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As chief residents of one of the largest internal medicine programs in the country, we entered the year expecting to send and receive a lot of emails, many ending with words of thanks or encouragement. However, as coronavirus disease 2019 (COVID-19) invaded New York City and every aspect of our lives this spring, there were few words that could yield comfort amid so much uncertainty.
“I have a cough. Can I come to work?”
“What is going on with my schedule?”
“Do we have enough PPE [personal protective equipment]?”
Our residents had a constant stream of questions, to which we could often only provide unsatisfying answers. However, as we navigated the complexities of the pandemic, we eventually found ourselves relying on one phrase: Thank you for your flexibility during these unprecedented times.
Unprecedented Times: Embracing Uncertainty
In early April 2020, there was a moment when the rate of intubations was rising exponentially, and one of our hospitals was awaiting a shipment of ventilators. We wanted to prepare our residents for whatever was to come and shared the news.
“I do not want to die alone,” one resident said with fear in her eyes. It was a moment indicative of the concern and uncertainty our residents had, not just about their patients, but also about their own lives. The ventilators arrived the next day, but any sense of relief was short lived.
Every day brought new surprises: hospital units opening and closing within hours, shortages of blood gas syringes, and conflicting policies on personal protective equipment. We went to bed each night having tried to solve the crises of the day, but every morning, we woke up to a slew of new ones. Anything other than a 24- or 48-hour plan was futile.
Rapid changes led to rapid decisions, and we often found ourselves falling victim to the errors of type 1 thinking. There was no precedent to follow, only a calculation of the risk-benefit ratio. Inevitably, there were unintended consequences and unexpected reactions. Something as well intentioned as geographic units yielded distress and confusion over patient handoffs and admissions. However, it was important to acknowledge, both to our residents and ourselves, that we would make mistakes even as we were trying our best.
Flexibility: Adapting to Change
In dealing with uncertainty, we recognized the importance of creating systems that were flexible and adaptable, frequently bypassing typical bureaucratic processes out of sheer necessity. We synchronized the residency schedule across rotations and hospitals such that residents could change services midweek. We wrote live, searchable rotation guides for every hospital site. We abandoned email and started using Slack for residents to ask and answer questions.
We also learned to be flexible as individual chiefs. As clinics closed, outpatient chief residents became inpatient chiefs, and we all stretched our abilities both administratively and clinically, becoming operations managers, donation coordinators, therapists, and even intensivists.
Our flexibility was outmatched by the residents’. Otolaryngology residents were suddenly medicine interns. Orthopedic residents were deployed on proning teams in the intensive care unit. House staff across the spectrum of training found themselves stretching their abilities as physicians. At the center of it all, our internal medicine residents, with their clinical skill and institutional knowledge, were the glue holding it all together. Even with an army of repurposed attending physicians and advanced practice clinicians, no one else could fill the role of team leader as well.
Thank You: Finding Compassion
We have been told many times that the practice habits learned in residency frequently define the way a physician practices for the rest of their career. However, instead of learning the joy and practice of medicine, our residents spent months learning about 1 disease and absorbing the many deep tragedies it wrought.
In managing this burden, perhaps the most important lesson was compassion. Some of our residents rushed into every room of a patient undergoing decompensation, while others were much more cautious and afraid. Some took the challenges in stride, while others responded with anger or sadness. The manner in which residents reacted to the loss of their educational experience, the loss of their personal lives, and the loss of their patients and loved ones could never be fairly judged or categorized. How is one supposed to deal with such profound loss during a vulnerable time in one’s career and life? We did not know. When people lashed out over something for which we felt responsible and worked hard to put together, we reminded ourselves to take a step back and respond with compassion, not resentment, even if it felt personal.
These experiences nevertheless wore us down, and we realized that caring for others meant we also had to care for ourselves. We scheduled forced breaks to stop, breathe, and reflect, even though our instincts begged us to keep running the marathon. Together as chiefs, we reflected on feelings of inadequacy, that nothing we did felt like enough for our patients or our residents. We are still learning to turn compassion inwards, to accept that we, along with our residents, can only continue to try our best.
That feeling likely will not go away. The pandemic will have a far-reaching and long-lasting effect. We all will continue to struggle but also carry these lessons with us: embrace uncertainty, be flexible, and practice compassion. In a time of few precedents, we have to establish new ones together.
Corresponding Author: Amy Ou, MD, NYU Langone Health, 462 First Ave, NBV 16N30, New York, NY 10016 (firstname.lastname@example.org).
Published Online: August 10, 2020. doi:10.1001/jamainternmed.2020.3020
Conflict of Interest Disclosures: None reported.
Acknowledgments: We thank co–chief residents Cary Blum, MD; Carolyn Drake, MD; Kelsey Luoma, MD; Custon Nyabanga, MD; Gabriel Perreault, MD; and Tanya Wilcox, MD, at NYU Langone Health for formulation of the topics covered in this piece. No compensation was received for this work.
Ou A, Torres CL, Rufin M. Thank You for Your Flexibility During These Unprecedented Times. JAMA Intern Med. 2020;180(10):1278–1279. doi:10.1001/jamainternmed.2020.3020
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