Corresponding author: Patricia Marie M. Lusica, MD Department of Medicine

Philippine General Hospital University of the Philippines Manila Email: pmlusica@up.edu.ph

The New Daily Grind

We used to begin our days with endorsements, with students and residents discussing patient morbidities, deaths, and admissions of the previous day. Afterwards, we would make rounds in the wards, with students helping us facilitate tests and procedures. The day would unroll with conferences, referrals for desaturations, hypotension and clarifications for indecipherable orders, charting of new admissions, and outpatient clinics, typically ending with a leisurely reading of our load of electrocardiogram tracings for interpretation.

When the community quarantine was declared, our usual routines were upended. Clinical clerks and interns were pulled out from their posts, so we had to take over their tasks. Our General Medicine wards were transformed to COVID wards, and the remainder of our patients who did not have COVID were transferred to borrowed beds from other departments. All conferences, meetings, outpatient clinics, and other activities abruptly ceased.

The residents were divided into two work teams with the second and third years assigned to the COVID wards while first year residents managed the non-COVID patients. Our new roles still have a semblance of our old routines – albeit now done wearing personal protective equipment (PPE). The rest of our activities have shifted online. The hospital has started implementing its electronic record system in the COVID areas. Our conferences and lectures are now given via Zoom, monthly examinations are now taken through Google Forms, and we now enroll in research courses in Google Classroom. Our virtual world used to be our leisure, and now work has occupied it.

Are we cut out for this?

This pandemic certainly places our training at a peculiar place. We understand the need to contribute to solving the crisis, but we also doubt if we are even prepared to take on its challenges. The first year residents have hardly completed three months of the program, barely getting into the rhythm of residency, and the seniors have also just begun embracing their new roles. As residents, we are simultaneously students and employees of the hospital. We fulfill our responsibilities while at the same time training to become internists. Our training involves guidance from senior residents and consultants, collaborating with subspecialty fellows, attending lectures and reading textbooks, and of course, interacting with our patients. But that too, has changed.

Now, residents at the COVID wards manage their own patients together with the subspecialty fellows. In the non-COVID wards, consultant supervision continues. However, there are questions regarding continuity of care and the quality of mentoring, because the turn-over of duty schedules of both trainees and consultants is now more rapid than before. Our patient load is just a quarter of what it used to be, and as the number and variability of cases have also changed, we worry that we will be inadequate. We have missed a lot, but we are hopeful that the next years will make up for these.

What about our patients?

Being a tertiary government referral center and the national university hospital, UP PGH offers services that may otherwise be inaccessible for less privileged patients. We soon realized that the trade-off for being declared a COVID- referral hospital is closing our doors to our usual patients, including those who require subspecialty care.

As we transitioned to becoming a COVID referral center, most of our remaining patients were quickly prepared for discharge or transferred to other hospitals. Though necessary, this made some of us feel guilty and worried because if it were not for this pandemic, we would still be managing them. New admissions were also limited to non- COVID patients needing emergent care or COVID suspects

who turned out to be negative. These few patients who do get admitted shared similar stories – of uremic patients denied dialysis, of persons with diabetes in sepsis due to infected foot ulcers, or of heart failure patients gasping for air, begging to be admitted; stories of hospital refusals, or of their inability to find means to go to hospitals due to the limitations of the lockdown.

COVID has also had a major impact on our outpatient training; this department closed down as soon as the hospital was designated as a referral center. Internal medicine training is heavily OPD-based, and so we moved from having more than 4,000 patients a month in the General Medicine census to none. This created uncertainty about our training, but the greater question was regarding the welfare of our patients, some of whom have been regularly consulting the hospital for years. A few patients who have cell phones have sent text messages or have reached us through social media. Our fear, however, is that the greater majority may have defaulted or have been lost to follow up, prioritizing other concerns during the community quarantine over their health. We fear for those who have been discharged recently and have had no opportunity to follow up. Our hope is that they have found other doctors in their locality even as the quarantine limits mobility. As we continue to listen to these stories, it has become clear to us that they are the collateral damage of this pandemic - patients whose previous difficulties in accessing health care have only been magnified by this pandemic.

Working together

Despite these challenges, it is also encouraging to see the various sectors of the hospital and the university coming together to create solutions to our problems. Soon, we found ourselves manning the COVID wards with our non-IM colleagues, our consultants, and even volunteer doctors not employed by our hospital. Other health workers also took on roles that were beyond their training. Our dermatology co-residents have been serving as safety officers in the PPE donning and doffing areas, and dentists are doing some of the swabbing for COVID testing. The medical interns also quickly volunteered to come back to help out in the wards and to do the triage for the telemedicine program.3 On top of being doctors, we ran errands to coordinate and receive donations including food for those on duty and PPEs which kept us safe while the hospital was still procuring supplies. It was during these times when the Filipino tradition of “Bayanihan” became very much alive, that of giving oneself in the spirit of community.

As frontliners, one of our biggest concerns is, of course, that we will also be infected with COVID-19, or worse, that we will bring it home to our loved ones. So, we live away from our families and the comforts of our own homes, reassured only by the online video chats and the company of friends at work. The hospital has become our second home, and our colleagues, our family in this time of adversity.

Moving forward

When all these changes started, it felt as if we were stuck in between the before and after of this pandemic, as if residency has been merely paused and will resume soon after. Gradually though, it became clear that this would extend for far longer, and that training would need to adapt as well. Even at this point, everything remains in constant flux. At the time of this writing, the country has begun shifting to more lenient quarantine measures, and the hospital is now planning to increase admissions of non-COVID patients while still maintaining its roles as a COVID referral center. The changes are far from over, and we anticipate that it may become more difficult for us to cope as the increased patient load will strain the workforce. The uncertainty brings with it a nervous discomfort. While we understand the gravity of the situation and the need to attend to the much larger problem at hand, still, we worry about how we will have to make up for the gaps and pauses made. As trainees, there are questions that continue to linger. How long will this stretch on? Will we transition back to how things were? What’s next? Which changes will become permanent?

Still, it is incredible to see how the department and its trainees come together in response to these times. It is difficult to decide if this is the best or the worst time to be an IM resident, but this is definitely an extraordinary chance to be part of something greater than ourselves. We have seen firsthand humanity collaborating and working together, even globally, and to see it up-close in our hospital is both beautiful and awe-inspiring. The times have swiftly changed, but the heart of medicine remains. Some of us wonder, had we known this pandemic would come, would we still have pursued residency? And in a heartbeat, our answer is (still) yes.

REFERENCES

1. Edrada EM, Lopez EB, Villarama JB, Salva Villarama EP, Dagoc BF, Smith C, et al. First COVID-19 infections in the Philippines: a case report.Trop Med Health. 2020; 48:21. doi: 10.1186/ s41182-020-00203-0.

2.Magsombol B. PGH accepts DOH's request to be coronavirus referral hospital [Internet]. 2020 March 24 [cited 2020 May 12]. Available from:  https://www.rappler.com/nation/255620-pgh-accepts-doh- request-coronavirus-referral-hospital.

3.Araullo E. Millennial ‘Bayanihan’: UP-PGH interns’ “call center”. Philippine Daily Inquirer [Internet]. 2020 April 22 [cited 2020 May 12]. Available from: https://lifestyle.inquirer.net/361405/millennial- bayanihan-up-pgh-interns-call-center/