Chip Kahn (00:10):
Hello and welcome to another edition of Hospitals in Focus. I’m your host Chip Kahn. Before we begin, I will take a moment to say that I hope you enjoy this podcast and visit our other episodes. And I’d like to ask a favor. In the podcast world, feedback is very important and it’s simple to do. So, if you would take a second to rate and review Hospitals in Focus on your podcast app, I would greatly appreciate it, and it helps us improve and continue to make great content for you.

Now to our podcast. Joining us today to discuss the impact of COVID-19 on physicians in training is Dr. Alison Whelan, the Chief Medical Education Officer at the Association of American Medical Colleges, the AAMC. The COVID-19 pandemic is a disruptor, not just in the lives of millions of Americans or the operations of hospitals and their health systems, but for all the caregivers in those hospitals and health systems.

This has particularly been true for some graduating medical students and the medical residents who train and provide so much of the physician care in hospitals across the country. From early graduations to changing training patterns, the graduate medical education of the next generation of physicians has been affected by this pandemic and may even be profoundly changed beyond the course of this medical crisis.

So, what does this imply for the hospital experience of these doctors as both practicing physicians treating patients and trainees? And what does it mean for those who oversee them, as well as the institutions in which they practice and train? What does it mean for patients, too? Alison is here to discuss these questions and more. Thanks for joining us Alison.

Alison Whelan (02:01):
Thanks, Chip. It’s a pleasure to be here and I really appreciate you taking the time to talk about this really important part of the pandemic.

Chip Kahn (02:08):
Before we start on our topic today, Alison, would you tell us a bit about your background, how you came to AAMC and what you do there?

Alison Whelan (02:18):
So, the AAMC, Association of American Medical Colleges, is a member organization. It’s 155 [inaudible 00:02:25] accredited medical schools in the US and all 17 of the medical schools in Canada. Also, have members of the major teaching hospitals and the academic societies.

So, before I came to the AAMC three and a half years ago, I am an internal medicine physician, and I was at one of our member medical schools. And there, I was the senior associate dean for education. And in that role, I oversaw all of medical student education, resident training and the continuing education for physicians. I also cared for patients in both the inpatient and the outpatient setting. So, at the AAMC as chief medical education officer, I see my job as really similar to what I used to do at a single medical school, but on a national level, working with, and for all of our medical schools and all of our teaching hospitals to improve medical education across the continuum.

Chip Kahn (03:16):
Alison, let’s start with one of the unprecedented aspects of the crisis that has been reported as a byproduct of the COVID disruption. More than 30 medical schools have given the option of early graduation to at least some of their graduating medical students, so that they may join the COVID-19 front lines. Besides the headlines on this, what has it really meant in practice? What are the medical school’s expectations for these early minted graduates, and what have they experienced? Did they really head to the front lines? And how will that mesh with the July 1 start date for many of these graduates for their medical residencies?

Alison Whelan (04:00):
Yeah, so let’s think about it for both these early graduates’ viewpoint and from the medical school viewpoint. So first the medical schools had to make certain that who they would offer early graduation too, was really ready for graduation, and they had met all the program requirements and all the competencies for early graduation.

So, those schools that did offer that had to certify for each individual student. And then of course it was up to the students, whether they were wanting to graduate early and also if they were able to take the opportunity to become an employed physician. So, most of the students who graduated early began working in a hospital that was affiliated with the school in which they had trained. A couple of things to remember that when students graduate with an MD, they are ready for supervised practice, not for independent practice, and they typically go into residency, and then have a special license related to that.

So, in order for these students, these graduates now, to become working physicians, the state boards had to grant them special licenses. And I think something you’ll hear throughout our conversation is how creative and flexible many different associations and governance and regulatory bodies have been to try to really help take care of what’s needed to be done for a pandemic while also protecting the health of the public.

So once the states allowed these graduates to get a special license, they worked within the hospital in which they had done their medical school, under the supervision of another physician. What they do depends very much on what’s needed in the hospital and don’t imagine that they’re all rushing into the ICU. They were really working at the level of which they were ready and competent to be doing work.

