The doctor in China who risked his job to warn the world about COVID-19 was not a frontline emergency medicine or ICU doctor. Dr Li Wenliang, was an ophthalmologist, a glaucoma specialist who died after contracting the virus from an asymptomatic patient.
Now a new preprint suggests that that may not have been a coincidence:
The survey data show that of all resident physicians who worked within the greater New York City area between March and April, anaesthesiology, emergency medicine, and ophthalmology residents were at greatest risk of contracting COVID-19. Study author Dr Royce Chen, spearheaded the survey soon after COVID-19 struck. Chen directs the ophthalmology residency program at Columbia University Irving Medical Centre in New York City. He along with other New-York based residency directors make up the New York City Residency Programme Directors COVID-19 Research Group. The group had few resources to help them decide how to protect their trainees.
"There was very little information we had to work with," Chen said. "Simultaneously, as the government was starting to provide directives about social distancing, there were reports from China that it was highly contagious, and we didn't know how to protect (medical) residents."
Early efforts in Chen's programme involved separating residents into smaller groups to lessen the number of co-workers they were exposed to and performing daily symptom checks. Anyone with fever, cough, or other symptoms immediately isolated themselves until the symptoms resolved. (This included Chen, who had mild symptoms).
But not every programme had similar protocols in place, and no one knew whether residents in certain specialties were safer than others. So, Chen and his co-authors sent surveys to about 340 residency directors – all the programmes within 30 miles of New York City's Central Park – to investigate risk levels for each specialty. Ninety-one of those directors responded, representing 24 specialties and more than 2300 residents.
Risk levels for three specialties in particular stood head and shoulders above the rest.
Two of the three, anaesthesiology and emergency medicine, were expected. Ophthalmology, however, was surprising – at least at first glance. "People think of it as outpatient, low-acuity, but the patient and doctor are less than 2 feet apart," Chen said. "And neither patients nor physicians were wearing masks at the beginning of March."
The nose and mouth are obvious exposure paths, but recent research shows that infection can also spread through the eyes. In mid-March, the American Academy of Ophthalmology recommended ceasing most non-urgent care but has since issued guidance on resuming elective surgeries.
The survey is far from definitive: Dr A Elisabeth Abramowicz, director of the Westchester Medical Centre Anaesthesiology Residency Training Programme, in Valhalla, New York, says it's difficult to interpret the data in the pre-print without a comparison with attending physicians.
The researchers only included the seven sub-specialties that received over 100 responses, and usage of personal protective equipment has improved since the survey period. Thus, the results could be different were the survey repeated today. But, she says, it does raise important questions, such as: Should hospitals be thinking ahead to better protect high-risk specialties during a second wave?
"Certainly, for higher-risk specialties, you want to pay attention to really good donning and doffing and strict protocols," Chen said.
During the first wave of COVID-19 in New York City, resident directors worried that their charges could fall ill or die, Chen said. Knowing that there may be a second wave – and that some areas are still waiting for the first wave to peak – the study authors are using the information they gleaned from this first survey to think about how future, follow-up surveys might be helpful in preparing for what comes next.
Abstract
Background: From March 2-April 12, 2020, New York City (NYC) experienced exponential growth of the COVID-19 pandemic due to novel coronavirus (SARS-CoV-2). Little is known regarding how physicians have been affected. We aimed to characterize COVID-19 impact on NYC resident physicians.
Methods: IRB-exempt and expedited cross-sectional analysis through survey to NYC residency program directors (PDs) April 3-12, 2020, encompassing events from March 2-April 12, 2020.
Findings: From an estimated 340 residency programs around NYC, recruitment yielded 91 responses, representing 24 specialties and 2,306 residents. 45.1% of programs reported at least one resident with confirmed COVID-19: 101 resident physicians were confirmed COVID-19-positive, with additional 163 residents presumed positive for COVID-19 based on symptoms but awaiting or unable to obtain testing. 56.5% of programs had a resident waiting for, or unable to obtain, COVID-19 testing. Two COVID-19-positive residents were hospitalized, with one in intensive care. Among specialties with >100 residents represented, negative binomial regression indicated that infection risk differed by specialty (p=0.039). Although most programs (80%) reported quarantining a resident, with 16.8% of residents experiencing quarantine, 14.9% of COVID-19-positive residents were not quarantined. 90 programs, encompassing 99.2% of the resident physicians, reported reuse or extended mask use, and 43 programs, encompassing 60.4% of residents, felt that personal protective equipment (PPE) was suboptimal. 65 programs (74.7%) have redeployed residents elsewhere to support COVID-19 efforts.
Interpretation: Many resident physicians around NYC have been affected by COVID-19 through direct infection, quarantine, or redeployment. Lack of access to testing and concern regarding suboptimal PPE are common among residency programs. Infection risk may differ by specialty. Funding AHA, MPB, RWSC, CGM, LRDG, and JDH are supported by NEI Core Grant P30EY019007, and unrestricted grant from RPB. ACP and JS are supported by Parker Family Chair. SXX is supported by University of Pennsylvania.
Authors
Mark Philip Breazzano, Junchao Shen, Aliaa H Abdelhakim, Lora R Dagi Glass, Jason D Horowitz, Sharon X Xie, C Gustavo de Moraes, Alice Chen-Plotkin, Royce W S Chen, New York City Residency Programme Directors COVID-19 Research Group
[link url="https://www.medscape.com/viewarticle/930553?src=wnl_tp10n_200605_mscpedit&uac=240746SY&impID=2406378&faf=1"]Columbia University Medical Centre – University of Pennsylvania material[/link]
[link url="https://www.medrxiv.org/content/10.1101/2020.04.23.20074310v1"]MedRxiv survey data[/link]