of resources available to inhabitants within a particular city or area, often leveraging support of multiple medical schools and enhancing local outreach. At a national level, LMSA continues to compile bilingual patient education materials. We welcome additional content from academic and community partners to further empower our patients.

Moreover, LMSA has sought to alleviate the added burden placed on healthcare providers. In concert with our efforts to bolster medical Spanish education and practice, LMSA members have helped provide unofficial Spanish interpreter services for hospitals and clinics. Our members have also played integral roles in sourcing commercial and homemade PPE; recruiting volunteers for blood and plasma donation; and supporting frontline healthcare workers through childcare, tutoring, and food delivery.

Lastly, in striving to ensure the welfare and success of URiM medical students, LMSA has significantly increased its programming to support trainees in their academic, clinical, and extracurricular endeavors. We provide virtual forums for our members to connect regarding the status of licensure examinations, visiting clinical clerkships, and residency interviews. We host mentorship videoconferences for premedical students to help them navigate the medical school application process. LMSA also educates members on how to draft policy resolutions for medical organizations to adopt, thereby encouraging them to actively advocate for communities in need.

Through these initiatives and others, LMSA and its members proudly support our communities and our colleagues as we all work to overcome this COVID-19 challenge.

Links: LMSA COVID-19 Response Google Drive; LMSA Website; LMSA Mission
Twitter: @LMSA_National
Instagram: lmsa_national
Facebook: @LMSANational

Contacts:
Zach Jaeger, B.S. (zjaeger@wustl.edu)
National Service Chair, Latino Medical Student Association (service@lmsa.net, covid19@lmsa.net)

José G Grajales-Reyes, B.S. (grajalesj@wustl.edu)
Vice-Chair of Internal Affairs, Latino Medical Student Association (internal@lmsa.net)

Richard Ferro, B.S., MSc. (richard.ferro@quinnipiac.edu)
Vice-Chair of External Affairs, Latino Medical Student Association (external@lmsa.net)

Donald Rodríguez, B.S. (dmrodriguez@uchicago.edu)
National President, Latino Medical Student Association (president@lmsa.net)

From the Sidelines

Jin Kyung Kim
Virginia Commonwealth School of Medicine

As a third year medical student waiting for the transition from pre-clinical didactic learning to hands-on clinical learning, I was faced with an unexpected halt in my long awaited clinical training with the onset of COVID-19. I wondered what best I could do as a student without any licensure in medicine as I read about the brave front-line healthcare workers I aspire to be. One of the ways I chose to utilize this uncertain time in-between online electives is to enlist myself as a volunteer for the Virginia Medical Reserve Corps. My application was marked as a “non-medical volunteer” as a student without a medical license and I expected to help with administrative items. When I showed up for my first assignment as a language interpreter for Korean at a local county COVID-19 drive-thru screening site, I was fitted in extensive personal protective equipment and the reality of this pandemic suddenly hit me. The following poem in iambic pentameter with rhyme scheme is a reflection of my experience as a medical student yearning to be of help during this pandemic from the sidelines at a COVID-19 screening site.

Some wore medical grade clean in all white
Some wore fashion studded with polka dots
Some wore a bandana wrapped around tight 
Some wore a piece of an old shirt in knots

Some born in the sixties like my own mom
Some leaned as thin as their own walking cane
Some young students who should have been at prom
Some in strollers with their blue toy airplane

Some did not need me to translate the form
Some asked me for my language assistance
Some approached me close I could feel their warmth
Some made my voice grow hoarse from a distance

Some told me they have never been sick, ever
Some said they lost their sense of taste and smell
Some revealed shortness of breath and fever 
Some scrolled through the news and felt more unwell

We all stood under the Virginia sun:
A line of over a thousand patients,
Tables of nurses faced them one-on-one,
Volunteers united under patience

I stood drenched in sweat writing intake forms,
In N95, gown, gloves, and face shield,
Hoping I made no mistakes on the forms,
My own fears of infection well concealed 

I stood wondering and dripping with sweat
When will I finally start my third year?
As a student without a license yet,
Am I at all making a difference here?