So much work to be done in taking care of these incredibly sick patients, gathering the labs and taking notes and taking the medical history from the patient, connecting with the family are all things that they can do for the patients that are in the hospital. And then, importantly, there are so many people who are concerned that they have COVID who are having testing, that many of the graduates have to follow up, in terms of letting people know what their test results were, and then following up to see if they were well or not, if they had not been admitted to the hospital.

And then, also, they could be involved in the non direct patient care that had been extended, more involved in the tele-health work that has going on. So a lot of different activities. So, that’s what most students did or most graduates did. They’re no longer students. They’re now employees of the hospital.

And for those graduates who are now employees, it is important that both they and the hospital that’s employing them come together so that they can start their residency for which they are contracted on July one on time. We know the work they’re doing now is important, but it’s equally important for them to continue their training so they can become full fledged, independent members of the workforce.

It’s also worth noting that a small number of the schools that graduated students early did put the students into residency directly after graduation. The most notable of those is OHSU, so Oregon Health Sciences University. And they were able to do this because they’ve had a longstanding practice, at least five or six years, where a portion of their students are offered early graduation. They truly work in a competency based progression model. Since they already had that in place, had agreements in place to the residency programs, their students were able to enter directly into residency.

But for most, both because of accreditation requirements for the program and limitations on individuals, it did not make sense for them to go directly into their residencies, but to serve the hospital in which they had done their training was a way for them to be most effective and most comfortable because they’re familiar with the system, familiar with the processes, familiar with the hospital. And I think for a lot of those students, it was a way to really give back to the hospital and the people and the patient and the communities who had helped them become physicians in their training.

Chip Kahn (08:07):
Alison, let’s move on now to those who are already medical residents and central to the care in most hospitals with the teaching role, are these medical residents. For those residents whose specialties are directly relevant to COVID treatment, what has it meant to be directly in the line of the pandemic’s fire? And is it different than what they were already doing as medical residents?

Alison Whelan (08:35):
Yeah. So let’s think about that in two parts. So, one is, the loss of the mix of other patients. That’s important to be fully competent in whatever specialty they’re doing. And then I think the other part is the impact of actually caring for the COVID patients.

So, for the first one, these residents are physicians, but they’re still in training, and they and their training programs expect them to have, and they really need to see a broad array of patients. I’m an internal medicine resident, and of course, internal medicine folks are on the front line. But during my training and during their training, it was really important for me to see a large number of patients (inaudible 00:09:11) diabetes, with heart failure, with acute myocardial infarction heart attacks.

And for those that are in a hospital that is 90% COVID, they are not seeing this diversity of types of patients and diagnoses. So there will be a need when the pandemic has flattened and the surge has decreased, for these programs to really find a way for them to get that broad diversity of patients. So, when they do finish their residency on time, they are competent in the broad array of what is their training in.

I think the other part that has been written about in the press, and I think can’t be overemphasized, is the work that it has taken for them that are on the front line and actually caring for COVID patients. Many of the hospitals in which there has been a surge, as I said, 90% of the patients are COVID patients and they are very ill. These are young physicians without a lot of experience, and there are concerns, as we’ve not typically faced, about their personal safety.

There’s huge pressure because of the volume of patients and the acuity, the sickness of these patients. And as we all know, there’s been a high rate of death, and so the loss and experiencing that has been a tremendous pressure for the residents.

I think it’s a lot of things. It also extends that to their broader world. They are worried if they’ve been in the hospital, bringing COVID home to their family. I’ve talked with young parents who are residents, who, after they do two weeks in the inpatient service, then they spend two weeks in their basement or at a friend’s house away from their spouse, away from their children, that they don’t pass on to them.

So, I think that’s a huge pressure. So, I think it’s a combination of worry for their family, worry for themselves, and also worry about their ability to work at that level and that hard for that long. And really what’s unprecedented would be hard for even experienced physician to be doing.

Chip Kahn (11:16):
You talk about the psycho-emotional pressures these residents are under. What are the institutions doing to help them cope with the kinds of pressures you’re describing?

Alison Whelan (11:29):
Yeah, let’s just talk a little bit more about the pressures, because I think it’s really important and it makes me think about what those pressures are. It can help us understand what the institutions are doing. I think back, as a young physician you always have doubts. But for them, being asked to be working under such pressure in new ways with a rapidly evolving disease.

