After 37 years practicing medicine in San Francisco, Dr. Donald Abrams is hanging up the stethoscope on June 29, 2020. A pioneer in the fight against AIDS, his extraordinary career is now, as he put it to me, “bookended by epidemics.” Because of the fear around AIDS in the early years, with an unknown mode of transmission and a 100 percent mortality rate at the time, some providers understandably did not want to care for that population. But Donald bravely and tirelessly treated these mostly gay young men who were withering with the disease. Now, still energetic at 70, Donald was eagerly anticipating his last-ever two weeks leading a hospital’s inpatient medical team starting on April 4. With the onset of COVID 19, however, he began to have second thoughts. He sheepishly asked a colleague about the risk, given his age and asthma. The colleague replied, “Grow up and wash your hands…You know how to handle an infectious disease.”
Over the next two weeks, his family and friends increasingly expressed concern. “I did not want to make [their] life difficult,“ he wrote of his employer, “but I was getting cold feet.” An inpatient medical team, led by a faculty internal medicine doctor, is composed of interns, residents, and medical students . Large hospitals usually have multiple teams caring for hospitalized patients. Also known as the medicine teaching service, they admit patients from the emergency department, take care of them on the wards, and, depending on the hospital, may follow them into the intensive care unit (ICU), if necessary. Finally, he mustered the courage to say, “I cannot bring myself to, and no one who cares for me would let me attend on the medicine service.”
“I felt guilty, forcing them to scramble and look for a replacement with such short notice,” Donald, a friend of two decades, told me. “And the irony of me being on the front lines in the HIV [start] of my career but declining to participate during the COVID portion was not lost.”
In the end, his colleagues reassured him “that I had paid my dues and now was the time to keep me safe,” he said. Bowing out is not how he wanted to end his career, but he had to accept that it was the sensible and ethical thing to do.
As a physician with a disability, I faced a fairly similar dilemma. I have a spinal cord injury, and although I am an associate professor of radiology at a top teaching hospital, I too became anxious about working after reading about the mounting cases of coronavirus infections and COVID-19 illness in the United States. Was I at higher risk for a severe infection or a bad outcome? In early March, the website of the U.S. Centers for Disease Control and Prevention (CDC) listed only a few chronic conditions as risk factors. Yet I knew the list was incomplete, leaving out obvious conditions such as immune suppression and neurological conditions.
I consider myself strong and resilient, having lived through the experience of rehabilitating and rebuilding my life after my accident. I am also generally “healthy” — I do not have a chronic illness. But my injury weakened my diaphragm and respiratory muscles in addition to my arms and legs, so I have diminished lung function and a persistent, feeble cough. That means I would have difficulty fighting coronavirus, and more difficulty weaning off a ventilator– should I need one.
Before social distancing and “shelter in place” orders, I felt acutely self-conscious about my concerns of working amid the virus. Was I blowing the risk out of proportion? After some intense reflection, I emailed my division chief and department leadership requesting permission to work from home. My department has always been supportive, and this was no exception. As a purely diagnostic radiologist, who doesn’t do invasive procedures or have a clinic, most of my patient “interaction” is through their radiologic images. For this reason, the accommodation request was not unreasonable. Indeed, I could do the same volume of work from my home workstation as I could in the hospital.
Call to Heroism – or Coercion?
Unfortunately, not everyone’s employer is so supportive. Around the same time, an immune-suppressed radiology resident at another institution emailed me for advice. The resident’s request to read CT scans and the like “remotely” was met with skepticism and delays. Despite an email from a director asking about pre-existing conditions, there was no reassurance that steps would be taken to protect them. A faculty member to whom the resident reached out for advice confided that not coming into the hospital might make other faculty less confident in the resident’s abilities. Ultimately the faculty member told him to “be careful,” emphasizing that all healthcare providers are taking a risk and that the physicians who have lost their lives to coronavirus are heroic, which added to the resident’s guilt.
The volunteerism of healthcare providers during this COVID crisis is commendable, and very different from the fearful response to AIDS. Many are risking their lives in the service of others, especially where there is a shortage of personal protective equipment (PPE). But is it ethical to put health care providers with high-risk medical conditions on the front lines? Some of our colleagues are on immunosuppressive drugs for organ transplants, have autoimmune diseases, or are on chemotherapy. Data are limited for SARS-CoV-2, as this coronavirus is named, but similar viruses can more easily infect them, taking advantage of their inability to mount an immune response, even leading to pneumonia and multi-organ failure. Not only would this take them out of the workforce, but they are more likely to utilize valuable resources, such as ICU beds and ventilators, should they fall ill.
So how could the physician workforce engage its “docs with disabilities” while not endangering them?
I believe that supervisors should work with providers who have disabilities and chronic illness to move them away from the front lines and into other roles where they can still participate, but at a safer distance. They could do virtual rounds with inpatient hospital teams, or perform telemedicine visits to help keep vulnerable outpatients away from the hospital. They could help their colleagues with unmet research obligations. Although some work up front would be required to rethink workflows, not much imagination is required to generate these and other options.
There are, in short, many cost-effective and humane accommodations that would be worthwhile. These measures make so much sense that hospital leadership should be inspired to act, and public health officials focused on the pandemic at the local, state, and federal level should consider ways to encourage such measures. In fact, now that we have seen that telemedicine works well, we should not abandon it after this pandemic. It not only is more convenient for patients, but it also could make medicine as a career more accessible, and to help marginalized physicians stay in the workforce.
A Culture of Ableism
Within the medical world itself, there is a powerful culture of ableism. Social norms emphasize “superhuman” efforts of those who toil around the clock, endure without food or breaks, and above all, don’t complain. Nowhere is this culture more prevalent than in medical schools and residency programs, where students and residents are even less empowered to self-disclose an illness or disability and ask for accommodations. One can imagine how these discussions sometimes play out on the backdrop of a professional culture that debated for years the wisdom of limiting residents to 80 hours per week.
Our more junior colleagues with disabilities are both more impacted by the ableism, and more likely to internalize it. They may be reluctant to admit limitations, and eager to prove their strength. Consequently, it falls to leadership to initiate the conversation broadly, to normalize sensible self-protective behavior for all, but especially for those at higher risk.
As cases and deaths mount, we should not be lulled into complacency by the possible successful flattening of the curve in some locations. We need to be aggressively proactive about protecting our high-risk staff. We may not even know the medical history of providers in our departments and may be surprised at who is vulnerable during this pandemic.
So, official policies must communicate support for high-risk providers, encourage requests for accommodation, and help reduce the guilt and shame that may serve as a disincentive to disclosure. Under these conditions, providers can request accommodations that minimize exposure, save lives, and still serve patients.
Editor’s note: Stay tuned for analysis of how the Americans with Disabilities Act applies to these kinds of cases, from top disability law expert Professor Samuel Bagenstos.
The author wishes to thank Drs. Lisa Meeks and Arghavan Salles for their suggestions and edits.