The number of patient who have contracted COVID-19 and seek care at a New York City’s hospital has exceeded the capacity of the healthcare system in some communities and will shortly exceed the capacity of the healthcare system in many hospitals in NYC and across the US. In addition to immediately increasing bed capacity, acquiring more ventilators and personal protective equipment, hospitals will also need many more physicians to manage the surge of COVID-19 patients.
My hospital has asked its physician medical staff to consider volunteering to take care of the expected surge of hospitalized patients. For many reasons, this request is both problematic and necessary.
HOW A PHYSICIAN BECOMES A PHYSICIAN
In order to fully understand the ramifications of the hospital’s request, one needs to understand how a physician becomes a physician. After 4 years of college, 4 years of medical school and 3 years of internal medicine training, a physician is considered an expert as an “internist.” This means they have an understanding of how the body works and how to take care of adult patients both in the hospital and in the office. Some internist will become primary care physicians (PCP) and some will go on for additional subspecialty training as cardiologists, endocrinologists, nephrologists, pulmonologist, gastroenterologists, infectious disease specialists, rheumatologist, etc. Physicians who acquire subspecialty training typically restrict their practice to their subspecialty and many/most eventually will stop acting as internists. Once that happens, with time, the skills they had learned during the training in internal medicine gradual evaporate through disuse.
I finished my medical training in 1989 in the subspecialty endocrinology. Until about 2000, I was the PCP for several hundreds of patients and I consulted for other physicians whose patients had endocrine problems like diabetes, thyroid, pituitary and osteoporosis. Until about 2000, most internists also took care of their own primary care patients when they were admitted to the hospital or ICU.
After 2000, the practice of medicine evolved as medical technology advanced, new medicines and antibiotics were developed, poorly designed electronic health record programs were widely implemented, and most hospitalized patients began to be managed by the new specialty “hospitalists.” Hospitalists are physicians who are trained to take care of patients when they are hospitalized with a wide range of illnesses. As the hospitalist system ramped up, I stopped taking care of my own hospitalized patients and concurrently serially reduced my panel of primary care patients as I re-focused my practice on my endocrine patients. In the process, my ability to manage acutely ill hospitalized patient atrophied.
Because the impending surge of coronavirus patients is about to swamp my hospital, my hospital has asked physicians like me if we would be willing to volunteer as a “hospitalist.”
Personally, I feel a professional obligation to take care of patients, whoever they are and wherever they’re located. That is why I became a physician.
However, I am concerned that my current set of medical skills is severely deficient in the areas of hospital care and I will not be able to take care of the hospitalized patients in a manner that I would deem “acceptable” in my own judgement.
On the other hand, I recognize that if I do not volunteer to help then there may come a time when there will be no physician to take care of the patients.
MOVING TOWARD A DECISION
In trying to resolve this dilemma, my primary concern was my wife. I am fully aware that if I work as a “hospitalist” my risk of acquiring COVID-19 will increase. Although I am otherwise healthy, I am a “65 year old male” which is a high-risk group. Although my wife is two years younger and is healthy, this disease can be a horrific experience for even the healthiest, youngest individual. After much discussion between us, she has decided that I should do whatever I thought was right and she will accept that decision.
I then reached out to close friends and physicians and explain my dilemma to them.
Those who are PCPs told me that they too are struggling with this issue. I told them that I thought it would be ethically inappropriate for PCP to become a hospitalist because they are responsible for the health of several thousand patients. Working as a hospitalist will increase their risk of COVID-19 infection and would put them out of work for 1-2-3 months and there would be nobody to take care of their patients. These orphaned patients would be more likely to visit emergency rooms and become hospitalized, thus incurring the outcome we most wanted to avoid. I told these PCPs that their first priority must be to ensure that they did not get sick, and that means that they should not volunteer as a hospitalist.
Other physician reminded me of my age and gender as a risk factor, which I acknowledge.
When I explained my dilemma to some close friends, their response was:
- Hayward, I know you and if you don’t do this now then years in the future you are going to regret it.
- I think it would be better for the hospitalized patients if they had a physician, even if less-than-fully qualified, rather than no physician at all.
I also ask the opinion of physicians who are intimately familiar with the staffing situation at my hospital and the reply was always “we need more hospitalists.”
After much thought, I told my hospital that I would be willing to volunteer as a hospitalist one day a week. I have repeatedly explained to them that my skill set is not what I think they need but I understand the ask. They have assured me that I will have the requisite “supervision.”
Some have told me it is “courageous” for me to volunteer. I do not feel “courageous.” I believe I have a professional obligation and “courage” has nothing to do with it. I am volunteering because I am a physician and it is the right thing to do,
My wife told me “being courageous means walking into danger with your eyes wide open knowing that there’s danger and choosing to do it anyway.”
In my eyes, her decision to let me to make this decision was truly courageous.
People have asked me “Aren’t you afraid of getting COVID-19?” Of course I am. I understand it can be a horrible disease and is associated with a significant mortality but that is not my biggest fear. I have two more significant fears.
I worry, despite my best efforts, I might infect my wife. How I will minimize this risk is to be determined.
My other fear is that in my role as a hospitalist, I will make a decision, with the best of intentions, but it will be the wrong decision and a patient will get hurt through no fault of their own. And I will have to live with that decision for the rest of my life.
The only solace I can draw from this situation is that I will be working with healthcare professionals who are immensely dedicated to their respective professions and virtually every one of them has exactly the same fears and priorities as I. And in this, we will find solidarity, strength and motivation.
To my future patients, I promise that I will do everything in my power to help you get well. Given the circumstances, that is the best I can do.
Hayward Zwerling, M.D.