When I was a resident, I was trying to learn the guidelines, what everyone else knew before me of what we were supposed to do. And what they’re doing is compliance where they’re creating the guidelines. How you can have confidence in that setting when even your attending physicians are saying, “We’re figuring this out as we go along,” is extraordinarily hard.

And I think the other part of it is the loss of patients. For any physician, losing a patient is one of the hardest things that happens for us. It remains hard for all of us forever, but with time and experience, we develop healing habits. We learn how to care for ourselves and how to heal and reflect and go on.

But for these young physicians, they haven’t had the experience to develop those habits. And because they’re working so hard, they haven’t had the time to reflect and refresh even in the moment. And really, some of them are facing more death and more loss and more sadness in a month of care than I probably faced in my entire residency program. So, it’s daunting.

And I think one important thing is that, even before the pandemic, there was a recognition that there was significant concerns about clinician wellbeing. So, a number of resources have been developed nationally and a lot of hospitals and medical schools were really developing offices related to wellness, chief wellness officers, and those individuals have really been called into play to help support the residents.

And so, it’s supporting them both in sorting through these emotions, sorting through the difficulties (inaudible 00:13:29) uncertainty. What we’ve also learned is that these wellness officers now are thinking about not just the psychological support, the day to day support. The idea of we need to provide food to these residents and actually the physicians that are in the hospital. We need to provide a place for them to stay that is safe and close and local, so they can be away from their families if that’s what they need to do.

So again, it’s taken a lot of creative work by people who were already doing some of this work, who are really pivoting and expanding their work in the COVID crisis, and more needs to be done. I don’t think any of us can understand how truly difficult this is and that there will be long lasting impact on all the health professionals, not just the young residents, but everyone who’s been involved with this, and we need to continue to really work, to understand it and to support everyone so we can have a healthy workforce going forward.

Chip Kahn (14:20):
In those hotspot hospitals, what is generally happening with the medical residents whose residencies focus on areas not directly related to the medical treatment for those COVID patients? What are they doing?

Alison Whelan (14:34):
So, I think one of the great things that the ACGME has done, the accrediting organization for the residency programs, is they developed the idea of three stages of the pandemic and they allow residency programs to say where they are in the stage. And so, at stage three, which is really a pandemic emergency, they explicitly say that residents can be redeployed to do work. If they have appropriate supervision and appropriate training for those things that they would typically be doing.

It’s a challenge, but again, with appropriate supervision and under the guidance of the ACGME, which again has continued to stress the idea of resident safety, working with appropriate supervision and keeping their work hours so that they don’t get even more overstressed, have been a good step forward. And then also for them, when the surge is over, they’ll need to make sure they have the opportunities to get the broad training that they need to be fully capable and competent in the full range of what their specialty is.

Chip Kahn (15:39):
This pandemic has so many effects on hospitals and those who work in hospitals. From the view, and we’ve been viewing this from the hotspot aspect, but what about those hospitals that haven’t been hotspots? And frankly, we know because of orders by local and state officials, most of those hospitals are near empty. Some are almost shuttered, and many of them have a few to hundreds of residents. What’s happening to those medical residents who are now in basically empty hospitals?

Alison Whelan (16:16):
Yep. You just exactly captured the problem there. And again, it was the right thing to do to flatten the curve, to really prevent such a surge that the hospitals are overwhelmed. But then, for these residents, and again, I’ve talked with both residents and program directors and they say, roaming the empty halls. And so, those residents, a couple of different things.

They’ve also shut down many of the ambulatory clinics, but there has been a large pivot in nearly every specialty to doing a greater proportion of care through telehealth and distance care than what could possibly have been anticipated. So, that has been a way that residents have been able to continue to stay active and continue to provide care and continue their education.

Recognizing again, that as hospitals reopen, there will need to be [inaudible 00:17:12] for the residents to get that broad trending as well. And it’s frustrating to them. They are there to work. They are there to take care of patients. They recognize that they’re doing the right thing, but it is hard to not being able to be giving care. And we all recognize, I think the people running hospitals, the people working in hospitals, is that if you put off elective surgery for too long, it becomes less elective and conduct can become urgent. So, finding that right balance between slowly reopening and preventing a surge is a challenge that we’re all facing.

