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.
We want to hear from you: Are you a health care worker affected by the coronavirus outbreak? Please tell us about your experience.
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?”
Support STAT: If you value our coronavirus coverage, please consider making a one-time contribution to support our journalism.
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.
This is an ethical dilemma that may ultimately depend on the cost/benefit, with the cost largely dictated by contractual obligations and their legal implications. Simply, medical students are not employees. Therefore, to my knowledge, for most North American jurisdictions they have no contractual obligation in a time of crisis (other than to not violate current policy). What if they contracted COVID19 and, although unlikely, suffered a complication that their institution was held liable for? If medical students were paid to learn, as is done in some countries elsewere in the world (where litigiousness is also different), the situation may be different.
Medical students can provide helpful service under supervision. However, my humble opinion is that their priority perhaps should be more weighted towards learning the fundamentals of medicine, which cannot be well taught in a crisis situation.
That said, many volunteer their time before and during medical school. I can think of no better time to volunteer to assist with lower-risk but very helpful services in shortening supply such as outreach for the socially distanced, childcare for providers on the front lines, education, etc. Just because we practice medicine the way we were trained to, and even if we feel like this should be the way to continue doing things despite changing times and new stressors, doesn’t mean it it best for our healthcare system or society in a time of crisis. Crisis may also breed creative solutions.
Fellow third year (almost fourth year) student here. Like the few comments already stated here, I too disagree with this to a large degree (with a caveat). We are indeed unnecessary parts of the medical team. Despite our sincere desire to be a meaningful, active member of the team, our level of experience needs to be seen through a sober lens.
We are prepared to recognize easily recognizable disease processes. We are prepared to know the theoretical treatment for most common illnesses – especially those that are time-sensitive and emergent. We are not trained in how to deal with a health system facing a pandemic, and in all honesty, neither is anyone else in the hospital. Administration in hospitals are learning how to respond, along with all of the doctors, nurses, and support staff critical to the care of patients.
We as medical students need to realize our role – as learners. Just like in your surgical cases, you only move when instructed. Why? Because you could kill someone if you thought you knew what you were doing, and in fact didn’t.
This pandemic is the hospital equivalent of a trauma surgery, where our entire population is critically unstable and the trained people in charge are still trying to figure out how best to stop the bleeding. That is not the place for a medical student. At this point, we would be doing more harm than good. However, there may come a point when the people in charge call on us to help. When that time comes, I know that 100% of my colleagues will jump to help in whatever capacity we can.
Until that time, we need to do what medical students do in the OR – stand ready, calm, prepared, and to never move until called upon. If and when we are called to action, we will be standing there ready. We needn’t be selfish and assume our lives and training won’t be disrupted when the rest of the world has to live with those conditions.
I too am conflicted of what I, a 4th year medical student, can do to help in this situation. My hospital recently banned all clinical rotations, where I was on a medicine subI, so I was at the point where I could carry patients on my own and put in orders with the guidance of a PGY3. Now being home, I have mixed feelings of whether it’s best that we are out of the hospital (lack of PPE, lack of clinical experience, risk to spread the disease) or if we could provide help. I’m going to be an intern in July and with rotations cancelled there isn’t going to be a change in the amount of clinical experience I’m going to have prior to becoming a physician. I also dont anticipate this illness going away by the summer, so part of me thinks might as well face it sooner than later and know how to be safe and best help these patients. Overall, maybe it’s best that they see the first wave of COVID-19 patients over the next week or two and be able see if there is a role that is best suited for medical students? I don’t think anyone has a definite answer, but if they need us in anyway, I hope that there are those ready to help. I agree with the surgeon in that we did “sign up for this”
can this be taken down? This is just plain old silly and a hazardous thought. Med students consist of the younger population who are more likely to get the virus and less likely to show symptoms while spreading it. They’re also more likely to go through crowded places and socialize in public areas. Med students also play very little role in the hospital setting. Most of us are there to learn. Physicians take time out to teach us. There are some things that can be learned from observation, but the risk of spreading the virus even farther far outweighs the benefits of learning. I don’t know what made you wrote this article. But as future physicians, I think we should be a role model for others and minimize the risk of exposing more of the population. If the coronavirus gets worse, at some point, we will definitely regret sending med students into the field. Medicine is known to eat its young. You don’t have to feed into it. Let the young doctors actually become doctors and please do not bring unecessary risk to the public and future doctors of our generation.
As a third year medical student myself, I completely disagree with you on this. Medical students are not there to shadow doctors, they are there to actively learn and partake in patient care. If doctors do not have the time to teach, and hospitals do not have enough PPE to go around, then students are nothing more than vectors. This is not the time to exploit medical students as free labor by emotionally blackmailing them about their “oaths”; medical students have minimal skills and, in the current clinical environment, serve more as a liability for medical centers than anything else. If hospitals want medical students to actually work in this environment beyond a clear educational capacity, fine – pay them like everyone else.
Either way, regardless of anyone’s opinions here about other departments, medical students should not be working in any capacity in the ER or ICU right now; that’s just common sense. Two ED physicians in Seattle are already in the ICU in critical condition from this virus, and COVID-19 is going to get much worse before it gets better. Having students there puts them, hospital staff, and patients all at higher risk of infection.
Dr. Farber,
I respectfully disagree with your comments regarding medical students helping. I wish there was a softer word but it seems almost arrogant for future medical professionals to take this position. I understand the idea of wanting to provide care. Perhaps your medical school was different than mine but does the scut work you help with really balance out the additional risk of being a vector for patients?
Any emergency professional knows to ensure the “scene is safe” prior to providing care. The reason behind this is to prevent additional patients (yourself) that will prevent the proper care going to the target patient. While the scene will never be safe in this situation, the idea of care being provided to your patient rather than yourself still holds true.
New Orleans learned this the hard way with Katrina. Hospitals allowed as many staff and their families to stay during the storm … ultimately adding to the number of people that needed to be evacuated. Now code greys in most hospitals require the absolute minimum number of people around if a hurricane is coming because of those lessons learned.
I think a more valuable lesson is for medical students to be healthcare role models. To practice the “social distancing” that is being instructed to the rest of the population is more valuable than sitting at a nurses station while you try to figure out what patient you are actually allowed to see.
As I write this, I found out that there are compact lines for screening at my local hospitals which medical students are part of. Is the excitement of being on the front lines worth it?
Thank you for your comments regarding clinical activities during this difficult time. I understand that many aspects of medical school (learning, aways, step, etc) will be difficult for this year’s class during this crucial time but if this is truly an emergency, then everyone needs to treat it like one, ESPECIALLY the future doctors of America.
Great post! They are definitely down playing how much one can learn from observations. I am currently a scribe and have learned so much from my last 2.5 years that I know I could help in many ways if I was allowed to so I know that third and fourth year medical students (who have had much more training and experience) can and should be able to help as well!
I fully understand and agree with you that third year medical students should be given this opportunity. Thats what ultimately we expect them to do . That how you are prepared as clinician. No theory classes will teach you all that.