Running against the clock: a qualitative study of internal medicine residents' work experience.

AIM OF THE STUDY: While hospitals are adopting strategies designed to increase the overall efficiency of the healthcare system, physicians are facing expanding requirements. Such changes in work environment add new psychosocial and physical stressors. Building on a previous quantitative time-motion study, we conducted a qualitative study to better understand the work experience of internal medicine residents. METHODS: The study used a qualitative description approach, and was based on focus group discussions with residents. Data were analysed using reflexive thematic analysis. The study was conducted among all residents of the Internal Medicine division of a tertiary university hospital in Switzerland. RESULTS: Time emerged as the major determinant of residents' daily experience, which residents want to waste on no account. Shifts are perceived as a constraining succession of distinct periods, with little room for adjustments. Moreover, residents feel held back and distracted in their progression toward the end of the shift. Under time pressure, some essential professional activities, such as caring for patients and families, dealing with medical complications and talking with consultants, may be experienced as unexpected undesirable bumps on the road. Residents describe "running through" a structured day, scattered with obstacles, and resorting to "tricks of the trade" in an attempt to influence the course of the shift. CONCLUSIONS: Time constraints are not new to medicine. However, our findings outline how time has become a constant preoccupation for internal medicine residents, permeating their daily work experience. This changing relationship with time carries the risk of undermining the foundations of clinical medicine and challenges the ability of hospitals to preserve the "sense of the profession". Introduction.

Antibody response and intra-host viral evolution after plasma therapy in COVID-19 patients pre-exposed or not to B-cell depleting agents

BackgroundAdministration of plasma therapy may contribute to viral control and survival of COVID-19 patients receiving B-cell depleting agents that hinder the endogenous humoral response. However, little is known on the impact of anti-CD20 pre-exposition and the use of different sources of plasma (convalescent versus vaccinated) on the kinetics of SARS-CoV-2-specific antibodies and viral evolution after plasma therapy. MethodsEligible COVID-19 patients (n = 36), half of them after anti-CD20 targeted therapy, were treated with therapeutic plasma from convalescent (n = 17) or mRNA-vaccinated (n = 19) donors. Each plasma-transfused patient was thoroughly monitored over time by anti-S IgG quantification and whole-genome SARS-CoV-2 sequencing. ResultsThe majority of anti-CD20 pre-exposed patients (15/18) showed progressive declines of anti-S protein IgG titers following plasma therapy, indicating that they mostly relied on the passive transfer of anti-SARS-CoV-2 antibodies. Such antibody kinetics correlated with prolonged infection before virus clearance, contrasting with the endogenous humoral response predominantly present in patients who had not received B-cell depleting agents (15/18). No relevant differences were observed between patients treated with plasma from convalescent and/or vaccinated donors. Finally, 4/30 genotyped patients showed increased intra-host viral evolution and 3/30 included 1 to 4 spike mutations, potentially associated to immune escape. ConclusionsConvalescent and/or vaccinated plasma therapy may provide anti-SARS-CoV-2 antibodies and clinical benefit to B-cell depleted COVID-19 patients. Only a limited number of patients acquired viral mutations prior to clinical recovery, yet our study further emphasizes the need for long-term surveillance for intra-host variant evolution, to guide best therapeutic strategies.