Involving Physicians-in-Training in the Care of Patients During Epidemics.

A s international travel grows, the risk of exposure to new and reemerging infectious diseases and the potential for epidemics continues to rise. Health care professionals are at particular risk for exposure during outbreaks. Training programs have varying policies regarding the involvement and safety of physicians-in-training (ie, medical students, residents, and fellows) in the care of patients with a highly infectious pathogen. Given that epidemics and emerging infectious diseases are becoming more common, the participation of trainees in the care of patients with a highly infectious pathogen requires further consideration, balancing safety, education, and duty. The risk of exposure to communicable diseases is intrinsic to health care, and professionals regularly care for patients with contagious diseases such as human immunodeficiency virus (HIV), hepatitis B, and influenza. While the use of universal precautions to mitigate this risk has developed and evolved, the risk to health care professionals becomes most evident during epidemics, such as the HIV epidemic at the end of the 20th century. During the early days of this epidemic, a physician recounted his experience of contracting HIV in 1983 as a resident after accidental exposure to a shattered capillary tube filled with blood, from a patient eventually diagnosed with acquired immunodeficiency syndrome (AIDS). In his commentary, the author highlighted the importance of physician safety in the workplace. ‘‘Health workers must not deny care to the victims . . . But if we are to be in the front lines, then we must make sure that we are better protected in all aspects.’’ Since the 1980s, the risk of HIV acquisition from occupational exposure has been found to be low. However, the public and trainees’ perception of risk, along with the emotional experience tied to exposures, was higher than expected. In the early 1990s, there was heightened awareness of HIV transmission in health care settings after a cluster of patients were exposed to a dentist with HIV. Based on the concerns of pediatric trainees, the American Academy of Pediatrics released guidelines for pediatric residents on the care of patients with HIV. These guidelines recommended that trainees be expected to care for patients with HIV, but first must be trained on modes of transmission and safety precautions. It also urged institutions and medical training programs to address the psychological and emotional aspects of caring for patients with HIV, including providing support to those with an occupational exposure. This guidance recognized that for physicians-in-training, there must be a balance between the risk of exposure to infectious diseases and the duty to provide care, while engaging in practical learning. Experiences with the transmission of bloodborne pathogens (such as HIV, hepatitis B, and hepatitis C) from sharps injuries have transformed our training of health care professionals in recent decades. A survey study showed that 40% of needlestick injuries occur among surgical staff and medical students. Given the prevalence of bloodborne pathogens, it has become clear that physicians-in-training must be taught safe practices without being sheltered from patient care. Providing care for such patients allows trainees to uphold their duty as physicians, while learning the art of medicine. However, Shaw and colleagues noted that the duty to treat is not absolute, and physicians have an obligation to care for themselves first, so they do not become patients themselves in times of crisis. Lim and colleagues suggested potential alternatives to real patient interactions to address the challenges of medical education during epidemics, while avoiding placing trainees at risk. These alternatives included utilizing patient simulators, e-learning modules, and video vignettes. Ultimately, this approach may be more feasible and appropriate for medical students rather than residents or fellows. Lack of preparation and involvement of physiciansin-training during epidemics has the potential to negatively affect medical education by disrupting teaching opportunities and challenging the professionalism and humanity of trainees. Times of crisis allow physician educators to model professionalism to trainees. A qualitative study in a Canadian training DOI: http://dx.doi.org/10.4300/JGME-D-19-00354.1