JAMA: Delay all incoming med students

[Matthew9Thirtyfive]

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According to the CDC, that chart is pretty accurate. My ID colleague tells me that numbers are even a bit higher on the Johns Hopkins SPH page for COVID19!

Coronavirus Disease 2019 (COVID-19) in the U.S.

View the number of confirmed cases COVID-19 in the United States.

www.cdc.gov

Keep in mind that the worldometer and the JHU charts close out at different times, so their numbers are going to be slightly different even if they are both equally accurate. Either way, the trend is the same. We have had about a week of essentially the same number of new cases every day. Furthermore, looking at the log scale, it had previously been taking us about 9 days to increase by an order of magnitude. We are now at a point where, since hitting the last order of magnitude, it has been about 12 days, and we are only about halfway to the next order of magnitude.

It has been slowing down for over a week now, and hopefully it will continue to do so. The models predicted a peak around now, and I wrote a post in the EM forum where I plugged in a lot of the data (up to last week) into Origin, and it predicted roughly the same thing--a little earlier, but it was a simple fit, so giving it a little wiggle room, it was close.

Obviously, things could change, but if we continue to do what we're doing, this could be the beginning of the saturation phase of the logistic curve.

 

[deleted621740]

I think these will factor into how quickly society can attempt to return to normalcy (however one may define it):

- How quickly the govt + private sector (nationally, globally) can channel efforts toward promising therapeutics (vaccines or treatments)
- Testing availability (kits, labs etc)
- Supplies (GM, 3M etc are making ventilators, masks..)
- Clinical trials using serum/antibodies from recovered patients
- Antibody testing to see who has already recovered from it.

How quickly these can be scaled will be the bottleneck toward getting people back out in society IMO.

Agreed. Personally I don't think that waiting for a treatment before opening is tenable given that it will likely be many, many months before we have something, but the above factors will be critically important. Ideally we would wait for a treatment, but that would almost surely sink us into a depression (especially since continued stimulus packages like the one we just passed would not be sustainable). I think that the severity/implications of an economic depression escape us (especially our generation) since we have been so far removed from anything even approximating it. People would lose their homes, there would be starvation, etc etc. It's a horrible moral dilemma and I don't know that waiting for a treatment would be better. It's really a lose-lose scenario.

 

[HopeP]

CNN is alarmist, Fox is calling it a war while also downplaying it. Liberals are generally glass-half-empty, conservatives are glass-half-full. It's so arbitrary and funny to see political leanings impact how people view coronavirus seriousness. Especially since conservatives tend to be more crisis-averse, or at least my family is.

Downplaying for what? so that business can generate income and people go more out and asymptomatic do more spread? Well how good hydroxychlo..hypothesis from right friends are effective? I don't think Fox did a good public service in this crisis.

 

[Raryn]

Keep in mind that the worldometer and the JHU charts close out at different times, so their numbers are going to be slightly different even if they are both equally accurate. Either way, the trend is the same. We have had about a week of essentially the same number of new cases every day. Furthermore, looking at the log scale, it had previously been taking us about 9 days to increase by an order of magnitude. We are now at a point where, since hitting the last order of magnitude, it has been about 12 days, and we are only about halfway to the next order of magnitude.

It has been slowing down for over a week now, and hopefully it will continue to do so. The models predicted a peak around now, and I wrote a post in the EM forum where I plugged in a lot of the data (up to last week) into Origin, and it predicted roughly the same thing--a little earlier, but it was a simple fit, so giving it a little wiggle room, it was close.

Obviously, things could change, but if we continue to do what we're doing, this could be the beginning of the saturation phase of the logistic curve.

That was my point. The log scale clearly shows a decrease in the rate of growth, appearing to trend towards a plateau.

 

[Tenk]

Despite being doctors, these two authors are incredibly stupid.

 

[Matthew9Thirtyfive]

That was my point. The log scale clearly shows a decrease in the rate of growth, appearing to trend towards a plateau.

Yeah, I just explained it because surprisingly a lot of people don't really know what a log scale means. Not saying you or @Goro don't get it, but I know some people don't.

 

[LizzyM]

Y'all know I love analogies. Here's one I heard recently: opening up the country too soon is like cutting the lines on a parachute before you're reached the ground.

 

[Raryn]

Despite being doctors, these two authors are incredibly stupid.

I would assume the editor-in-chief of JAMA isn't an idiot. Just... incredibly shortsighted in this case. And perhaps blind to reality, sitting in his ivory tower. I'd be curious if he asked any of his peers to review this or if he just pushed it through being the one in charge.

