Rounding in the Time of COVID

My first week on service as a new pediatric hospital medicine fellow was, frankly, a mess. My team had no idea what I wanted, because I had no idea how to run a team. While debriefing the week, my attending encouraged me to find a way to set learner expectations at the beginning of each week of service to keep the team organized. I remembered the advice of 2 inspiring medical educators as I focused on keeping my expectations concise, straightforward, and easy to remember. This led to me creating 4 rules, the first of which, listed in big bold letters at the top of my emails, being—THE PATIENT COMES FIRST.

As I transitioned to faculty and was able to fully implement these rules, I became engrossed in the learner flow—the stress and rapid growth in the early months, the confidence of the midyear, and the burnout at the end. I saw the cycle continue year after year. “My evaluations are positive,” I thought. “I’m doing what I should do.”

However, my fellowship and early career have never been what you could call stable. They have been taken over by twin epidemics: COVID-19 and emboldened acts of racism and prejudice, both of which have highlighted a system of oppression that has been ingrained in the fabric of the country since its inception. Our profession has felt this in a unique way: BIPOC, LGBTQIA+, and women professionals continue to suffer trying to do what’s best for our patients and medical systems. At the peak of this suffering were our trainees, whose livelihoods are dictated by medical and education systems with roots in racism and prejudice.

As a young faculty member, the weight of these events was initially paralyzing for me until our hospital took the chance to bring the insidious and silent aspects of these pandemics to light. As part of a launch for a new upstander training, our grand rounds focused on the effects of microaggressions on our trainees. Multiple trainees whom I had enjoyed working with shared their experiences in front of our large faculty. Seeing them be so vulnerable with their suffering and struggle made things truly “click” in my mind.

Maslow’s Hierarchy of Needs is a motivational theory that suggests that before an individual can meet their full potential, they need to satisfy a series of needs. The largest of these needs are physiological—things like air, water, shelter, and sleep—but they are closely followed by safety needs, then love and belonging. Our residents and students weren’t safe. They didn’t feel like they belonged in a system designed for inequity and suffering.

What could I do to scale this mountain, to change a system that continues to grind down our residents and learners? And how can I make such a change when also trapped in the same system?

I knew I had to start in the small moments where I was a leader: on rounds. To do that, I knew I needed to change my rules.

No longer was the first rule about our patients. Now, in big bold letters at the top of my email, was a new first rule—YOUR SAFETY COMES FIRST. The learners’ physical and psychological safety is my number one concern. I am here to provide a safe place to learn, to take care of patients, and to reconcile the effects of the world on how we do those things. I show that fostering a safe environment is a priority not just through writing it at the top of the page, but also through my actions. I am an upstander, not a bystander. Everyone is addressed by the names and pronouns they choose. I make sure everyone wears the appropriate PPE. No one needs to enter a situation in which they feel unsafe or uncomfortable, at least not without me by their side. I will help do anything that needs doing. We are all here to grow, learn, and make mistakes.

After I made these changes, the air during rounds felt lighter. I could see the residents’ and students’ shoulders relax; their eyes begin to look straight ahead, rather than down. Not a week on service goes by without a learner commenting on how comfortable they feel learning and practicing medicine together. Now, at least, when I think about how I’m doing, I know I truly am doing what I should do.