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Thursday Jun 18, 2020

Closure, COVID, Chaos: A Resident's Tale of Resilience

I came out of medical school doe-eyed and with high hopes of making the world a better place. Little did I know that every obstacle I encountered in residency would reveal a hidden layer of what we weren't taught in medical school.

[Hahnemann University Hospital]

Hahnemann University Hospital, shown here in 2010, closed last year. The closure of the teaching hospital in Philadelphia displaced more than 500 residents and fellows. [This image is being used in accordance with the Creative Commons Attribution-ShareAlike 2.0 license.]

I was drawn to Philadelphia because of the unique qualities of the underserved population and the dynamic of society here. This was indeed a City of Brotherly Love. I saw it in the actions of everyone I met. The poverty could not be concealed, and I didn't want to be sheltered from the reality that this was who I was meant to serve. Hahnemann University Hospital was booming with patients who were victims of neglect, people chained to addictions and individuals who had nothing to call their own. My family medicine heart saw the people behind the diagnoses, and I trained in a program that truly taught me to provide solutions not only for the chief complaint, but also the circumstances that brought these patients to the hospital.

Tenet Healthcare Corp. sold Hahnemann University Hospital to American Academic Health System in January 2018, during my intern year at Drexel Family Medicine, and so began the series of email domain changes that marked my residency career. I don't think any of the residents and fellows at Hahnemann knew what lay ahead, but we took this change positively. Life continued, and we still provided the same dedicated care to our patients as we slowly began to learn the way hospital systems operate by becoming chess pieces on the board.

I still remember the moment I argued with an insurance company for prior authorization of oxycodone for my patient with newly diagnosed metastatic cancer. That was the first time I realized there was something broken in our health care system. Our focus was entirely on our patients, and what was going on around us didn't align with the values we held so dearly as a program. None of it made sense, but with the schedules we had, there wasn't much time to think about what was boiling beneath the surface.

We found out the hospital was being dismantled through an article in The Philadelphia Inquirer. Rumors of financial instability had been floating around for years before I ever entered the halls of Hahnemann, but generations of trainees continued on. Just two months earlier, in April, there had been a layoff of 175 hospital employees, including nurses and attendings, and we all felt the pain. Even then, it was impossible to anticipate the complete closure of a 496-bed teaching hospital that continued to provide care for patients with great needs. The morning after we heard about the dismantling, there was a huge meeting for residents and fellows; all I remember was that the tension and fear in the air was palpable.

In the middle of rounds, my class found our program director, who took the time to be with us to hear our fears. He was so honest about the uncertainty. I cried listening to an intern present a patient on service who hadn't eaten in four days because they just didn't have access to food. My heart was broken for the vulnerable patients we took care of in this hospital because it started to seem like the world didn't care what happened to them. Surgeries came to a halt because materials were not being ordered. The complexity of care we had provided was suddenly being scaled back because of lack of supplies and medications. Closing an inner-city level one trauma center in that way felt inhumane, and all any of us could do was watch and pray.

The Drexel residents and fellows from every specialty at Hahnemann were scattered across the country within the span of a month. Many paid exorbitant fees to break their leases. Many had to extend their residency training to prove themselves again to another institution. Our residency positions were essentially sold, and it took a long time for that to register.

Residents and fellows scrambled to give trainees a voice. Due to the declared bankruptcy, our last paycheck was minimal. Although teaching institutions pay trainees with funding provided by CMS, our last paycheck amounted to $1.25 per hour. I learned what tail coverage malpractice was when it was no longer provided. And in the harshest way, I learned how residents and fellows -- people training to save lives -- were handled as property.

My mentor, Brent Simmons, M.D., encouraged me to keep my dream of fellowship alive despite what was happening. I interviewed for PGY-3 positions while also applying for fellowship. Our program director, Leon McCrea, M.D., M.P.H., and department chair, Susanna Evans, M.D., would not let us be in the dark with anything that happened. Every meeting was filled with so much anxiety from not knowing what could happen next or where the 21 of us would be scattered.

Every day of that chaotic month felt like an eternity until the day we were told that Drexel Family Medicine was able to stay intact. We were all given a choice to stay or go. My incredible class of seven chose to continue our PGY-3 year with Tower Health, which marked our third and final residency email change. Out of the 570 residents and fellows across 30 specialties, we were the only Drexel residents to survive the hospital closure. Although our hospital changed, the way we cared for patients didn't.

COVID-19 was the next disaster that could have robbed us of hope. This pandemic has changed the face of medicine and exposed a wound that has been ignored for years. We are only as healthy as the most fragile person in our society. It was our second reminder after living through the closure of our hospital. We were strategically separated into different clinical spaces, whether it was the hospital or the clinics. Through virtual interactions with each other, the rise of COVID-19 cases on our service and the advent of telemedicine, the end of our training was transformed. We all once again came together, but this time to battle the shortage of personal protective equipment and the continuous change of management as we faced a virus carrying devastation that was new to everyone.

Our class stayed physically separated until the death of George Floyd. We came together with our white coats to take a stand for black lives. Every aspect of our training showed us how wide the health care disparities were, but we just didn't talk about it. We served in free clinics and regularly did outreach walking the streets of Philadelphia. Whether it was through home visits for homebound patients or providing care to IV drug users at a needle exchange program, we entered environments that opened our eyes to the intricacy of human suffering. When marching for black lives, we saw how the power of our white coats could be used beyond our profession to make the world a better place.

Our class of seven women was forged by the fire that tried to consume us. We started our training as pieces of coal but are coming out as diamonds. Ansa Anderson, M.D., is moving to Atlanta, and Nikole Czapp, M.D., is moving to the Florida Keys to provide first-class primary care in the south. Katherine Savage, M.D., is staying at Drexel/Tower Health to pursue a fellowship in palliative care. Pavandip Virdi, M.D., is pursuing a fellowship in geriatrics at Abington Hospital Jefferson Health. Lily Payvandi, M.D., is pursuing a fellowship in clinical informatics at Harvard/Boston Children's Hospital. Fotini Debonera, M.D., and I will be starting a geriatrics fellowship at the Hospital of the University of Pennsylvania.

The health care disparities we witnessed and the broken system we survived gave us experiences that will help us implement real change wherever we go. I find myself with a renewed hope here at the end of my training. This is only the beginning.

Merlyn Sunny Abraham, M.D., will complete her training at the Drexel University College of Medicine/Tower Health Family Medicine Residency program on June 30. She begins fellowship training in geriatrics at the Hospital of the University of Pennsylvania in Philadelphia on July 1.

Posted at 03:55PM Jun 18, 2020 by Merlyn Sunny Abraham, M.D.

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