Forget my prior points about this being logistically impossible. Just think of the complete disconnect this shows to the actual struggles of medical students, particularly the ones who don't have significant savings. I'm sure this harebrained scheme won't be particularly well compensated. These students would then have to defer attending income for another year. They might have to delay childbearing another year down the line - which for people staring down spending their 20s in training is already a big deal.

All this to get a bunch of recent college grads to do grunt work? You could get all the MPH students to do the same and you know, actually have it be relevant. You could ask for general volunteers - there's about 16 million newly unemployed people, many of whom have college degrees and would be just as qualified. Leaving a huge hole in the medical student/physician pipeline is probably the worst way to go about doing this.

 

[HopeP]

Y'all know I love analogies. Here's one I heard recently: opening up the country too soon is like cutting the lines on a parachute before you're reached the ground.

and expect a tripod to stand on two legs.

 

[KnuxNole]

and do what? over 16 million filed for unemployment over the past 4 weeks with estimates of another 4 million gig workers unemployed and get nothing. With 20 million people out of work, jobs are becoming scarce

Something that would not put myself in an unsafe place lol

Hypothetically, would do telemedicine somewhere that doesn't force unsafe policies

 

[Raryn]

and do what? over 16 million filed for unemployment over the past 4 weeks with estimates of another 4 million gig workers unemployed and get nothing. With 20 million people out of work, jobs are becoming scarce

Live on savings for a few months. Find a telemedicine job. Find a job doing exclusively outpatient care at a small practice without hospital contracts - tons of those around in my specialty, hiring even now.

Oh, and find a lawyer, who's going to love the breach of contract incurred by my employer completely changing the terms of employment unilaterally. My contract - and most physicians - explicitly specifies my role, and while it does allow for it to be changed, it requires mutual consent.

Don't get me wrong - if my area got hit as hard as NYC and they needed people to do floor work, I would be in line to join them voluntarily. If compensated appropriately. I'm a board certified internist and only a few years out from doing floor work myself. But good luck forcing me to do that - I have enough savings I don't have to work for a number of months, and last I heard slavery was still illegal in this country except as punishment for crime.

 

[deleted555445]

There have been many articles (https://www.washingtonpost.com/heal...ork-battle-coronavirus-most-are-sitting-idle/ as an example) about how people are trying to volunteer and not getting an assignment. I doubt there will be a call for drafting medical students any time soon.
Just for perspective, I am in the National Guard, which is obligated to respond to emergencies, in a decently hard-hit state. So far, we've been told to have our bags packed and wait for further guidance, which means no one needs us yet. If grunt work needs to be done, they'll call us first, so this isn't impending in any fashion.
In my opinion, the best option would be for M1 to still happen, but also strongly encourage students to help out in their community, and maybe universally switch to true P/F for the duration of the pandemic to allow students more latitude to volunteer. Like people have said before, there's no reason to cancel the easiest year to do remotely. Med students want to volunteer because they know it looks good on a resume (and a rare few actually care about helping 😉), but they don't want to delay graduation for a year to do unskilled or semi-skilled labor.

 

[HopeP]

This crisis has exposed bottlenecks of the largest healthcare industry in world, whether it is supplies, safety, insurance, public health policy, diagnosis and what else.

 

[Tenk]

I would assume the editor-in-chief of JAMA isn't an idiot. Just... incredibly shortsighted in this case. And perhaps blind to reality, sitting in his ivory tower. I'd be curious if he asked any of his peers to review this or if he just pushed it through being the one in charge.

Forget my prior points about this being logistically impossible. Just think of the complete disconnect this shows to the actual struggles of medical students, particularly the ones who don't have significant savings. I'm sure this harebrained scheme won't be particularly well compensated. These students would then have to defer attending income for another year. They might have to delay childbearing another year down the line - which for people staring down spending their 20s in training is already a big deal.

All this to get a bunch of recent college grads to do grunt work? You could get all the MPH students to do the same and you know, actually have it be relevant. You could ask for general volunteers - there's about 16 million newly unemployed people, many of whom have college degrees and would be just as qualified. Leaving a huge hole in the medical student/physician pipeline is probably the worst way to go about doing this.

No... he is definitely an idiot if he wrote that.

 

[KnuxNole]

Live on savings for a few months. Find a telemedicine job. Find a job doing exclusively outpatient care at a small practice without hospital contracts - tons of those around in my specialty, hiring even now.