Chip Kahn (17:45):
Alison, from the midst of COVID, it is difficult to look into the future, but let’s try. What effect do you see the crisis having on graduate medical education and particularly those residents that are scheduled to start this summer?

Alison Whelan (18:01):
Yeah. My crystal ball kind of turned off a few months ago, but I think it will depend a little bit on the pandemic locally. What we have seen as we’ve talked to medical educators across the continuum, and so if you think about it, this is at every transition spot. How are we going to enroll the next class of medical students? How are we going to help our final year medical students select a residency, interview for residencies and get into residency? And those students who are graduating, how will they get into their residency?

And one thing that I’ve been really impressed with is the willingness of schools and programs, and importantly, the associations involved in medical education to really work together. So, there is a whole group of the associations that will be coming out with, really, guidelines for thinking about what (inaudible 00:18:55) all need to pay attention to, to help a student who just graduated enter residency in a timely fashion? We need to think about do they enter on time? Yes, they should. What do we do about if there needs to be quarantine? What do we do about orientation? How do we help people think about moving across the country? And so the idea of people sharing best practices and working from there, it will look different, depending on what’s going on in the pandemic. There is a real commitment to continuing to train our workforce, to continue to help them move through the continuum.

Chip Kahn (19:30):
Sort of in conclusion, what’s your perspective from AAMC? What role will AAMC play in working through the issues of COVID in terms of its effect on healthcare and physician training? And how do you see it, over time, affecting your organization’s concerns about physician workforce generally?

Alison Whelan (19:52):
Yeah, those are great question. And I think, like everyone, we have both our short term and our longer term things. So, short term, we have been actively creating guidelines or guiding statements for thinking about students [inaudible 00:20:08] direct patient contact. And then, now, thinking about, again, that those transitions into medical school and what to be doing in the fourth year for residency applications.

We’ve also been doing some of what we do best, which is bringing people together. So, when you are facing big, tough problems that you’ve never faced before, the best solutions come from bringing great minds together. So that, across all of academic medicine, so the deans, the education deans, the student affairs deans, the people involved in residents, and even our students and residents, bringing them together on regular phone calls to share ideas, but also collecting resources. We’ve created a new educational repository for medical student education.

When we said the students shouldn’t be involved in direct patient contact. Well, how else can you have meaningful clinical learning activities? Our school stepped up, we brought them together. So, now we’ve created this great resource, created another resource related to volunteer activities that students are doing. So again, data gathering and sharing best practices.

Recognizing that telehealth has expanded hugely and is here to stay. We had already started developing a set of telehealth competencies for medical students, residents, and faculty, and we’ve expanded that. And then I wanted to highlight one other aspect that we’re currently doing.

And it goes back to just a part of that whole wellness part of things. And that’s that recognizing AAMC has been working for a couple of years and really thinking about the role of the arts and humanities in medicine, recognize that it’s important. That particularly in times of crisis and distress, we have accelerated that and are going to be launching a couple of projects specifically related to that, which is specifically collecting stories and poems from healthcare professionals related to COVID-19. It’s in association with The National Endowment for the Arts.

And so the first is really a call for creative works, poetry and 55 word stories, with or without images, from students, residents, and faculty. And these are going to be curated and shared broadly, both online and probably in a future time when we all get together and can look at things together.

And then the second opportunity, again, in conjunction with The National Endowment for the Arts, is something called the Listening Poet. Again, it’s a strategy they’d used before, but we’re adapting for health professionals, related to COVID, where a trained listening poet listens to a healthcare provider, takes their words and turns it into a poem.

And what I have found as I’ve read social media and actually just notes and information and sharing from colleagues among ourselves and importantly for our learners, that oftentimes the arts, narrative and poetry, can capture our feelings in ways that nothing else can. And so I’m actually really proud of this work that AAMC is going to be doing with NEA. And we’re looking for other opportunities through other organizations to expand that as well.

So, those are all short term things that we’re doing. In longterm, as you said at the beginning, the pandemic has changed the way we think about medicine, and probably how we do medicine forever, partially because of the pandemic and we have to adjust, but also because sometimes crisis causes innovations that are unexpected, but worth continuing and expanding.

