Last week, while seeing a patient in the emergency department of Stanford Hospital, I witnessed the well-orchestrated commotion that follows a suspected case of coronavirus. Masked nurses, doctors, and janitors quickly isolated the patient and began disinfecting surfaces. A technician who had been in contact with the patient on transport nervously asked the staff, “How will I find out if they test positive? Who will tell me?”
Fear, contained only by the bounds of professionalism, coursed through the department as if by infusion.
I felt it as a bystander, a medical student passing through the emergency department on my psychiatry rotation. The psych resident and I had come to see a man with auditory hallucinations. We rushed past the viral activity en route to our patient’s room. As I took in the scene, I thought, “Should I be here?”
In a slew of emails over the past week, Stanford University shared with our community that the hospital is caring for a few patients infected with the novel coronavirus, and that a member of the faculty had tested positive for it. By last Friday evening, administrators had informed medical students that we’re restricted from caring for patients suspected of having Covid-19, the disease caused by the virus. By Saturday, the school pulled third-year physician assistant students out of their final rotations. By Sunday, medical students were further barred from having any contact with patients who came to the hospital with fevers and respiratory symptoms, regardless of cause.
Across the country, schools and universities are suspending courses or moving to online lectures. First- and second-year medical students, who learn mainly in the classroom, can transition to remote platforms. But clinical students, those in their third and fourth years of medical school, work in hospitals. That means they face new concerns about their health, their education, and their roles in patient care.
In the hospital, medical students generally operate on a spectrum between shadowers and providers. Sometimes we’re silent flies on the wall. In a surgery, we observe, stepping forward to assist only when asked. Other times we take the reins — for our own learning but also to carry a share of the heavy workload. On a busy internal medicine service, for example, students can contribute to patient care by coordinating medications and procedures, consulting with nurses and specialists, and updating patients and their families on the care plan.
Given the diversity of roles medical students play, I’m left wondering where trainees like me — as well as future nurses and physician assistants — stand on this spectrum during a pandemic. Do we show up to learn or are we coming to work as junior medical providers? If the answer leans towards learning, should we still stick around during an outbreak? Is our education worth the potential risk of infection and subsequent spread?
If there’s a clear benefit to having extra hands on deck during the outbreak, I believe that our role as students should shift toward the provider end of the spectrum — and sooner rather than later.
Students training in health care, like other frontline medical providers, are at high risk of exposure to SAR-CoV-2, the virus that causes Covid-19. Sixteen nursing students from the Lake Washington Institute of Technology visited the Life Care nursing home as part of their training; more than 50 of the home’s residents have been diagnosed with Covid-19. Four medical students at Dartmouth are currently on self-quarantine after exposure to a case. Given that there are almost 93,000 physicians-to-be spread out across more than 150 medical schools, trainees are bound to contract the infection.
The Association of American Medical Colleges (AAMC), which oversees all medical schools, issued guidelines for students during this outbreak on March 5. Although the association recommended that “it may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of Covid-19,” it also endorsed students’ continuing all other clinical duties, at least for now. Despite these guidelines, on Friday the University of Pennsylvania suspended clinical rotations for its students.
While the U.S. may be asking medical students to step down, the United Kingdom may be asking them to step up. Chris Whitty, England’s chief medical officer, told Parliament that the government may have to consider drafting senior medical students to help the National Health Services deal with the outbreak.
Historical precedent exists for recruiting medical trainees during times of crisis. During the 1918 Spanish Flu, volunteer medical students in Spain were deployed to villages with insufficient medical personnel. In the U.S., the University of Pennsylvania School of Medicine reportedly gave just one lecture on influenza before sending clinical students to run an emergency hospital with little to no supervision.
Pulling medical students out of the hospital can have long-term consequences. There’s no online substitute for learning direct patient care; sending students home would likely halt their education. It could even delay graduating an entire class of new physicians, since students work on tight timelines to finish all the requirements necessary to become doctors.
In response to growing concerns, Dr. John Prescott, the AAMC’s chief academic officer, said in an interview that the association is working with medical schools to ensure that their graduates “are going to be good doctors, even as we are confronting the challenges of Covid-19.” Prescott also added that students might be asked to leave clinical rotations for two reasons: a potential shortage of protective equipment, or because doctors no longer have time to teach.
Prescott ignored the fact that medical students don’t always need active teaching. We’re expert sponges, adept at trailing behind physicians and observing to learn. He also failed to acknowledge that students can meaningfully contribute to patient care, or at the very least, pick up some of the slack to help far busier team members. In the event of a protective equipment shortage, we can help manage care for patients without respiratory infections or assist with non-patient-facing tasks like making phone calls, writing clinical notes, putting in orders, and working with specialist consults.
When I’ve spoken to classmates and doctors about the role of medical students during this outbreak, the conversation usually takes an ethical turn. While in the operating room recently, I asked the surgeons to share their opinions. “Didn’t you sign up for this?” one asked. “Didn’t your responsibility to care for patients start on day one of medical school?”
Along with many other health care professionals and most people generally, I’m scared. Intellectually, I’m concerned about social and economic disruption, about a health care system that can’t keep pace with the spread of the virus. Personally, I worry about my more vulnerable family members and about my friends stationed in different hospitals and clinics. And when I passed through the emergency department the other night, fear hit me.
But setting fear aside to the best of my ability, I want to stay put. I, like the other tens of thousands of medical students in the U.S., made a commitment to promote and enable health. As the surgeon in the operating room reminded me, we signed up for this. I understand the limitations in our ability to provide care: We are not doctors, we are not unequivocally necessary members of the care team. But third-year students are 16 months away from becoming physicians and fourth-years have only four months until they get their degrees. If our training thus far has prepared us to be helpful, in even the smallest ways, we should stay on the wards.
It remains to be seen whether U.S. medical students will be asked to assist an overwhelmed health care work force or sit on the sidelines for the duration of the pandemic. In weighing that decision, let’s not forget that medical students like me can support clinicians on the front lines. Just as importantly, let’s not forget that we, too, took an oath to provide care.
Orly Nadell Farber is a third-year student at Stanford University School of Medicine and a former STAT intern.