Ebola, Physicians in Training, and the Duty to Treat

The importation of Ebola virus disease (EVD) into the United States and its subsequent transmission to two nurses has occasioned a tsunami of activity, training, policies, position statements, and media coverage not seen since the early days of the HIV epidemic. As of October 18, 2014, eight confirmed EVD patients have been treated in American hospitals, with the only death being that of Thomas Eric Duncan, the index case at Texas Presbyterian Medical Center in Dallas.1 All other cases were health care workers who returned to the United States from West Africa and the two nurses who treated Mr. Duncan. One of us (PS) works at one of four hospitals nationwide with special biocontainment units built to treat patients with EVD and similar infections. In the Emory system, suspected Ebola patients are cared for only by faculty. This was an institutional decision made by an expert work group focused on safety and best care for the patients, but without the input of residency program directors. The same is true at Yale–New Haven Hospital, where we (SB) had one suspected case of EVD (he subsequently ruled out). We understand, of course, that preparation is complicated and the necessary training is intense. Hospitals need to have a small group of highly ready expert clinicians and need to both limit and coordinate exposure. In addition, hospitals are reasonably worried about the media and public perception That said, a patient with an Ebola exposure can walk into any emergency department (ED) at any time and expose any of us. Emergency medicine (EM) occupies the front lines of defense, which means that each of us, including residents, has some implicit and continuous risk and needs to be educated on how to participate, with proper precautions. A corollary principle is that creating a “SWAT” team of highly trained physicians, nurses, and others may be less salient for the ED, although it may be the preferred approach to caring for EVD suspects in inpatient units. As of this writing, the national accrediting bodies for residency training and medical schools have begun to weigh in. The Association of American Medical Colleges (AAMC), which represents 141 medical schools in the United States and 17 in Canada, along with nearly 400 teaching hospitals, has not taken an official position in residents and students treating patients with suspected EVD. The AAMC does report that nearly all schools and systems have forbade students from providing care to EVD suspects (John Prescott, MD, AAMC Chief Academic Officer, personal communication, e-mail, October 17, 2014). The AAMC has created a website (https://www.aamc.org/ebola/) with resources and links for schools, residency programs, hospitals, and health care systems. The Accreditation Council for Graduate Medical Education, which reviews about 9,500 residencies and fellowships in the United States, released a guidance statement addressing the care of EVD patients by residents and fellows.2 The statement calls for these physicians to be properly trained in the recognition of EVD, to care for these patients according to local institutional protocols and, if doing so, to provide care under the direct supervision of faculty members who have been properly trained. Only attending physicians, or in cases where this is not possible fellows or senior residents, should provide care to proven/suspected EVD patients. The professional virtue of self-sacrifice does not create ethical obligations for medical students and other healthcare professional students in this context, because their fund of knowledge and clinical skills set are not adequate for participation in the care of these patients. We believe that residents are a community resource and should be expected to participate in disaster responses. Residents understand what we do and want to be part of any important response. Our profession requires risk. We care routinely for patients with AIDS, hepatitis B, and influenza. In addition to EVD, we must be vigilant to suspect, recognize, and treat other emerging infectious diseases, like Middle East respiratory syndrome, enterovirus D68, severe acute respiratory syndrome, and West Nile virus, and older, reemerging infections, like measles. We catch the mundane and common upper respiratory tract infections. From time to time, we acquire scabies or epidemic keratoconjunctivitis. We care for violent, intoxicated, psychotic patients. On occasion an ED provider is assaulted by a patient, as happened to this journal's editor-in-chief last month. In general, these are infrequent events, but they are real and should be understood by all first responders. In reality, our drive to work is probably the most dangerous part of the day. Our job is to educate students and residents to these risks, so they can make their own informed, ethical decisions about both routine risks and participating in more dangerous disaster responses. For generations, residents and medical students have played critical roles in the care of patients with epidemic infectious diseases, and other types of mass casualty events. Indeed, responding to disasters has long been a cherished, immensely gratifying activity for emergency responders, including residents. We have worked disasters, both natural (blizzards, heat waves, hurricanes) and man-made (the attacks of September 11, 2001; plane crashes; blackouts) as residents and with our residents. These are among our proudest, most indelible moments as physicians. We are not unmindful of the real risks faced by providers, including learners. Throughout the history of medicine, physicians have occasionally suffered the same diseases as their patients. In the Middle Ages, plague; in colonial and early America, smallpox, yellow fever, and typhus; in the 1980s, human immunodeficiency virus. And, always, tuberculosis. In the 1980s, one of us trained with a colleague, a fellow resident, who acquired HIV infection from a used needle that was left in a patient's bed. Another resident we knew died from fulminant liver failure caused by hepatitis B, acquired from a puncture wound sustained in the operating room. We have worked with residents who developed active tuberculosis and many more who converted their tuberculin skin tests or anxiously awaited the results of body fluid exposure testing. Over 20 years ago, a resident physician at Johns Hopkins wrote of his occupationally acquired infection with HIV.3 Hacib Aoun was infected in 1983 by a shattered capillary tube containing blood from an infected patient. He was married and a father. He wrote movingly of his experiences, becoming an advocate for proper training and supervision of house officers caring for people with lethal, infectious diseases, including provision of adequate compensation in case of acquired infection. But he never advocated that residents not treat these patients. Dr. Aoun noted that it is up to physicians, “… as members of the most humane profession, to fight against discrimination, to fight against our own natural fears, and to see to it that these patients are not abandoned.”3 Dr. Aoun died of complications of HIV in 1992.4 Hence, we do not wish to minimize the risks posed to physicians in training. We recognize the need for proper training, supervision, and access to and use of personal protective equipment. And, in the case of Ebola, the most prudent approach that maximizes patient safety and minimizes risk to all staff—not just learners—may be to create small SWAT teams of highly trained physicians, nurses, and other health care personnel. These teams may or may not include residents. We understand, and endorse, excluding pregnant physicians from caring for EVD patients. And participation must be voluntary, with each provider determining what risk he or she is willing to tolerate. One may contend that the infectivity and lethality of Ebola require academic medical centers to limit, or eliminate, potential contact between these patients and physicians-in-training. If so, one cannot help but feel that something intimate and noble in the physician–patient relationship is being denied. We also wonder what kind of message that sends to our colleagues who will also provide care for EVD suspects, but do not have such exemptions and who lack the years of training that even house officers have—our nurses, nursing assistants, laboratory technicians, transportation aides, housekeepers. And to those who have so quickly and easily denied medical students and residents the ability to care for EVD patients, we would wish to point out that the old dictum “primum non nocere” refers to the patient, not the doctor.