Podcast 259: A first-year resident tells us what he sees in the Covid-19 pandemic

Dr. Matt Young is a first-year resident in obstetrics and gynecology in suburban Delaware. Between the day I invited him to be interviewed and the interview itself (a 36-hour span) things had changed a lot for him. Anxiety levels are up among his colleagues, and everyone in his hospital must wear a mask all the time.

A ground-level view of an incipient epidemic is what we offer.

Running time: 13 minutes

TRANSCRIPT OF THE CONVERSATION WITH DR. MATT YOUNG

Joe Elia:

You’re listening to Clinical Conversations.

I’m your host, Joe Elia. Like everyone else on the planet, we in the US are obsessing over the morbidity and mortality charts of the COVID-19 pandemic. We’ve done interviews with Dr. Anthony Fauci and Dr. Susanne Sadoughi and I wondered what the newcomers to clinical life are seeing through their fresh eyes.

So I’ve reached out to Dr. Matthew Young, who is completing his first year of an OB/GYN residency in suburban Delaware. I know Matt from working with him on a social media project for the NEJM Group. He was a Harvard medical student back then, finishing up law studies there as well. He’s kept pretty busy (but he admits he hasn’t practiced on his piano for many, many months).

Welcome to Clinical Conversations, Dr. Young.

Dr. Matt Young:

Hey, Joe. Thanks for having me.

Joe Elia:

So you’re finishing up your first year of an OB/GYN residency at Christiana Care in Newark, Delaware. As of this morning, March 24, the state had about 90 cases of COVID-19, so I’d like to ask, what in your experience of obstetrics and gynecology has changed between when you started last July and now?

Dr. Matt Young:

Really the big difference has been work shift and our scheduling. Basically, we’ve adopted a model I think other house staff has — a similar model across the country where we tried to cancel elective procedures and have residents who don’t need to be here, not be here.

So a lot of GYN entails elective surgeries and procedures, and we’ve basically shut those down. Our surgery center is quiet. I’ve never seen it that way. I was there last Monday and there were just no patients there. We’re just complying with CDC and national standards in that regard but it allows sort of this on-and-off model where we have some residents off at certain times. They’re sort of backup or taking home call while other residents who are considered essential and immediate — for example labor and delivery and our obstetrical triage unit — they need to be there because they’re absolutely essential, and certainly that allows patients who need to be delivered or who have obstetrical problems, they need to come in.

Of course, not all elective things are canceled. So elective induction of labor is still considered important and necessarily. So we are allowing all those folks who are scheduled for elective inductions or who want elective inductions to come in.

Joe Elia:

Okay. Labor and delivery, whether elective or not, is not something that you can’t opt out of for more than a reasonable amount of time. So OB/GYN is staying pretty busy I guess you’d say.

Dr. Matt Young:

Absolutely, but we are being very aggressive in terms of trying to curb potential exposure and infection. We are limiting the number of visitors, we’re only allowing one support person to accompany a patient postpartum. We’ve also adopted a new masking policy, and I’d be happy to tell you more about that.

Joe Elia:

Go ahead and tell me about this.

Dr. Matt Young:

So our hospital has been aggressive and followed that directive as well [Matt’s referring to a directive from Boston’s Partners HealthCare that mandates mask-wearing for all employees]. Basically in its initial days and weeks we were told do not consume or use surgical masks or N95 masks unless you’re interacting with a rule-out COVID patient or someone with symptoms or if you yourself have symptoms. Unless you’re dealing with somebody with symptoms you are not to wear or consume PPE (personal protective equipment) like N95 masks or surgical masks. Basically been a 180 degree reversal of that. I mean that policy probably was driven by severe shortages, folks who are calculating out that we’re going to run out in days to weeks, but there’s been a total reversal of that.

Basically, our hospital has adopted a mandatory mask-wearing policy. We basically made masks mandatory for all visitors and for all providers in any patient care areas. Partners Health in Boston is doing this and Christiana Care where I am at we’re doing this now, effective immediately, and we’re all really actually relieved because we got an email saying that we’re kind of lucky we don’t have such an acute shortage like major urban centers do, but even major urban centers like Mass General are adopting this mandatory mask-wearing policy. So I think that providers are getting…every day is a different day with new guidelines evolving, and I think that there’s a lot of provider anxiety.

There are a lot of labor and delivery nurses with families. Some of them are expecting, and that puts them at high risk. There are a lot of residents who are vulnerable or have exposures to vulnerable people. There’s a lot of anxiety among providers about protecting our healthcare workforce. So I’m so glad that major institutions like Mass. General and ours here at Christiana are adopting this.