So AAMC, with other associations, is really committed to thinking about and understanding what have we learned that we need to keep and expand and do better with, even if the pandemic doesn’t force us do that? And again, because we serve students, residents, educators, student affairs folks, teaching hospitals and medical schools, we think we’re in a great position to bring people together a little ways down the line and really begin thinking about that.

AAMC has a medical school application service. It opened this week, May 4th. And in our first three days, we had a 50% increase of initiated medical school application over the same time period last year. So, really extraordinarily high number of people initiating their applications.

Don’t know that that means we’re going to have that many more when the cycle is done, and some people have said this may just be because people are home and they have time on their hands. I think it’s something [inaudible 00:24:32] Because what I see on social media is that our young people are really full of passion, desire to help, desire to change the world. And that the news from the front lines of the pandemic has really reinforced the idea that a career in medicine or any of the health professions really gives you an incredible opportunity.

And the world is looking for heroes and people can see that physicians and nurses can be heroes. And although the heroism that we’re seeing these days is really epic and front page, I think we all know anyone who’s associated with hospital work, that there are quiet moments of courage and heroism in the everyday life of every physician.

And I think this is a real opportunity for us to help these people who are paying attention to medicine to really potentially understand that. So, I actually think there’s great hope and great future for medicine, the medical profession, the health professions, and there are challenges. The health of our current learners, residents, [inaudible 00:25:34] patients we need to care for. We need to care for the health of our hospitals as well. I think we have great opportunities.

Chip Kahn (25:43):
Well, it’s gratifying to hear that Alison, and frankly, this has been a great conversation. I think the last part particularly, hopefully, will be enlightening to our audience. And I’m confident that the whole conversation will be meaningful to the audience. It certainly was for me. We really enjoyed having you and just deeply appreciate your taking time to join us today.

Alison Whelan (26:08):
Thank you, Chip. And I really appreciate you taking the time to really think about, again, our learners and our future physician workforce. It’s been a pleasure.

Chip Kahn (26:17):
Thanks a lot.

Alison Whelan (26:18):
Thanks.

Chip Kahn (26:19):
Join us next time as we speak with experienced leaders on new ideas about healthcare delivery and financing.

Please listen, rate and subscribe wherever you get your podcasts. And if you haven’t already, you can follow the Federation on social media @FAHHospitals and me, @chipkahn. This was Hospitals in Focus. I’m Chip Kahn. Thanks again for listening.

Dr. Alison Whelan, Chief Academic Officer, Association of American Medical Colleges

Alison J. Whelan, MD, became the AAMC’s chief academic officer in January 2021. In this role, Dr. Whelan oversees efforts that prepare and assist deans, faculty leaders, educators and future physicians for the challenges of 21st century academic medicine. She leads a staff that addresses critical medical school data, administrative and operational issues; explores new models of successful mission alignment; focuses on key student and faculty issues; transforms current models of education and workforce preparation across the full continuum of medical education; and supports medical school accreditation activities.

Dr. Whelan joined the AAMC as chief medical education officer in 2016. Prior to joining the association, she served as a professor of medicine and pediatrics at Washington University School of Medicine in St. Louis (WUSTL School of Medicine). She held multiple education roles during her tenure, including course director, clerkship director, curriculum dean and the inaugural senior associate dean for education. In this role, she oversaw the continuum of medical education from medical school admissions through continuing medical education. She also liaised closely with the MD-PhD program leadership. Dr. Whelan led or oversaw local accreditation for LCME®, ACGME and ACCME, and she participated in overall university accreditation as well as accreditation for a new Master of Public Health program. She was responsible for interprofessional education and led the creation of a Center for Interprofessional Education, a joint venture between the school of medicine and two completely independent organizations: Goldfarb School of Nursing and St. Louis College of Pharmacy.

An internist and clinical geneticist, Dr. Whelan continued both clinical care and research involvement until she left WUSTL School of Medicine. She created and ran the hereditary cancer clinic, co-ran an interdisciplinary Marfan clinic, was co-director of the Siteman Cancer Center Hereditary Cancer Research Core and served five years on the Siteman Cancer Center Executive Committee.

Dr. Whelan received her bachelor’s degree from Carleton College in 1981. She earned her medical degree from WUSTL School of Medicine in 1986 and completed her postgraduate work and residency at the former Barnes Hospital, now Barnes-Jewish Hospital.