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Battlefield Promotions

A call to action for medical students
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Editor’s note:

The following open letter is adapted from remarks delivered in a video conference on Friday, March 13 to students at the University of California Irvine School of Medicine, where the author is director of the Medical Ethics Program.

In the coming months, we will face enormous professional challenges worldwide and locally. This will be unlike anything we have seen in the history of modern medicine. In the United States, many fourth-year medical students are still processing their disappointment from last week’s announcements of cancellations of Match Day gatherings and the likelihood that you will not be sitting together with one another and families at commencement this year. This week, most of you, including third- and fourth-year students on clinical rotations, are being sent home.

The Coronavirus Pandemic
From the Special Series:

The Coronavirus Pandemic

While these announcements may have felt unexpected and abrupt, we need to do our best to process these changes quickly and move beyond them. Now is the time to focus not on our own individual interests ­but on the common good. Realize that you are not being sidelined for the long term but kept on reserve in the short term: We simply cannot have too many health care workers getting infected at once. You will soon be needed for tasks that could not be more urgent and important.

I know that all of you are eager to help, to serve our patients and be of use during this crisis. You do not want spoon-feeding or sugar-coating from those higher in the medical hierarchy. You want to be treated like the physicians you (almost) are — after all, this is why we are here, to treat the sick even if this entails some personal risk. This is why you are becoming doctors. Just as firefighters go into burning buildings when others run the other direction, so physicians go where the sick are when others try to avoid them — using all available precautions and training, of course, but still putting the needs of the patients ahead of our own convenience. This is clearly articulated in the American Medical Association’s code of ethics (Opinion 8.3):

Whether at the national, regional, or local level, responses to disasters require extensive involvement from physicians individually and collectively. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This obligation holds even in the face of greater than usual risks to physicians’ own safety, health, or life.

However, the physician workforce is not an unlimited resource. Therefore, when providing care in a disaster with its inherent dangers, physicians also have an obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future.

There are many grassroots efforts that you can organize now while you are off the wards temporarily. Some medical students are arranging to provide child care for health care workers with kids at home due to school closures. Blood banks are already running low on donated blood because people are staying home and not donating (a supply problem, not yet a demand problem). We need creative thinking for drive-through blood drives that practice adequate screening and social distancing while continuing to supply necessary blood. You can be the first to donate blood and can help organize these initiatives. You can get the word out on social media.

This week, the White House encouraged construction companies to donate their stocks of N95 respirators to hospitals. If you know someone (or know someone who knows someone) with a construction business, reach out and encourage these companies to donate their N95 masks to your hospital. These essential supplies can literally save lives. We also need tablet computer donations to hospitals to facilitate telemedicine on rounds and for patient use. Some local groups in Italy have organized tablet donation drives so that dying patients who are in hospital isolation and cannot take visitors can speak with their families in their last moments. Students can organize and contribute to these efforts.

Med students will be even more essential and important, and less “superfluous” to medical teams, in the coming days. Due to shortages in personal protective equipment like masks and eye protection in the U.S., your contact now with patients, especially those in isolation, will be limited for now. However, as many residents, fellows, and attendings become furloughed at home with symptoms, staff numbers could become strained. Then you could be called upon.

Our current Covid-19 testing shortage in the U.S. means that many doctors will be quarantined at home longer than necessary due to our inability to detect which of them are not actually infected. This means that there will be — to borrow a phrase from one medical school dean — “battlefield promotions”: third-year student clerks will need to become acting interns, and fourth-year students will need to act like interns.

You are prepared to rise and face this challenge. This is why you are grinding through the hell that is medical school, with its long hours, heavy demands, and massive debt. You may not feel like one quite yet, but starting now, we will treat you like physicians.

This will be the best possible training experience for you — an opportunity that physicians-in-training have not seen in the age of modern medicine. The Spanish Flu of 1918 came just a few years after the publication of the Flexner Report, the document that eventually helped to create our system of modern medical education. In the modern period, we have not seen the likes of what now confronts us. We can choose to see it only as crisis, or we can choose to see it also as an opportunity — an unprecedented chance to train and form the greatest generation of physicians in modern times.

Covid-19 is our World War II. You are ready for it.

Aaron Kheriaty, “Battlefield Promotions,”, March 18, 2020.
Image credit: A demonstration before Army doctors and officer candidates at the U.S. Army medical field service school in Carlisle, Pennsylvania, 1943. (Marjory Collins / Library of Congress)

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