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.
In stark contrast, when severe acute respiratory syndrome (SARS) broke out in 2002, medical schools in Hong Kong and Toronto suspended lectures and prohibited students from patient contact.
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.
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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?”
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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.
Well written. Thank you for sharing your perspective. You’ve clearly touched a sensitive nerve with your eloquently broached opinion on an important topic. I just completed a two week rotation in the emergency department. It was a fascinating and disturbing experience.
Let’s be honest – third year medical students are highly dependent on physicians, residents, and support staff to get anything done. You would just be in the way, take up valuable time from providers, and decrease efficiency of hospital operations. By allowing untrained medical students to bustle around the hospital, you would also increase traffic, leading to increased risk of exposure to vulnerable patients. Please think these things through before posting. Thank you.
Safe to assume that the UK’s Medical School Council did think these things through. Today they made an announcement that “current students should be enabled to work in the NHS during the crisis, by working as call handlers for the NHS’s 111 telephone service or taking over other non-critical roles to relieve staff.” Very much in line which the author’s points.
Not quite. Please read the sources you are quoting. They are fast-tracking GRADUATING students who have ALREADY written their final exams in December 2019.
Again, please stop misrepresenting sources to push your (and the author’s) viewpoints. Nowhere does it say they are proposing (or permitting) third-year students like Orly to clog up the healthcare system.
Could not disagree with this more. The less vectors the better- all it takes is one medical student with little training to transmit to an unseemingly immunocompromised person to make them a hazard. I would absolutely have felt I was better off practicing social distancing and reading from home as a med student, at least in the beginning when we’re still figuring everything out.
Would have to agree with you. We are walking vectors for this virus not only within the hospital but also outside in our communities. The author is delusional-now is not the time to exploit the free labor of med students. We have minimal skills and are a hazard.
I 100% disagree with this. Firstly, I am NOT a paid provider like the rest of the healthcare team. Secondly, my school does not offer health insurance plans. Given that M3s and M4s are of the age where we are getting kicked off our parents insurances we are left to seek Medicaid, a pricy plan from Healthcare.gov, or go without entirely. Lastly, and perhaps MOST importantly, we need to minimize any nonessential staff at the hospital. I am a walking vector for this virus and have the potential to infect sick patients in the hospital that I come across AND elderly family members with pre-existing conditions. What worked in the UK can’t necessarily be emulated here. They also pay a fraction of what we pay for to attend medical school and believe that healthcare is a human that every citizen can have. When the hospital or school is willing to (1) pay me to put patients and my community at risk AND (2) offer me health insurance and to foot my medical bills in the unlikely event I do get sick then *maybe* you might have a point. Otherwise, this is opinion is naive and immature.
When did students become paid employees with health coverage and benefits?
Sorry, but I have to disagree 100% with you. I am on my APPE rotations right now. It is clear that you are blinded and are only seeing what you want to see to justify having a hand in playing doctor.
There is so much we don’t yet know about COVID-19 and yet you are willing to risk students to be exposed to this new virus. Why are you so comfortable in doing this beyond my comprehension. I think you must not have given this enough thought or considered this in the long term scheme of things.
Additionally, some students have the at risk population in their homes. These same students likely do not have the proper health insurance nor resources needed if anything happens within their household. I take it you haven’t given this much thought either.
If you are going into the medical profession in the near future, I suggest you start to do more SWAT analysis not only on yourself, but on others as well. You aren’t seeing the whole picture, yet you are willing to risk students who have no coverage through their school or the hospital systems.
Who pays the medical fees if a student gets severely sick from COVID? That surgeon does? There is a difference between employees and students, when did this line get blurred?
From my perspective as a former public health Medical Director (Houston area), I’d like to see all medical students (and other clinical students) away from clinical care for a week or two while we figure this out, and likely longer. There’s not enough PPE for clinicians already, and we shouldn’t have learners using it until there’s no longer a shortage. Medical students can be huge helps, though. When I worked in a huge shelter post-Hurricane Harvey, medical students set up credentialing and handled information-sharing and record keeping. We needed their expertise and intelligence, and we didn’t need to be teaching using patients who were in crisis. Y’all could help un-tech-savvy doctors with telemedicine. You can do phone triage and information-sharing with patients and the public. You can be the “life-line” for clincians from home, looking up things, doing charting in an EMR, calculating things – in support of clinicians in hospitals/clinics. There’s plenty to do and plenty to learn without using scarce resources. We need y’all to find the regulatory and other bottle-necks that keep us from getting needed care done, and get together and talk with CMS to get things loosened up and redirected so we regulate quality of care and not get stuck in a morass of billing and coding and checking boxes. We need y’all. But we don’t have enough PPE for you right now.
I think this is the kind of help the author had in mind when suggesting “non-patient-facing” tasks in the event of a PPE shortage. Interestingly, the UK’s Medical School Council just announced “current students should be enabled to work in the NHS during the crisis, by working as call handlers for the NHS’s 111 telephone service or taking over other non-critical roles to relieve staff.” It sounds like you and they think alike!
If we don’t have enough PPE for med students, we also don’t have enough for elective surgeries, dermatologists, etc. So let’s make sure our hospitals’ policies match up on that.
Also beyond PPE conservation, keeping med students in hospital settings where they can get COVID-19 and *worse* spread it to vulnerable patients, when they aren’t needed in those settings is irresponsible.
Please give blood, healthy medical students !!
Do you want to infect your friends and family? Because this is how you infect your friends and family.
Just because there isn’t patient contact doesn’t mean that medical students crowding the hospital won’t increase risk of infection. To the fool above this comment, congrats on knowing how to read English – maybe its time to think about what you are reading now.
Thank you for such a thoughtful and well articulated piece. As a fellow medical student contemplating my potential role for both help and harm in this pandemic, I really appreciate how you carefully considered multiple arguments in formulating your opinion. And I’m sorry people on the internet can be so rude and leave such inconsiderate comments—eff the haters!
Thank you!
What is this self-righteous bs? It’s time to stop pretending that medical students are a vital part of the treatment team. We are unable to bill for visits and any work that we do is redundant as we are supervised – therefore we are not “essential” personnel. We are walking vectors in the ED and other high-risk places to get the disease and spread it to other vulnerable populations. It would be different if we were given more autonomy but we are not. “A good learning opportunity” isn’t a good enough reason to expose students who are not essential.
FYI that’s incorrect – medical student documentation, when co-signed, can be used to bill Medicare: https://www.aamc.org/advocacy-policy/washington-highlights/cms-revises-rules-medical-student-documentation