By Lauren Oshry
In 1982, when AIDS was first described, I was a first-year medical student in New York City, the epicenter of the epidemic in the U.S. To the usual fears of a medical student — fears of failing to understand, to learn, to perform — was the added fear of contracting a debilitating and universally fatal infection, for which there was no treatment. But our work felt urgent and valued, and the camaraderie among medical students and our mentors is now what I remember most.
Nearly forty years later, my experience as an attending oncologist during COVID-19 has been different. Yes, I am older and less naïve, but also this pandemic has been managed in fundamentally different ways. Aside from the obvious federal mismanagement, my own institution has deeply disappointed me. The institutional shortcomings we had long tolerated and adapted to were laid bare by the COVID-19 pandemic, and massively failed our patients and morally devastated those of us on the frontlines.
As a provider in a large safety net hospital, I care for a predominantly minority population in the lowest economic bracket. These would be the individuals disproportionately affected by COVID-19, with highest rates of infection and worse outcomes. My patients have the additional burden of cancer.
Prior to the pandemic, we lacked outpatient palliative care services and had been without a dedicated social worker for over a year. In February 2020 (before an appreciation of the emerging pandemic), I, and other members of my section, had written to leadership (including the Vice President for Quality and Safety) expressing an urgent need for palliative care, and noting that an absence of such of services was a violation of nationally recognized standards of care for cancer patients.
These failings were thrown into sharp relief in March 2020, when the pandemic prompted the shift to telemedicine for patients who did not absolutely require in-person visits.
In light of COVID-19, we were provided with scripts to facilitate discussions about end-of-life care. Very few of my patients had activated their accounts to enable access to the electronic medical record, and so were not prepared to have video visits. The visits I would conduct were almost entirely by phone.
I decamped to the dining room with my laptop and phone to begin the long days of patient calls using the suggested script, which included the intro:
Hello, I am calling to talk about how things are going with COVID-19… You have probably heard that most people who get this virus actually do fairly well, but that some people get extremely sick and even die from COVID-19…
Leading into the crux of the matter:
Ok, so, I need to be more specific to understand how we should take care of you if you get extremely sick. For example, if your breathing became so weak that you would need a breathing machine to survive, would you want the breathing machine even if we thought the chance of ever getting off the breathing machine was very small?
Since we lacked outpatient palliative care services, which typically entail end-of-life planning, these conversations were urgent, but awkwardly delivered by phone in the midst of a pandemic.
I also provided information about local food banks and telephone numbers for emergency assistance with unemployment and housing (from a separate script), given our lack of social work support.
It was nauseating experience, compounded by the lack of institutional preparation. In early 2020, at a national meeting in Miami, I attended a lecture about physician burnout reframed as moral injury. The talk was based on the writings of physicians Simon Talbot and Wendy Dean, who argued that in an increasingly business-oriented and profit-driven health care system, physicians are less able to provide high-quality care and healing. Just as soldiers who witness acts that transgress moral beliefs experience moral injury, they held that so too do physicians who are unable to meet patients’ needs. During these calls, I experienced this with an intensity I never could have imagined.
Employees also have faced risks of direct physical harm because of our institution’s failings. From the outset of the pandemic, rather than acknowledging a lack of preparedness, my hospital misinformed employees and deliberately placed us in harm’s way. The document that best represents and began the misinformation campaign is an email from March 22, 2020 to all staff in the hospital where I work regarding Personal Protective Equipment (PPE) policies.
The message was in part a response to the announcement by our neighboring institution, Partners (Massachusetts General Hospital/Brigham and Women’s Hospital) that all health care workers were advised to wear masks while providing patient care. My institution allowed masks only for employees providing care to patients with suspected or confirmed COVID-19. Universal masking in “low risk” areas was not allowed.
The document went on to say that this recommendation was not specifically based on inadequate supplies (which would have recognized poor planning on the part of the hospital), but cited (false) concerns that donning and doffing masks throughout the day caused risks, and that wearing a mask might “give a false sense of safety” that might potentially lead to cross contamination. I remember vividly the sickening disbelief in receiving that message. Partners had prepared better, or acted faster, or both. They had masks, we did not; full stop. The rest was a lie and everyone knew it.
Some completely ignored the directive, prioritizing their own safety over the risk of institutional rebuke. My family urged me to use the masks I had at home, including the N95 masks that we had previously been given to discard after FIT testing in years gone by. I had heard of medical workers who had been terminated for violating orders not to mask. I didn’t think that would happen to me, but was not accustomed to violating the rules, and so complied with a great sense of foreboding.
The vaccine distribution process at my hospital was similarly mired in institutional dysfunction. In December, an opaque distribution process began. I was given no information about where I was in the order, or when I might receive the vaccine. One weekend, while working to care for the inpatients on the Oncology unit as well as to provide consultative care for other inpatients with issues related to hematology or oncology concerns, the intern I was working with announced that he had received his COVID-19 vaccine after a learning about extra doses available through a text chain among the medical residents (trainees).
I sent an email to the administrators in charge of vaccine distribution, noting that this process seemed unfair and that despite my contact with COVID-19 positive patients, I had not had the opportunity to be vaccinated and had no idea when my time would come. I was told “we will get to you soon” and “If you want to help: please do feel free to advocate for us to get more [vaccine].” The “if you want to help” part particularly stung. I was putting in 14 hours a day providing patient care, including weekends, and had just received notification of a patient exposure for which a COVID-19 nasal swab test was recommended, the second occurrence that month.
Just as the pandemic has accelerated changes in telehealth, remote working, and distance learning, it has also accelerated the exposure of inequities and inadequacies in the health care system, and accelerated the process of moral injury in frontline health care workers. Prior to the COVID-19 pandemic, I had never thought about leaving medicine. Lately I think about it all the time. Many of the issues exposed by the pandemic have been long-standing, but the abandonment and mistrust I feel toward my institution are new. Any path forward will require much work, with greater transparency, greater accountability, more equitable distribution of resources, and greater respect for the health and safety of frontline workers.
Lauren Oshry is an assistant professor of medicine and a hematologist-oncologist who serves vulnerable populations with a focus on breast cancer care in Boston, MA.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.