Since the first reported case of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019, more than 1.8 million cases have been confirmed globally, with more than 100,000 attributable deaths. New York City quickly became the epicenter of this pandemic, with more than 6,000 deaths since its first confirmed case in early March 20201. The public health and societal impacts of this disease burden have been remarkable, with ongoing directives for social distancing and a resulting rise in unemployment and decline in the economy. Furthermore, the ongoing rise in critically ill patients has called for a rapid evolution in health care systems, particularly with regards to access and delivery of equitable care among all patients. Unsurprisingly, this evolution has led to critical changes in our health care infrastructure, directly impacting the lives of all health care professionals, including resident trainees. The department of obstetrics and gynecology at Columbia University Irving Medical Center (CUIMC) has been profoundly affected by the SARS-CoV-2 pandemic, and our transformation during this crisis has revealed the versatility in each aspect of our organization. We write this article to share our experiences as newly pronounced administrative chief residents, and to inform the health care community of opportunities and obstacles we have faced amidst this unparalleled pandemic.
The month of March brought about unsettling concerns regarding the pandemic’s implications on specialty specific training. Surgical residents across all departments and divisions addressed the rapid rise in SARS-CoV-2 patients, and the requirement to attend to this new influx of critically ill patients was evident. Within the CUIMC department of obstetrics and gynecology, the decision to cancel all elective gynecologic and infertility cases and select gynecologic oncologic cases that could be postponed was a monumental initial step. The gravity of this decision reverberated for trainees at all levels.
An initial attempt was made to revise the resident schedule by modifying our traditional month-to-month block schedule. However, those who were assigned to in-patient obstetric services were quickly faced with patients requiring an intensive level of care on top of the normal volume of pregnant patients on our busy service. At the same time, those assigned to in-patient gynecology and gynecologic oncology services were often forced to work from home and saw their clinical duties dwindling. There was a clear inequity in trainee education, clinical responsibility, and exposure to SARS-CoV-2. In our program consisting of 24 resident trainees, consternation about surgical skill development soon transformed into a desire to provide direct service to COVID-positive patients. Whether this service entailed deployment to an unexpected obstetric rotation or to a different department within the hospital, these trainees' altruistic desire to participate was incontestable.
Recognizing the inequity within rotation schedules led to the creation of an unconventional system: a newly minted “pod” schedule. In this system, groups of six residents rotated through three different services that required each of their active participation. While predominantly focused on caring for obstetric patients, this pod system allowed for continuation of other required services, such as scheduled gynecologic oncologic cases, emergent gynecologic cases, and resident out-patient continuity clinics. Despite being a drastic change from our previously scheduled rotations, there was a newfound energy within the residency to support one another and focus on our main priorities: patient care and limiting health care worker exposure to SARS-CoV-2.
Moreover, as the number of patients diagnosed with SARS-CoV-2 across the hospital multiplied, main operating rooms and acute floors were converted to intensive care units. It was clear that obstetric patients requiring an intensive level of care could no longer be transferred to off-service units. The innovative creation of an interdisciplinary obstetric ICU on labor and delivery, managed independently by a team of obstetricians and anesthesiologists, was unprecedented. In addition to the new critical care training that residents would receive, this ICU allowed for us to care for patients in an unparalleled manner. Trainees at every postgraduate year level participated, either through direct patient care or efforts in expeditious critical care training. Our reliance on each other, both as collaborative team members and for emotional support, is incomparable. Standard education hierarchies were quickly dismantled: there was an enhanced opportunity for everyone to teach and learn from one another.
Department of Obstetrics and Gynecology
Outside of our residency family, larger department-wide changes were coming to fruition as a result of SARS-CoV-2. The constant alterations in hospital wide protocols and departmental policies necessitated a streamlined method of communication. Amidst a barrage of emails stood an unwavering, daily conference call to the entire departmental medical, administrative, and nursing staff that was warmly embraced. Led by the chair of our department, Mary D’Alton, MD, this call not only disseminated high-yield updates, but also established a time slot in which we were all treated as a single family. Independent of our role in the department, this quickly became a safe space for all to voice their fears and concerns. Each call concluded with a unique segment: a few minutes to pause and listen to a member of our community reflect on their experiences or express their gratitude for our work. Our gathered sense of unity and purpose was palpable in those moments and served as a haven in the face of this pandemic.
