Ever since he was pulled off his clinical rotations in mid-March, Randy Casals has been watching from the sidelines as COVID-19 tears through every hospital in New York City. As a fourth-year medical student at Columbia University Vagelos College of Physicians and Surgeons, Casals was just weeks away from graduating and a couple of months from starting his residency in urology at Wake Forest Baptist Health in North Carolina.
Now, in response to New York Gov. Andrew Cuomo’s plea for more front-line providers to relieve an overwhelmed health care system, Casals will be graduating on April 15 and mobilizing soon after at NewYork-Presbyterian Hospital. “It’s been a little frustrating to be so close and unable to help; I’ve been itching to get back in,” says Casals, a native of Queens. “I chose to go into medicine to help people, and I’ve been privileged to be called upon to help during this crisis. I couldn’t not answer that call.”
Casals will be part of a cohort of students from five New York medical schools — Columbia, Weill Cornell Medicine Medical College, New York University (NYC) Grossman School of Medicine, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and the Icahn School of Medicine at Mount Sinai — who will graduate early, says Jonathan Amiel, MD, interim co-vice dean for education at Columbia. These young doctors will be deployed in short-term, nonresident roles in New York hospitals before they depart for their PGY-1 residencies in June. Those who are staying in New York for residency will transition from the special service to their specialty residencies at the designated time.
“COVID-19 is hitting New York City and its physician workforce and nursing staff hard,” Amiel says. “The idea is that these new MDs will be deployed to help decompress some of that workload for the entire system.”
Other medical schools around the country are taking similar action. All four schools in Massachusetts — the University of Massachusetts Medical School, Tufts University School of Medicine, Boston University School of Medicine, and Harvard Medical School — announced plans to allow students to graduate early, potentially freeing up as many as 700 new MDs to enter the workforce. The Massachusetts students will receive a 90-day provisional license to work in a COVID-19 service capacity.
“COVID-19 is hitting New York City and its physician workforce and nursing staff hard. The idea is that these new MDs will be deployed to help decompress some of that workload for the entire system.”
Jonathan Amiel, MD
Columbia University Vagelos College of Physicians and Surgeons
At Oregon Health & Science University (OHSU) School of Medicine in Portland, 68% of the class of 2020 finished their degree requirements on March 20, says George Mejicano, MD, senior associate dean for medical education at OHSU and an infectious disease specialist. Of those students, 18 are staying at OHSU for residency, and several have been given the opportunity to start their residency programs early.
And at Michigan State University College of Human Medicine, interim dean Aron Sousa, MD, says that 150 of his 200 fourth-year students are eligible for early graduation, with 61 of those staying in Michigan for residency. “I had a wonderful meeting with our fourth-years about a week ago and they said, ‘You know we’re just sitting here. We’re not getting any smarter. And in three or four months, we’re going to be interns. You might as well let us start early,’” Sousa says. “It speaks to their dedication to helping people and to their eagerness to be useful during this crisis.”
Lessons from long ago
Not since World War II has there been such a push to expedite the training of physicians. Indeed, during the war and also during the 1918 influenza pandemic, medical education was altered — sometimes significantly — to accelerate the deployment of trained physicians to the front lines.
Between 1939 and 1945, the federal government encouraged medical schools to create three-year accelerated programs to address physician shortages both at home and abroad. During this time, Yale Medical School “temporarily increased class size, admitted some students with two years of college, shortened the program leading to a degree to three years, and made the thesis requirement optional, all in an effort to increase the output of physicians,” according to archival documents from the school. The University of Louisville School of Medicine “negotiated a contract with the Federal government to educate students for the armed forces' medical corps. Throughout much of the 1940s, the school year consisted of two 16-week semesters, with a new class entering every nine months.”
During the 1918 pandemic, medical students were thrust even more abruptly into patient care. “Students of the upper classes of Philadelphia’s medical schools went from the lecture hall and laboratory directly to sick rooms and wards and the abrupt assumption of the responsibilities of mature physicians,” writes A.W. Crosby in America’s Forgotten Pandemic: The Influenza of 1918.
Today, as then, there is an unprecedented need for trained physicians to relieve some of the pressure on an overwhelmed health care system. In some cities, that need is quickly approaching the scale of the 1918 pandemic.
In New York, an increasingly desperate situation prompted the governor on March 23 to issue an “all hands on deck” call for health care workers, including soon-to-graduate MDs and retired physicians. That, in turn, prompted new guidance from the Liaison Committee on Medical Education (LCME) on March 25 to help schools determine which students had met the requirements for graduating early. Many fourth-year students were doing their final electives which, the guidance noted, “by definition do not have required learning objectives.”
“There is enormous latitude in the fourth year of medical school,” says Veronica Catanese, MD, MBA, AAMC senior director of accreditation services and LCME co-secretary. “A significant number of activities are electives, which are not required. So schools, with the agreement of their Curriculum and Student Advancement and Promotion committees, can choose to waive a certain number of elective weeks.”
“I had a wonderful meeting with our fourth-years about a week ago and they said, ‘You know we’re just sitting here. We’re not getting any smarter. And in three or four months, we’re going to be interns. You might as well let us start early.’”