Telemedicine for Clinical Experiences in the COVID-19 Era of Medical Education: Two Student Perspectives

Tanir Moreno, MS1, John Rafael, BA1, Brianna Marschke, BS1, and Stephanie Bui, BS1
1 Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430, USA

Correspondence concerning this article and requests for reprints should be addressed to Tanir Moreno (Tanir.Moreno@ttuhsc.edu)

Abstract

Nationwide cancellations of clerkships for third- and fourth-year medical students due to COVID-19 spurred the quick implementation of alternative learning methods. Although the preclinical curriculum is less affected, widespread interruptions of student volunteerism involving patient care such as student-run free clinics contribute to the effective halt of clinical experience for medical students in all stages of their education. Due to this disruption, our institution implemented telemedicine as an alternative method of continuing clinical experience both in clerkship settings and at our free clinic. As four medical students of various years, and therefore varying experiences in using telemedicine, we hope to reflect on its effectiveness and implications for the future of medical education.

Background

Clinical experience as a medical student has consisted of practicing skills such as taking a detailed history and performing a thorough physical exam since the advent of modern medical education. However, COVID-19 abruptly altered today’s landscape of medical education due to the widespread cancellations of clerkships and extracurricular activities involving patient care. Medical schools across the nation have scrambled to create curriculum changes quickly to allow students to continue their education in some form, including the unique implementation of telemedicine.

Telemedicine is an established, evidence-based practice that has been in use for decades and involves “two-way, real time interactive communication between the patient and the physician or practitioner at [a] distance site” [1]. The World Health Organization (WHO) recommended the use of telemedicine to “complement, rather than replace the delivery of health services” and recognized it as a viable option for increasing access to health workers in rural areas [3]. At Texas Tech University Health Sciences Center (TTUHSC) School of Medicine in Lubbock, Texas, an institution that serves 108 counties and covers an area of 131,000 square miles [4], telehealth has long been a necessity to increase access to healthcare for the vast West Texas area. Thus, TTUHSC was one of the early pioneers of telehealth leading to its development into a robust department since 1989.

Our institution’s preexisting infrastructure with telehealth enabled a relatively seamless progression to its utilization in student clinical education in response to COVID-19. As four medical students in various stages of our education, we recognize the widespread applications of telemedicine as a response to mitigating the lack of clinical experience and perhaps even as a learning tool that will revolutionize medical education for years to come.  

Telemedicine in Third-Year Clerkships

As a third-year medical student, I was in my psychiatry clerkship when COVID-19 hit.  Clerkship directors struggled to find appropriate alternatives for me and my classmates to continue our final rotations without the option of in-person activities. I fully expected my level of clinical involvement in my psychiatry rotation to significantly decrease as a result. However, in a matter of weeks our psychiatry department created and implemented a telemedicine curriculum combining inpatient and outpatient experiences.

I was initially concerned that telemedicine as a medium of patient care would be impersonal, a concern shared by many new users of telehealth. In fact, “resistance to change” is the second largest barrier to telemedicine behind the technological challenge [5]. However, I found that the patient visits were not at all compromised during my clerkship. In fact, virtual interactions with patients became even more meaningful, as the limited human interaction both students and patients were experieincing increased the value of each visit beyond its clinical context.    

It is also an important consideration as to whether telemedicine is generalizable to other rotations beyond psychiatry; this clerkship generally involves limited “hands-on” interaction compared to other rotations, such as surgery, which are comprised of more technical skills.  Telemedicine’s compatibility with these rotations is not proven,  but I consider it the best option we currently have during clinical cancellations. At the very least, telemedicine allows for observation of physicians performing physical exam techniques and allows students to practice interviewing patients, which would otherwise be unavailable at this time.

Although I wish that the circumstances were different, I am thankful to have continued my clinical experience through telemedicine in the midst of COVID-19 and hope to see its broader implementation in medical schools around the nation. Telemedicine’s drastic increase out of necessity during a global public health emergency suggests that the future holds increased roles for digital healthcare solutions and more widespread acceptance of their usage. Hence, it will likely also have a lasting role in medical education in the coming years, as clerkships tend to mirror the current trends and techniques utilized in practice.

Telemedicine in Student-Run Free Clinics

As first-year medical students at TTUHSC serving on The Free Clinic leadership team, we struggled to facilitate patient care for the uninsured and indigent population of Lubbock when COVID-19 restrictions began. In-person patient visits and student participation were curtailed, meaning that patients were losing their only source of healthcare and students were losing a valuable clinical learning opportunity. Student-run free clinics across the nation faced the same problem and models of telemedicine were created and shared with promising results. Understanding that effective care was still possible even in the face of the pandemic, our leadership team worked quickly to finalize the protocol and smooth out logistics for the implementation of telemedicine at our clinic. Within a couple of weeks, telemedicine at the TTUHSC Free Clinic came to fruition.

