It is 4 a.m. in the Yale New Haven Hospital Children’s Hospital. I am standing outside a door festooned with colorful signs declaring “contact” and “droplet” precautions. I am already wearing a mask, but I put on a yellow isolation gown and purple gloves to comply with the “contact precautions.”
I have been to this room several times already tonight and I know that the door squeaks. I push it open only partway and slip inside. The room smells of Albuterol and sweat. A shadowy form lies on the guest couch. It shifts as soon as I enter and I see a parent’s dark-circled eyes, illuminated by the dim light from the hallway. “Just checking in,” I whisper.
The eyes nod and I make my way over to the patient’s bed. I lay my stethoscope on the small chest, listening for wheezes and patterns of air movement. I adjust the nasal cannula providing oxygen. I count a rapid respiratory rate and look at the cardio-pulmonary monitor for oxygenation status and pulse. I lift the hospital gown to see the patient’s abdomen and note how the skin sucks in slightly around each rib.
“About the same,” I whisper to the eyes. “I’ll be back at 5.” Then I move on to the next room; the next “respiratory check;” the next child struggling to breathe under my care.
In September 2021, three months into my first year as an internal medicine-pediatrics resident at Yale New Haven, I began my first pediatrics rotation. After three months spent caring for medically complex adults, I arrived on the general pediatric floors brimming with confidence. However, I soon found myself facing the unique challenges of caring for children during respiratory viral season.
I worked non-stop to complete progress notes, histories and physicals, consults, educational sessions, and other first-year resident tasks in between up to hourly “respiratory checks.” Adult patients requiring this much monitoring are only found in step-down and intensive care units, which have lower patient-to-provider ratios. On the general pediatric floors, however, I often carried up to 12 patients.
In the fall of 2022, as reflected by the January 2023 New York Times documentary video “Why Saving Kids is Bad Business in America”, pediatric hospitals were inundated by record numbers of admissions for respiratory viral infections. This documentary, which features footage from Yale New Haven Hospital, discusses how the closure of pediatric inpatient units across the United States — largely due to lower insurance reimbursements for pediatric care — compounded this crisis.
Beyond straining the overall system, these record numbers had a particular impact on pediatric residents. In the fall of 2022, first year pediatric residents at YNHH routinely carried up to 16 patients — a remarkable number when I recall how overwhelmed I sometimes felt my first year with 12. This workload was only partially lessened by laudable but unprecedented measures by our residency program, which included eliciting volunteers from among attending pediatricians and pulling pediatric residents from sub-specialty rotations.
Despite duty hour restrictions implemented over the past two decades, the United States medical system still relies on medical trainees’ willingness to work grueling hours — up to 80 a week, although we often creep past this number. My pediatric co-residents are willing to sacrifice many things — sleep, meals, time with family, educational opportunities, to name a few — before providing less than optimal care or asking for help. This is not out of pride, but more from the knowledge that we have no choice.
There are no extra residents to pick up our slack. We must do our best, accepting the costs to our personal well-being and the quality of our education. In the back of our minds, we fear that these sacrifices may someday impact patients. We know mistakes happen when residents do not get enough sleep. And we cannot begin to quantify the effects of missing educational sessions or feeling pressured to complete patient interactions in less time, perhaps missing a vital physical exam finding or eroding patient-doctor relationships.
Many factors impact the number of pediatric residency positions available in the United States. However, as with all residency programs, this number is determined in part by federal funding through Medicare and Medicaid. Additionally, just as pediatric hospitals face lower insurance reimbursements, pediatricians have overall significantly lower salaries compared to adult doctors, undoubtedly deterring some would-be pediatricians from the field. Some argue that these differences in salary and funding are justified by lower patient complexity. However, one need only spend a few hours shadowing a pediatric resident during peak respiratory viral season to know that these arguments are more a matter of opinion than fact. And while our workload may fluctuate, we are always busy — even without record-breaking respiratory viral seasons. We can always benefit from having a few extra residents.
Of course, pediatrics is not the only field facing record inpatient admissions. In January of 2023, I was informed that internal medicine services would be increasing their patient caps for first year and senior residents. At Yale New Haven Hospital, as in many hospitals, skilled physician associates and advanced practice nurse practitioners help alleviate resident workload. But even their presence had proven inadequate.
We need more residents — and doctors — and the issue is not lack of interest. Thousands of senior MD and DO students and prior medical school graduates go un-matched for residency each year. Farther back in the pipeline, only 2.6% of medical school applicants were accepted in 2021 — with medical school slots being determined in part by the number of residency positions. These numbers do not tell the full story. A medical school applicant may decide to pursue another career. A residency applicant may be willing to go un-matched rather than match to a less desired program. Overall, however, statistics show that we do not have a dearth of would-be doctors.
At the beginning of COVID-19, pediatric residents were pulled from pediatric units to care for adult patients. Now, we have faced our own crisis and seen the cracks in our own system — and no internal medicine residents can come to help. The fall of 2022 showed us that the United States needs more pediatric inpatient beds. But we also need more pediatric residents. To meet this need first requires a recognition that the need exists — followed by increases in both pediatric residency program funding and pediatrician salaries, along with increased insurance reimbursements for pediatric care. I know these are idealistic and aspirational thoughts. But pediatric care needs to be a priority in fixing healthcare in the United States. Children soon become adults —the same adults filling internal medicine wards with health conditions that could have been mitigated by comprehensive pediatric care.
As I write this in April of 2023, pediatric admissions for respiratory viruses have fallen from their autumnal peak. However, I suspect cases will rise again and I will spend more nights circulating from room to room — listening to labored breathing, counting labored breaths — before the summer months may grant us a more durable reprieve.
The systemic problems underlying strains on pediatric healthcare, and American healthcare more broadly, will not be solved during this time. But I hope that they will be better recognized. I hope that we might expect more beds and more residents during future crises.
June Criscione MD is an Internal Medicine-Pediatrics Resident Physician in New Haven.