Oh, and find a lawyer, who's going to love the breach of contract incurred by my employer completely changing the terms of employment unilaterally. My contract - and most physicians - explicitly specifies my role, and while it does allow for it to be changed, it requires mutual consent.

Don't get me wrong - if my area got hit as hard as NYC and they needed people to do floor work, I would be in line to join them voluntarily. If compensated appropriately. I'm a board certified internist and only a few years out from doing floor work myself. But good luck forcing me to do that - I have enough savings I don't have to work for a number of months, and last I heard slavery was still illegal in this country except as punishment for crime.

I agree, I have enough in my savings to last me for at least 1-2 years. Maybe 3-4 if I don't splurge. Ultimately, its my livelihood and I'd rather be alive and happy than be on the vent and deteriorate alone due to pleasing someone else.

 

[SeaHusky]

I'd be happy to participate in something like this if the administrators sitting in their ivory towers earning millions of dollars also jump at the opportunity to join the front lines.

Until that mythical day comes, I'll stick to earning peanuts at my current gap-year job rather than earning peanuts putting myself and others at risk because there's no PPE.

 

[LizzyM]

Despite being doctors, these two authors are incredibly stupid.

Howard C. Bauchner, MD, vice chairman of pediatrics at the Boston University School of Medicine
Joshua M. Sharfstein, MD, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health

"The program should begin at the start of July. The federal government should fund this project as a national service effort with a salary for the students and Incoming medical students should spend the month in online training on infectious disease epidemiology, infectious disease control in high-risk settings, and outbreak response. In August, they should deploy to state and local public health departments to enhance the capacity to support a test, trace, track, and quarantine strategy.health coverage; it could be part of a larger initiative to engage other students, including those in nursing and public health, as well as out-of-work community members in the national response."

"One urgent task is to implement rapid testing that informs community surveillance. Even today, only a small fraction of people with suggestive symptoms can be rapidly tested; in some acute care settings, even the sickest patients wait days for the result. Access to testing is so haphazard that it is difficult to draw reliable inferences about incidence, prevalence, and populations at risk. As testing becomes more available—results available within hours—there will be an urgent need to use these data to assess the scope of the epidemic. Whereas the lack of adequate testing and surveillance has been a major weakness of the initial response, it must not be by the fall."

"A second urgent task is to enhance protection of high-risk populations, with the goal of reducing the likelihood and effect of outbreaks now occurring in nursing homes and prisons. Medical students should help ensure implementation of critical preventive policies and join teams that swiftly and aggressively respond to infections that occur. "

"A third role for medical students should be to staff community call centers that offer guidance and services to individuals with symptoms of or exposure to COVID-19. In addition to arranging testing, medical students would ensure that adequate information has been collected from individuals who require quarantine. This information could facilitate efforts to provide food delivery at home, alternative housing if necessary, and additional medical treatment as needed. "


I would also note that the word "draft" does not appear in this editorial.


There are about 80,000 medical students at any given time compared with approximately 16,000 MPH students (based on 8,000 grads/yr and most programs being 2 years in length see SAGE Journals: Your gateway to world-class research journals) There are approximately 190,000 students in BSN programs New AACN Data Confirms Enrollment Surge in Schools of Nursing – Jonas Philanthropies


Frankly, as I look at the numbers and also think about the number of employees in health care roles who have been laid off due to the closure of outpatient facilities, some of this work could be taken on by those unemployed nurses and other HCWs who are currently sidelined.

I do think that the concern is that medical schools that pride themselves in early clinical exposure will not be able to provide that to new students (or even the more advanced students) this fall as it will still be too dangerous. This is some thinking outside the box by people who think that everything is a nail when all they have is a hammer.

 

[ComebackKid345]

I'd be happy to participate in something like this if the administrators sitting in their ivory towers earning millions of dollars also jump at the opportunity to join the front lines.

Until that mythical day comes, I'll stick to earning peanuts at my current gap-year job rather than earning peanuts putting myself and others at risk because there's no PPE.

This. And if they make the argument that their duties are too important, kindly point out that the Irish Prime Minister recently reregistered as a doctor and is working weekly shifts during this pandemic. Even if it was a move to gain political clout, that is an acting head of state working on the front lines. Do they think their duties are more important than someone in charge of an entire country?

These administrators should look at this as an opportunity to lead by example and regain the trust of healthcare workers.

 

[proudofmykids]

No... he is definitely an idiot if he wrote that.