As the cases of SARS-CoV-2 continued to climb in our community, the familiar issue of space would soon compromise our ability to optimally care for those in need. Acute floors, step down units, and clinics were consolidated to make way for new intensive care units. Football stadiums, newly created tent enclaves, and a U.S. Navy ship were transformed into field hospitals. It was therefore not surprising when the decision was made to shut down our sister hospital’s labor and delivery unit and consolidate all laboring patients into one hospital at CUIMC. This new volume, without the provision of new space, provoked creative solutions from the administration. The merging of our hospitals also gave way to the merging of our divisions: gynecologists, gynecologic oncologists, family planning, and infertility subspecialists all asked to step forward in unison to help on the obstetrical service. Without hesitation, our family of many subspecialties truly became a family of one. Our labor and delivery unit, infused with new energy and expertise, now offers a unique opportunity for residents to learn and develop our skill sets with a broadened host of familiar faces.
As we maintained our commitment to the obstetric population at large, our department continued their commitment to us. Despite the constant remodeling of our infrastructure and reallocation of our senior trainees and faculty to different divisions, we witnessed an outpouring of dedication to ongoing education. Access to innumerable resources were delivered to us, void of any financial burden that may have previously served as a barrier. The Council on Resident Education in Obstetrics and Gynecology created a national remote didactics website, offering the unique opportunity to learn from experts from across the country. Alongside the transition of our formerly in-person weekly didactic sessions to newly devised video conference calls were a natural calling for some of our senior staff. Phrased as an attempt to not let this pandemic rob us of our learning, weekly nighttime learning sessions have become the home to residents and beloved fellows and faculty who are adamant in their desire to continue gynecologic learning. As they stood firmly in their dedication to us, our gratitude to them will continue in perpetuity.
Prior to the SARS-CoV-2 pandemic, the underserved, predominantly Latina population in Washington Heights, where our hospital is located, was particularly prone to social inequities and injustices. The community of physicians caring for these patients are primed to address these issues and are dedicated to delivery of equitable and high-quality care for all patients. As this pandemic unfolds, these issues have not been lost on us, and our commitment to this patient population remains our utmost priority.
As residents of New York City, we witnessed the unprecedented metamorphosis of a community that once prided itself on social intimacy adopt a new norm of social distancing. This transformation poised a unique challenge to health care professionals, in which the principle of close surveillance was weighed against the priority of minimizing patient contact with health care systems. Although disparate outcomes persist in the SARS-CoV-2 pandemic, this period also offered an opportunity to revolutionize the means by which patients access care. Independent of their socioeconomic status, race, or ethnicity, we have learned that telemedicine has the potential to create equity in our delivery of care.
Prior to the SARS-CoV-2 pandemic, the CUIMC department of obstetrics and gynecology’s use of telemedicine was negligible. Now, use of this modality is nearly ubiquitous across all divisions. Guidelines for appropriate telemedicine visits have been implemented and are inclusive of both obstetric and gynecologic patients with and without SARS-CoV-2 infection. Anecdotally, patients are not only appreciative of their ongoing receipt of medical care but also take comfort in overcoming barriers such as transportation that previously limited their access to care. Our health care professionals have simultaneously found that telemedicine is easily adaptable and provides new insight on a patient’s social circumstance that may not have been previously evident.
Despite ongoing social distancing, our interactions with this community have strengthened organically, based on a newly founded respect and appreciation for one another. Whether in the form of an unexpected meal, handmade banners, or freshly chalked sidewalks, these public displays of gratitude have not been lost on us. A powerful thunder of applause saluting health care workers emanates from every corner of this city daily and revitalizes our existence and desire to fight this pandemic. Our relationship with this community has been imbued with new meaning—a new significance—that we will never forget.
Through the lens of obstetrics and gynecology residents in New York City, the unfolding of the SARS-CoV-2 pandemic has had a tremendous impact on our residency program, department, and the community of patients we serve. We take solace in our departmental community and the surrounding community at large, where the values of service, collaboration, and equity have permeated every aspect of what we do. From creating a nonconventional residency pod schedule to helping build up telemedicine in our community, we have seen the direct impacts of this pandemic on our health care system. Going forward, we hope to perpetuate the many wonderful things that have united our communities and strengthened our health care system as a result of this pandemic. The world will watch closely as we move forward from this pandemic, and we are excited to help rebuild and hopefully improve a better health care system for all. To those approaching the peak of this disease, we hope that these reflections can reinvigorate meaning in your various communities and evoke creative ideas in overcoming the ensuing weeks. To those who have supported and led us through these difficult times, thank you for everything. Looking beyond the peak of this pandemic, we can see a brighter future on the horizon.
Sbaa Syeda, M.D. and Aaron Praiss, M.D. are chief residents in the Department of Obstetrics and Gynecology at NewYork-Presbyterian Hospital - Columbia University Irving Medical Center in New York, NY.
Disclaimer: The thoughts and opinions in the Frontline Voices initiative reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.