Now, I have seen other measures being taken as well to sideline certain residents. So we usually have family medicine residents participate in our GYN and OB clinic outpatient ambulatory setting. Those residents are getting pulled and sidelined because there are concerns that because the family medicine residents are interacting with all kinds of populations that we may not necessarily want them interacting and possibly infecting our patients.

Now, all of this is in the setting of a concern about asymptomatic viral shedding or asymptomatic spread and that is what undergirded this new mandatory sort of making-masks-mandatory policy because providers are recognizing that there is serious concern of asymptomatic viral shedding, and we don’t know who has it and there’s so much uncertainty that we need to take universal precautions. It seems like the policy initially was not this way because of the severe shortage concern but we’ve now done a total 180, and I think that’s really important because we are now recognizing there really is asymptomatic viral shedding. So really this is a good policy because some of us — a lot of our attendings, et cetera — were wearing masks against hospital policy because we realized that there is a serious risk of asymptomatic viral shedding and we’re glad that our administrators have realized this and realigned policy.

Joe Elia:

I interviewed Susanne Sadoughi at Brigham and Women’s last week, and she said that they were doing most of their routine visits (now she’s an internist) but they were doing most of their routine visits via telephone and that that was working out well. Are you doing anything like that there?

Dr. Matt Young:

We are calling ambulatory patients and trying to triage and assess if we can just potentially diagnose them and write a script for them, trying to basically assess how urgent their needs are. We just got new policy today, which basically says we’re happy to see people for their follow-up postpartum visits but if they’ve had an uncomplicated vaginal delivery or an uncomplicated C-section, there haven’t been any blood pressure issues or major surgical issues, endometritis or any interventions that may require more aggressive follow-up we are just going to conduct phone postpartum visits instead. And I’ve had patients who…this really requires more advocacy on the part of the provider but I’ve tried to schedule for those more sick patients, routine follow-up with our service or other services, and I’m getting a lot of pushback saying, “We really aren’t scheduling right now until this is over.” And it really requires advocacy on our part to say, “Hold on a second, I really need you to see this patient, we really need your help.”

That has allowed me to sort of get around some of these policies saying we really aren’t going to see folks on an outpatient basis unless it’s urgent or necessary and really it requires advocacy to make that happen, but I think everybody’s trying to do their best. The problem is the situation is constantly evolving. I’m just glad that our healthcare system is adapting day to day and that we have a very responsive healthcare leadership. I will say I was just recently invited to join a Facebook group called SARS COV-2 House Staff Experience and it’s almost a thousand different house staff from across the country coming together in a private group to discuss our anxieties and our worries and our policies across various hospitals.

I’m shocked, frankly, to see that (I won’t mention who or where) but so many other institutions where other house staff and trainees and residents and fellows are, they are coming up with policies that either are misguided or lagging or just wrong-headed and I’m glad that our hospital and other hospitals we talked about are evolving their policies day to day but there’s so many other physicians and clinicians and residents that I’m hearing from that they’re still being told, “No, don’t worry about asymptomatic viral shedding. If you’re asymptomatic and the patient’s asymptomatic, save our PPE. Don’t wear masks.”

I had another resident who just told me that her hospital said to them that they don’t really believe that there is asymptomatic viral shedding, which is in direct contravention to what the national guidelines policies are, and they’re telling them not to wear masks. I just hope and pray that their hospitals are able to see the light and quickly revise and update their lagging policies.

Joe Elia:

I think that the light may be coming pretty quickly. When we had a telephone conversation two nights ago and I was inviting you to do this, Matt, things seems pretty quiet there then, and now I detect the urgency in your voice.

Dr. Matt Young:

Yeah. I’m in touch with a number of my colleagues who are in emergency medicine, and there’s a tremendous amount of anxiety and they’re just saying this is just going to get worse. This is going to get much, much, much worse. I mean the curve will be flattened but it’s still, relatively speaking, exponential. So there’s a lot of anxiety among frontline emergency providers. Most of these conversations are happening in private Facebook groups and in physician-to-physician chat rooms and dialogues, but I will tell you there is a severe discrepancy or asymmetry between the public government narrative and what front-line providers at the healthcare work force is seeing and what we’re bracing ourselves for.

Joe Elia:

Okay. Well, I want to thank you very much, Dr. Matt Young for talking with me today. And best of luck to you.

Dr. Matt Young:

Thank you, Joe. And best wishes and thanks to all the healthcare providers and the entire healthcare workforce that is on the frontlines now.

Joe Elia:

That was our 259th episode, all of them are available free at Podcasts.Jwatch.org. We come to you through the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

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