The article would have made a Lot more sense if it was dated April 1. The date was the first thing I looked for after clicking the article link. 🙂

 

[Angus Avagadro]

I agree with you. What's frustrating is that we didn't have to be behind, or at least not as behind as we were.

No doubt govt has let us down on many levels, and not just recently . One of the few roles of the govt is to protect Americans. Our lack of preparedness goes back to 911, and many examples since.

Fair point, but Docs who are at the end of their careers did not have to face 300-400k in compounding debt and declining reimbursements along with their autonomy being sold away. And the powers that be wonder why less people want to enter a primary care field

I agree the debt load is higher and the interest rates are excessive. Thank the govt for that one. I wont say who is to blame but it's an easy Google. It wasnt a picnic when my wife had a HEAL loan at 17% and our first mortgage was at 10.75%. Focusing on the past is not productive IMO, better to focus on the future. People should always do the math and see if if the cost is worth the journey. My wife and I are both overpriced specialists and my son chose FM, and is a 2nd yr resident.

 

[Angus Avagadro]

“Hup-two! Hup-two!” Old gonnif cries
With dreamy glory in his eyes
“All of you premeds, fall in line
And MARCH—don’t let me hear a whine!

“You whippersnappers ought to know
What WAR was like, so long ago!
When sammy drafts you for the FIGHT
I want salutes—stand straight—FULL might!

“For MY wet dream, you all should know:
Premeds, with nowhere else to go
Should waste an extra year of life
Delay the fruits of 8 years’ strife
While drowning all the while in debt
Many who live like paupers yet—

Should be herded and promptly sent
To jobs that barely pay the rent
And possibly may risk their health
If not long-term concerns on wealth—“

“And—WHAT? You think it’s EXPLOITATION?”
(He swells with righteous indignation)
“You miserable, weak premed lot
Should be THANKFUL for what you’ve got!
The chance to train for NINE years straight
Is actually BETTER than eight!”

Now listen, gonnif, my good man
I’m just as much an ardent stan
Of action by community
I volunteer, glad as can be,

But this weird armageddon spiel
Is just too much for me to deal
Delete it, sir, before it leaks
It smacks of privilege—nay, it reeks

All that this war-like language nets
Is that the country all forgets
That docs AREN’T soldiers, and deserve
To question admins that they serve

So I’ll repeat, before I go
What you told me five years ago
A little rudely, on a post
Advice that will now help YOU most—
(Maybe that’s why I’m salty, still)—
Remember when you told me, “Chill?”

Very right brained! Well done. Makes me think of crocheted hats, tie dyed shirts and birkenstocks

 

[tri99]

As an MS0 working in a position similar to the one proposed I have a few thoughts on this...

If you are expecting to matriculate this fall with no changes to the curriculum you are fooling yourself. We will be social distancing to some extent until there is a proven vaccine (that can be produced and distributed to the entire nation in a timely manner), medication (that can be produced and distributed to the entire nation in a timely manner), or the large majority of Americans are infected. Not all areas will be to the extent of NYC, but no community will go completely untouched. Our clinic is out in the boonies and we've already seen 50+ cases that are likely COVID, even though our "official" number is 1/10 of that.

The logistics of the article are messy but at this time what isn't. If these positions are in high demand, I can see where recruiting MS1s would be one of the better options. Besides the majority of us being low risk we've also proven some level of interest/knowledge/ critical thinking ability in the field. These aren't essential but they certainly help. Plus I doubt many people will be chomping at the bit to spend every day in a hospital for $12 an hour unless absolutely necessary.

I can't imagine the government covering the cost of our employment, tuition, and health insurance or schools forcing matriculants to work full time. However, I'll be shocked if we're not thrown in the mix somehow before it's all said and done. I think a better way would be to give students the option to work 3 shifts a week for a level of loan forgiveness on top of pay/insurance. Schools could extend the online curriculum through the summer and lengthen each block by a few weeks to make sure students stay on track. It's not ideal but at this time not much is, we've just got to roll with the punches like everyone else.

 

[AnatomyGrey12]

I'd be happy to participate in something like this if the administrators sitting in their ivory towers earning millions of dollars also jump at the opportunity to join the front lines.

This. And if they make the argument that their duties are too important, kindly point out that the Irish Prime Minister recently reregistered as a doctor and is working weekly shifts during this pandemic. Even if it was a move to gain political clout, that is an acting head of state working on the front lines. Do they think their duties are more important than someone in charge of an entire country?

I do think that the few that are doing the right thing need to be recognized as true examples of leadership.

