No One Is Supporting the Doctors

I have ceased to expect appropriate help from administrators, institutions, and the government itself.  

An illustration of a doctor
Ina Jang

About the author: Steven McDonald is an assistant professor of emergency medicine at Columbia University Irving Medical Center (CUIMC). His interests to date have largely focused on physician wellness and the barriers that minority physicians face during and after residency.

I trained for this moment. All emergency-medicine physicians did. Residency —the notorious gantlet that turns medical students into attending physicians—prepared me to manage an onslaught of patients entirely on my own. I may be ready, but that doesn’t mean the situation I’m in is right.

At Bellevue Hospital, where I trained, New York’s most disenfranchised patients come through the doors at every hour of the day. While my attendings taught me to diagnose appendicitis, ectopic pregnancy, and multiple sclerosis, they also watched me fail. They watched me struggle to keep up with the pace of the department, to remain calm when patients would mock my race or sexual orientation, to cope with my own emotional reaction to the destitution, hunger, and loneliness that so many patients take as a given. The directive throughout was that I needed to pull myself up by my bootstraps. No one would do it for me or teach me how.

So why should I or any physician have expected more than a meaningless cacophony of messaging at this exceptional time of need? President Donald Trump has promised Americans access to testing. And yet, before the state of emergency, the New York City Department of Health mandated testing only for admitted patients. As a physician, I was stuck in the middle, left to absorb the ire of patients who accused me of being uncaring. They did not want to hear from me that they had been lied to, that the system did not have the capacity, and that they needed to come back when they were even sicker for treatment.

Health-care systems in America do not support physicians and do not support the most vulnerable patients. Physicians are seen as upwardly mobile and willing to pay the price of unacceptably low residency pay and backbreaking work in order to do what they love. Patients without access to care are seen as unambitious—they lack insurance because they do not work. Hopefully this crisis opens the eyes of Americans to the plight of both groups.

The White House, the Centers for Disease Control and Prevention, the Department of Health and Human Services, the National Institutes of Health—they all failed to deliver on sufficient testing, on guidelines, on coherent messaging. Hospitals across New York City failed to report health-care-worker fatality rates or to produce ventilation-eligibility criteria, leaving me to guess at my own risk and to decide who lives and dies. There has been an abdication of leadership at the highest levels of this crisis that has trickled down to me, a physician in an ER with inadequate personal protections telling oxygen-starved patients to come back when they cannot speak a full sentence or are coughing up more than one tablespoon of blood. These institutions, just like my attendings, are teaching me a lesson through absence: how to manage a pandemic alone. And I am ready because I have been left alone before.

“Sink or swim” seems to be the mantra of medical training. The second year of my residency was physically taxing, with eight or nine 12-hour overnight shifts in a row. I frequently had to flip my sleep schedule to wake up at 6 a.m. or 5 p.m., depending on the day. The physical rigor of residency left me moody, weary, stretched thin. And yet that was only the beginning of the process. On top of the physical exhaustion, residency pushes new physicians to extreme autonomy.

My attendings could have easily lightened my patient load, but they did not, so that I could learn self-sufficiency. They could have acknowledged the particular challenges I faced later as a black physician at NYU Medical Center, treating upper-class white patients who sometimes doubted that I was even a doctor. But they did not, so I could learn resilience. They could have counseled me on how to process the immense human suffering of Bellevue. Instead they mostly did not, leaving me to internalize my agony, and see the next patient. Their effective absence—only there as a malpractice safety net—taught me how to work efficiently, to manage an entire team of caregivers in the emergency department, and eventually to manage the ugliest parts of myself and others.

This approach was not without its costs. The isolation at work was made worse by isolation at home. A resident work schedule spares no nights or weekends; I craved moments of release or nourishment with friends and family and found them few and far between. The social isolation compounded by intense personal tragedies—the loss of my mother while I was in medical school and my father during my residency—had me at wits’ end, and eventually forced me into therapy and a two-week elective period that I used as a wellness leave. But residency had made me competent in my field and able to practice in a vacuum. Costs be damned.

Now, at Columbia University Irving Medical Center, I again find myself socially isolated from friends and family, navigating experiences my loved ones will never truly understand. During the surge of patients sick with COVID-19, personal protective equipment was promised to me, but only a month ago I had to intubate patients with a used sheet protector and industrial paper clips as protection. This is not why I became a physician, but I did not resist, because I have ceased to expect appropriate support from administrators, institutions, and the government itself.

The volume of patients has plateaued, so I have more time to prepare myself for the difficult decisions ahead that I am certain I will again face alone. Contemporary analyses already demonstrate that the burden of this pandemic is falling most heavily on our country’s most disenfranchised groups. I fear that postmortem analyses will show the death count to be orders of magnitude greater in hot spots like Elmhurst, Queens.

The wealthiest Americans stay home and practice social distancing while essential workers continue to expose themselves and their relatives in dense, multigenerational family housing. And although the world should look to its legislators to provide basic income and housing to vulnerable groups, instead it looks to hospitals, to doctors, to save as many as possible. And we will do our best to sort the living from the dead, because we cannot say no. Because we work in a system that mandates we say yes. Yes to extra shifts, yes to unsafe working conditions, yes to deciding who lives and who dies. This can-do attitude will be the undoing of many of us.

In the meantime, doctors are left alone to sort through our own mental anguish. Which end-of-life conversation will keep me awake at night in a decade? Which face will flash into my consciousness when I’m commuting to work? Essential to sink or swim is acting now and thinking later.

Those that live through this crisis must not let its lessons go unlearned. People must elect leadership that will not lie to us. We must seek transparency from our institutions. We must reform a culture of medicine that tells trainees they must endure alone. Otherwise, how will we survive the next crisis?