The arrival of the novel COVID-19 to the U.S., and the inevitability of its eventual spread, raises an interesting question: Should we avoid exposing residents to the virus?

Before we try to answer this question, we should start with some important qualifiers. While a good deal about this novel virus remains unknown, the majority of cases appear to be low risk, particularly for the demographic of the average resident. Furthermore, if this outbreak does reach pandemic levels, exposure to healthcare workers of all levels ultimately will be unavoidable. Finally, even with the best of protocols in place, it will be impossible to triage out every potentially infected patient at the point of first contact.

With all this in mind, COVID-19 may not be the best case study, but it’s an interesting opportunity, nonetheless, to pose a broader question regarding the role of trainees during epidemics and pandemics.

History

Let’s start with a brief historical overview of this question. Physicians have always been at the frontlines of deadly outbreaks, and as a result, were regularly infected by the same diseases as their patients.\ The first century of U.S. history can be recounted in a sequence of epidemics, from yellow fever to cholera to typhoid fever. In an era of unregulated medical and graduate medical education, and limited understanding of the spread of these diseases, there was scarcely any thought given to the protection of students and trainees during these outbreaks.

Graduate medical education evolved over the course of the twentieth century from a mix of apprenticeships and a limited number of more structured programs, to a landscape of predominantly hospital-based internships, and eventually specialty-focused residencies with a unified accrediting body. Important questions that persist to this day were considered during this time, including the place of the resident on the spectrum from student to employee.

The AIDS epidemic was likely the first major infectious disease outbreak during which the unique experiences of students and residents were explored, although the emphasis tended to be on the duty to treat in spite of the fears and perceived risk. In the intervening decades, however, the vulnerability of the trainee has been reconsidered, and this has shifted the conversation. By the time of the 2014 Ebola epidemic — although different in scale and mode of transmission from HIV — much wider efforts were undertaken to protect trainees from potential exposure, prompting a healthy debate.

Pros

We can entertain a couple of arguments in favor of trying to protect residents from a potential pandemic exposure:

• The infection control argument: Because residents are mid-level providers, any patient a resident sees will also be seen by a supervising attending. To limit the total number of exposures and mitigate the potential for disease spread, the fewest number of providers possible should see any at-risk patient.
• The student versus employee debate: During the Ebola epidemic — which was vastly different from the current pandemic — nearly all medical schools forbade students from providing care for rule-out Ebola cases. There may not be one unifying theory about why these policies were developed, but the reasons probably include insufficient training, liability, and a less than clear moral imperative. Conversely, faculty are compelled to care for all patients, at times even in the face of personal risk, by virtue of their training, their contracts, and their professional codes of conduct. The question, as always, is where residents fall on this spectrum; this has been argued both ways over time, often according to what is most convenient for the employer.

Cons

At the same time, some real downsides might occur in trying to shield residents from potential exposures:

• Missed training opportunity: This is especially true when it comes to outbreaks that require rigorous infection control practices, as was the case with Ebola. If rule-out protocols exclude trainees, health systems will be less likely to invest resources in training them. This may, in fact, put residents at higher risk, both now and in the future.
• Modeling professionalism: Residency is about attaining not just the knowledge and skills, but also the attitudes, necessary for life as a physician. At times, this encompasses embracing some risk in the service of our patients. Whatever the status of residents — student, employee, or student-employee — there might be value in imparting this message.

Conclusion

The role of the resident during a pandemic raises interesting questions; although they generally operate at the front lines, the instinct is there to protect them when personal risk is involved. COVID-19 might not be the best case study for a number of reasons, but it is more than just a thought experiment. Health systems are developing protocols at this very moment, and the role of trainees will be an essential consideration. In some instances, the protective instinct of a particular attending might be to handle the rule-out cases personally. But most importantly, the next pandemic might pose even greater risk, and it will be all the more essential to find the right balance between expectation, education, and limitation.

Eric Bressman is an internal medicine chief resident who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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