The benefits of this new telemedicine protocol are far-reaching. Not only are we able to allow students of all years to continue gaining experience seeing patients independently, but we are also able to provide direct care to patients in need. Furthermore, the future applications of this method of healthcare are particularly exciting. We have discussed its continued usage when clinic operations return to normal as an additional tool to allow medical students and patients unable to physically appear in clinic to still participate in the provision and receipt of care, respectively. Additionally, telemedicine can expand our services, particularly in mental health, to patients in the region and serve as an educational tool for students interested in using telemedicine in their respective careers.  

Although we feel that the benefits of offering telemedicine far outweigh any costs, some challenges continue to need further attention. Not all established patients at our free clinic have access to or knowledge of how to seek care through telehealth. Some patients also report hesitancy in adopting telemedicine, instead insisting on waiting for physical visits or more established models of communication such as phone calls. Even with our clinic’s emphasis on bridging the technological gap (e.g. providing tablets for telehealth visits, sending clear instructions to access telehealth visits, etc.), it is difficult to control for variables such as a stable internet connection or a private space in which to conduct the appointment. Given the correlation of low health literacy with a lower likelihood of using newer forms of health technology [6], increasing both health and technological literacy of patients drives our refinement of telemedicine use for the benefit of our patients.   

The COVID-19 pandemic may have altered our respective clinical educations, but it has also reaffirmed our desire to find innovative ways to serve the community. Both our students who make up the backbone of our operations and the patients we serve constantly remind us that, even in the face of adversity, a collective of mission-driven stakeholders can still work together to serve others.

Final Thoughts

Virtual options such as telemedicine are already rising in popularity as modalities to continue medical education. The United States Medical Licensing Examination (USMLE) has released a statement that accelerated plans are being made for a “testing solution that employs a telehealth model, where examinees and standardized patients would interact online, via a web browser” for the Step 2 Clinical Skills (CS) exam [7]. Additionally, “virtual sub-internships” are being created in multiple specialties for fourth-year students unable to participate in typical away rotations. Overall, it seems that telemedicine drastically increased its presence within the medical school curriculum in the span of a few short months.

The WHO outlined potential limitations to telemedicine’s widespread implementation, including infrastructure requirements, costs, and training requirements of health workers to use these technologies [3]. From our experience, these limitations are not significant barriers to telemedicine in medical education evidenced by our institution’s successful implementation in our student-run free clinic and psychiatry clerkship within one to two months. Despite minor issues with internet connectivity, both medical students and patients were able to utilize telemedicine effectively with limited training.

Ultimately, we believe that telemedicine has the same applications for medical school curricula as for patient care described by the WHO; it is not a substitute for clinical experience, but a reasonable and effective alternative when options are limited. Caution should be exercised in implementing telemedicine where it is not regularly used, such as an assessment tool for student clinical skills for Step 2 CS or individual schools’ Objective Structured Clinical Exams. Further research and data are needed to understand the full scope of telemedicine’s curricular applications, but it is undoubtedly a promising new practice for the future of medical education.

References

  1. Centers for Medicare and Medicaid Services. Telemedicine. Medicaid.gov: Keeping America Healthy (Accessed May 18th, 2020, at at: https://www.medicaid.gov/medicaid/benefits/telemed/index.html).

  2. WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019. License: CC BY-NC-SA 3.0 IGO.

  3. Roodenbeke Ed, Lucas S, Rouzaut A, et al. Outreach Services as a Strategy to Increase Access to Health Workers in Remote and Rural Areas: Increasing Access to Health Workers in Rural and Remote Areas. Geneva: World Health Organization; 2011. (Technical Report, No. 2.) 4, Results. 

  4. Texas Tech University Health Sciences Center Factbook: 26th Edition. History. Texas Tech University Health Science Center. December 2019. (Accessed May 18th, 2020, at https://www.ttuhsc.edu/about/factbook.aspx).

  5. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018;24(1):4‐12.

  6. Mackert, Michael, et al. Health literacy and health information technology adoption: the potential for a new digital divide. Journal of medical Internet research 18.10 (2016): e264.

  7. Announcements. United States Medical Licensing Examination website. Updated April 3, 2020. (Accessed May 18, 2020, at https://www.usmle.org/announcements/default.aspx?ContentId=266).