You better believe I'll be applying to the UMass residency program in my field after seeing their CEO give up his entire salary to help pay staff while there is the emergency shutdown in MA, make sure that every single employee gets, at minimum, a new mask at the beginning of each day, AND works shifts in the ED as he is a board certified EM physician.

 

[deleted846158]

I understand the need for personnel at some overwhelmed hospitals and epicenters may be frightening, but none of the data I have looked at points to this lasting long enough to the point where recruiting M1s to mop floors becomes a viable solution to any conceivable problem.
Here are the projections for peak resource usage in the US. If you don’t want to click the link, it projects April 11th will be the peak of resource usage and the peak of deaths from COVID-19 in the U.S. (the source is legit, research from UW). If my soon to be medical school tells me they need me to be on the frontlines as this thing tapers off (which it will be by the time I am on campus by every projection) then I would be more than happy to do anything I could. I think it would be pretty awesome actually and definitely beat hitting space bar all day. If they asked me to delay a year to stock shelves... I’d ask to see any study that says resources will be spread thin for a year to the point where a hospital cannot pay someone else to do that job while I learn what I need to learn to become a physician. This is a non-evidence based publicity stunt. If they need me now or later, happy to help. If they want to make headlines because they’re jealous NYU got all the hype for graduating students early, I’d rather stay home and try not to loose my mind.

 

[Daphne7]

For example, if they tried, I’d be more than happy to tie this up in court until everything blows over. My parents actually have several lawyers on retainer so again, I’ll have to take a hard pass.

"My father will hear about this!"
xD

 

[Sky138]

"My father will hear about this!"
xD

And?

 

[tri99]

I understand the need for personnel at some overwhelmed hospitals and epicenters may be frightening, but none of the data I have looked at points to this lasting long enough to the point where recruiting M1s to mop floors becomes a viable solution to any conceivable problem.
Here are the projections for peak resource usage in the US. If you don’t want to click the link, it projects April 11th will be the peak of resource usage and the peak of deaths from COVID-19 in the U.S. (the source is legit, research from UW). If my soon to be medical school tells me they need me to be on the frontlines as this thing tapers off (which it will be by the time I am on campus by every projection) then I would be more than happy to do anything I could. I think it would be pretty awesome actually and definitely beat hitting space bar all day. If they asked me to delay a year to stock shelves... I’d ask to see any study that says resources will be spread thin for a year to the point where a hospital cannot pay someone else to do that job while I learn what I need to learn to become a physician. This is a non-evidence based publicity stunt. If they need me now or later, happy to help. If they want to make headlines because they’re jealous NYU got all the hype for graduating students early, I’d rather stay home and try not to loose my mind.

While I think the model you mentioned is useful to determine when we will likely max out our resources, I wouldn't look at it for long term projections. The graph also shows no resources being needed after July 1 which is highly unlikely. Every other country that has seen their daily new cases and daily new deaths peak is still within 50% of that peak, some weeks later. The data coming out of Wuhan is irrelevant, but the fact that they put the province of Hubei on total lockdown (only 1 person allowed out of each household every 2 days) and maintained that for a month in a half speaks volumes.

If we do get placed in hospitals it will likely be screening, tracking, and contacting people. Mass testing for the virus and antibodies will be the only way to keep this under control after the peak and that will require a lot of manpower. And that's assuming the best outcome where our hospitalizations are drastically lower than they will be this month.

 

[Talldoctor96]

All I will say, is that as an EMT I worked with first year Medical students in a clinical setting. They literally are no more prepared than some random person on the street. It was actually easier to teach high school kids how to take a BP than the first year Med students. M1s are literally useless at baseline.

 

[music2med]

Have you been to any ICU lately?

You have a point from an east coast perspective, but what about the west coast? We prepped ICUs for the surge but it's looking like we aren't going to need half of the beds. West coast schools would probably have a lot of people sitting around twiddling their thumbs. Something that could be more useful would be having those with molecular biology research experience (which is a lot) being offered positions in testing centers (maybe part-time even) because a lot of us would likely be qualified to run PCR, etc with minimal training. We need testing, and a lot of pre-meds would be much more qualified for that IMO

(edit- this doesn't necessarily apply to every city in the west coast but a lot of them have excess right now)

 

[DrOngoGablogian]

I love this topic. It is wild. Sometimes I think people see numbers and then add or subtract zeros to better suit their mood, as the wise Rob Thomas once said whilst Santana played his guitar so smooth.