Aron Sousa, MD
Michigan State University College of Human Medicine
Early graduation does not necessarily mean that students can jump right into residency, though. After Match Day, which was held on March 20 this year, students sign agreements that contractually obligate them to start their residency programs on a certain date (usually by July 1 of that same year).
So in about three months, more than 32,000 PGY-1 residents are required to report to work at their assigned residency programs around the country.
But three months is an eternity in the time of COVID-19, and medical school deans around the country have been scrambling to figure out how many of their students qualify for early graduation, and even more importantly, what those new doctors could do between now and July 1.
In New York, where an exponential rise in cases of COVID-19 has quickly overwhelmed the health care system, several medical schools are graduating students early for deployment into special service at hospitals.
Graduates from Columbia and Weill Cornell will be deployed to NewYork-Presbyterian, while NYU Grossman graduates will be working at NYU Langone under 30-day contracts, with the option to renew every two weeks thereafter. The 100 or so students who are eligible to graduate early from Hofstra/Northwell will likewise be given the opportunity to work in a special service within the institution, says David Battinelli, MD, chief medical officer at Northwell Health and vice dean of the Zucker School of Medicine.
“They will be licensed house officers, with the appropriate amount of supervision, and we will be paying them a PGY-1 salary, but they will not be part of any ACGME-accredited program,” Battinelli says. “We anticipate that about half of our students will be signing up for this.”
Fourth-year students at the Icahn School of Medicine who have met all the requirements for graduation are also being given the option to graduate on April 15. Approximately 45 of those students have matched at Mount Sinai and have the opportunity to enter a special “medical corps” prior to the start of their PGY-1 residencies, says David Muller, MD, dean for medical education. The rest of the graduating students are encouraged to check in with their PGY-1 residency program directors — whether in New York or across the country — to see if they can be of service prior to July 1. “They should get to their destination city and see what they can do to help,” Muller says. “In many cities, they will be far more experienced than other health care providers there now.”
Muller and other New York deans are quick to note that their students will not be deploying early into residency, in part to ensure they don’t run afoul of guidelines from the Accreditation Council of Graduate Medical Education (ACGME). On Saturday, March 28, the ACGME issued a statement on early graduation and early appointment to ACGME-accredited programs that noted the “serious ramifications to early appointment (CMS reimbursement for DGME/IME and match participation agreements, among many others).”
The ACGME further urged medical schools and graduates “to seriously consider these ramifications prior to initiating early graduation for any medical students.”
But the ACGME guidelines haven’t stopped other schools from moving forward with early graduations.
At OHSU, Mejicano has been graduating medical students early for several years now. “We’ve been pushing competency-based medical education since I was recruited to Oregon eight years ago,” he says. Each year, more students have met their competency-based requirements for graduation earlier than the typical May graduation date. In 2018, about 25% of fourth-year students graduated early; this year, 68% did. OHSU is also 252 physicians “over cap,” meaning the academic health system pays for many of their own residents rather than relying on the Centers for Medicare and Medicaid Services (CMS) for funding, Mejicano says.
A few weeks ago, when it became clear that COVID-19 might soon overwhelm every health care system in the country, Mejicano reached out to his residency program directors to see which ones might be able to take their new interns a few months early. Emergency medicine, family medicine, and anesthesiology all enthusiastically said yes.
“There are so many people who are in need right now, thousands of people all over the country who are sick and need someone to help take care of them. This is one of those moments that will define the rest of your career and your life. I want to be remembered as one of the people who contributed as much as I could during this time.”
Mark Cort, MD
New York University Grossman School of Medicine
That is how Alix Cooper will be starting as a family medicine resident on April 20 at OHSU’s Cascades East family medicine residency program in Klamath Falls, Oregon.
“This is not how I had envisioned the end of medical school and the transition to residency but I’m excited to be able to contribute,” Cooper says. “It’s scary, especially since every day we are reading about health care workers who are dying. I don’t know that I’ve fully processed it yet. But I’m looking forward to being able to take on some of the more standard and less critical patients in order to ease the burden on the more experienced physicians on the front lines.”
That’s exactly what Mark Cort, MD, hopes to do as well. After receiving his medical degree on April 1 — about six weeks ahead of schedule — the NYU medical school graduate will be reporting to NYU Langone on April 13 to “help in any way that I can.”
“As soon as the announcement came out, I signed up,” says Cort, who is scheduled to start his PGY-1 residency in neurology at the University of Pennsylvania on June 11. “Afterwards, I kind of thought, ‘Holy crap. I just volunteered to go into the hospital at this absolutely crazy time.’ I mean, starting your intern year is hard enough. Starting your internship during one of the worst times the country has ever seen is terrifying.
But medicine is one of those careers that’s really about giving of yourself and being willing to help others when they are in need,” Cort adds. “There are so many people who are in need right now, thousands of people all over the country who are sick and need someone to help take care of them. This is one of those moments that will define the rest of your career and your life. I want to be remembered as one of the people who contributed as much as I could during this time.”