From 'Unnecessary' to Indispensable

Fortunately for the people of New York -- who are now at the epicenter of the COVID-19 pandemic -- the residents, faculty and others rallied to save their program. So where would the Allen Hospital -- where residents do all their adult inpatient rotations -- be without family medicine now?

"That's a question we've all been asking ourselves a lot," said Hima Ekanadham, M.D., an assistant professor in family medicine and inpatient family medicine hospitalist. "We were made to feel unnecessary by the institution. They were going to end the program. Now in the era of COVID, we have stepped up in every domain of handling this pandemic, from creating and staffing a triage tent, telemedicine, staffing the ER and ICU, and expanding our inpatient service. We have been involved in every aspect of caring for these patients. Most people's roles have changed dramatically."

Ekanadham said the 200-bed community hospital is typically near capacity from January into March before numbers dip in the spring and summer, but the facility actually experienced a peak in mid-March that lasted for several weeks. At times there were up to 170 patients with COVID-19.

"It was unprecedented," she said. "We were at capacity all the time. We used the ORs, endoscopy -- any space we could find. We had people in hallways. Sometimes beds weren't available and we managed people in the ER."

By the beginning of April, the hospital had lost 59 patients who had tested positive for COVID-19. Many others have not recovered and remain hospitalized, and those who remain are more likely to die than recover, she said.

Residents, attending physicians and nurses also became sick. One -- Lorna Breen, M.D., an emergency room doctor at the Allen Hospital -- recovered from the virus but later died by suicide.

"I think a lot of physicians tend to keep their heads down and keep working," Ekanadham said. "We all knew Dr. Breen pretty well. It shook everyone up. We had to take a step back. Her death made us really think about whether we are taking care of each other, especially our residents. I feel responsible for them."

One resident recently experienced four patient deaths in a 48-hour span. Ekanadham attempted to send him home, but he stayed when yet another of his patients acutely decompensated.

"We really need to be mindful of the physical, emotional and psychological toll this is taking on us," she said. "During this pandemic, collaboration and solidarity with physician colleagues has been instrumental to not only furthering my understanding and management of COVID but also in giving me a sense of support and community -- that I am not alone in this."

Ekanadham, who has twice won the AAFP's Exemplary Teaching Award and was her residency program's Physician Teacher of the Year in 2018, said the program has continued a previously established biopsychosocial weekly group meeting with residents focused on allowing them to process their experiences and help protect their well-being.

"People are having nightmares. They're completely drained," she said. "We've tried hard to maintain that meeting for preserving mental health."

The program also altered its scheduling, with residents now working seven days on and seven days off. Similarly, most attendings work three days on and three days off. Ekanadham -- who has continued to work five days a week -- said the change gives people a needed break and also helps limit exposures.

"The residents have been amazing in how they have stepped up," she said. "This is not the residency experience they were expecting."

Ekanadham, whose previous work included stints as a visiting scholar at the Robert Graham Center and a research fellow at Columbia, said there will be important issues to study when the pandemic is over, including racial and socioeconomic disparities in disease burden.  

"We really need to think about what has contributed to the disparities in who is dying and who is hospitalized," Ekanadham said. "There is no one better equipped to look at that than family physicians."

After graduating from Georgetown University School of Medicine, Ekanadham trained at the family medicine residency at Montefiore Medical Center in Bronx, N.Y.

"I went into family medicine wanting to be able to care for all types of individuals, regardless of age or comorbidity," she said. "I never wanted to be hyper-specialized in one particular niche. Equity has always been something I strive for, and I wanted my skills to be applicable to every human being."