How Medical Trainees Can Cope

What your doctor is reading on Medscape.com:

APRIL 18, 2020 — During my third year of residency, a peer whispered to me that something strange was happening in the ICU: A patient was in isolation, with only staff allowed in. That patient had had contact with one of the index cases of severe acute respiratory syndrome (SARS) in Canada. A few days later, our lives changed.

Rotations were altered. My friends and I were often stuck in intermittent self-isolations, checking our temperatures every few hours. Life as we knew it ground to a halt. It was a long time before things got back to normal.

That experience shaped our healthcare community and changed all of us. In Toronto, SARS disproportionately affected healthcare providers. For most of us, this was our first concrete exposure to the reality that our career exposes us to the threat of death. Staff physicians at one of our teaching hospitals became seriously ill. I was indescribably angry at system failures that contributed to their risk. Three healthcare workers died during that outbreak. I grieved for them and their families and worried obsessively about my own safety.

No handbook can help navigate a crisis that disrupts education and leads to the critical illness of our teachers, friends, and peers. However, my experience as a medical trainee during SARS has taught me some important lessons about navigating grief and loss—lessons I want to share with you for the weeks and months ahead, as we confront the ongoing COVID-19 pandemic together.

The Medical Community Is Your Community —Lean Into It

We all know that imposter syndrome among trainees rattles confidence. Early in a medical career, it can also affect the sense that we “belong” as part of the healthcare community. Depending on where you are in your training, you might feel as though you haven’t logged enough years to claim this professional group, this medical “family,” as your own.

I used to frame that feeling for students in more familiar language: “When do you go from being a tourist to a local?” The answer has nothing to do with how you feel. You become a local when the locals see you as one of them. Please know that as of right now, you are one of us.

You may wonder if you have a “right” to grieve for the doctors, nurses, and other healthcare providers who are dying in this terrible crisis. You do. You see yourself in them, and rightly so. If you are questioning your right to grieve for them because you have not “earned” it, trust that your conflict is entirely normal. But make no mistake, this is your community.

The actions being taken by so many learners across the country—students providing childcare, fighting to secure personal protective equipment (PPE), serving however they can—are all ways to show solidarity with your community. Every job, every effort, matters right now, and it is all in support of one thing, which is our mission.

Accept That There Will Be No Quick Answers

Worrying about what the pandemic means for your future is not disrespectful to those currently on the front lines. Calling COVID-19 a “disruption to your education” feels woefully inadequate. Clerkships are on hold indefinitely. Board and fellowship exams in most countries have been suspended or canceled. For learners with massive  debt, no budget could factor in the impact of a natural disaster  on the economy. The match result that was your biggest concern weeks ago now probably seems much more trivial.

You’ve spent years planning your path to becoming a doctor, so it is only natural to ask: What is next for your education?

I’d like to reassure you with specifics. The truth is, nobody knows. They likely won’t know for quite some time. Licensing bodies and medical schools don’t have a pandemic playbook, although they have issued guidance as they are able. Be assured that every institution and organization is working to sort this issue out in real time.

I have heard some demands for quick resolutions on social media and elsewhere. I know that the interruption to training and career advancement is dizzying. It can be hard to remember that everyone’s life is unfathomably interrupted right now. The doctors who run the medical schools are scrambling with childcare and elder care, clinical duties, and health fears. Our expectations for how quickly questions about education can be answered during a pandemic may simply not be realistic.

One of the lessons that I learned during the SARS outbreak: The people who make decisions about our academic future are still just people, and they are dealing with lives of their own that have turned upside down.

 Another lesson I took from my experience is that we can look to patients as a model for a path forward through uncertainty. Every day, we push patients toward a future filled with questions and then usher them out of the room. We can’t tell them whether their cancer will come back. We can’t tell them how long they might live. We can’t tell them what tomorrow will hold. They live with not knowing. We can too.

Embrace Your Old Nemesis

This kind of chaos is hard for trainees to accept. Becoming a doctor is a scripted path. Medical education is a long phase of our lives. When that is finally behind us, we often experience a deep sense of closure. When our chosen path is set on fire, our entire concept of the future goes up in flames. It is okay to be frustrated and to grieve for the loss of your plans. You will need to come up with new ones that cover the more immediate future.

At the top of the things that can help you feel like you are moving forward, an old nemesis is one of them: studying. Do not discount the value of its familiarity and structure. During times of extreme disruption and unrest, you need that structure more than ever. To the degree possible right now, I would urge you not to abandon studying.

If this advice feels silly, think about the deeper message you send to yourself when you carry on with plans for the future. I can only begin to imagine the distress and uncertainty of those whose graduation or fellowship exams may be delayed for months or longer. During the SARS crisis, I didn’t feel much like studying. But when I did, it centered me because it was one of my rituals. Don’t abandon the rituals you can still maintain. Rituals keep us from the abyss.

That said, you may need to change what you are studying. You won’t be alone. Many of us are learning about ventilators and procedures we never expected we’d find ourselves doing again. Still, don’t abandon your exam notes or your board study groups unless or until it’s absolutely necessary for you to do so. These routines provide us with comfort; they remind us of both the life we had before and the life we will return to when this is over. They signal to us that not everything has been lost.

Remember the Mission

Recently, I had the privilege of interviewing an astronaut and a general, seeking their counsel on behalf of our profession at this brutally difficult time. Both have talked about the importance of answering this question: “What is the mission?”

Sometimes, when we encounter unexpected or overwhelming difficulty, we rage or bargain. We are heartsick and terrified at what is happening to our friends, patients, and colleagues. We tell ourselves that this isn’t what we signed up for. We are afraid. We don’t want to die.

This doesn’t mean you’re an imposter. It means you are human. Instead of asking whether this is what you signed up for, look at the efforts of the people who are doing the job you signed up for around the world. You will see role that is even more meaningful and impactful than you ever thought possible.

I hope that you also feel something else when you look at the phenomenal efforts of health care providers: pride. I am loath to glorify the achievements of our colleagues in spots where they are working under unacceptably difficult conditions, especially without PPE, which is a failing of society to protect its health care providers. What I am willing to glorify is their commitment to a mission and their willingness to serve and care for each other, even in the face of fear.

We have a mission. We are witnessing in real time the reason so many before us have chosen this profession. We are seeing its higher, greater purpose on a scale we never imagined we would see in our lifetime.

The weeks and months ahead will challenge and test us in ways we hoped we would never be tested. We will face grief, chaos, and anger. Hopefully, we also feel closer to our teachers, our friends, and our colleagues than we have ever felt before.

For me, SARS now feels like a dress rehearsal for a test on a different scale. It taught me that periods of great distress and stress do ultimately pass. We will undoubtedly emerge from the COVID-19 crisis with knowledge, purpose, and resolve. It is okay to mourn the life we knew, and we must mourn those whose lives are lost. But when the mourning ends, a new life will begin.