Mel L Anderson, MD

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.