As a newly minted attending physician, I could not have imagined my first months of independent practice would coincide with one of the most devastating medical disasters in U.S. history.
However unfortunate the timing, I am a fully trained physician, with the capacity to determine my involvement in the pandemic. I choose to work in the emergency department and care for COVID-19 patients. But I find myself with an ever increasing concern for medical trainees, who are unable to choose their roles during this time.
Somewhere between employee and student lies the land of medical residency. To become a board-certified “attending” physician in the United States, you must complete a residency. These years of training are considered the most challenging of a physician’s medical career. The difficulty stems from a combination of isolation, sleep deprivation and in some cases institutionalized abuse.
A systemic review published by the Journal of the American Medical Association showed the prevalence of depression or depressive symptoms among resident physicians ranged from 20.9% to 43.2%, a percentage that increases with each year of residency. In 2018, two New York City physician residents tragically took their own lives within several days of each other.
These same residency programs are now under the increased pressure of serving at the epicenter of the COVID-19 pandemic.
I have spoken to residents during the pandemic who have expressed concern for their health and safety, including inadequate personal protective equipment, but many will not speak out for fear of repercussions by their institutions. Most of the residents I have spoken with asked that their quotes remain anonymous; some refused to be quoted at all, for fear their words may somehow be traced back to them. But one resident was ready to speak out.
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“We are in a unique situation,” said Dr. Megan Tresenriter, an emergency medicine resident in San Diego. “Unlike other employees, if we feel unsafe or coerced, we cannot quit. We will not be eligible to become autonomous physicians if we do not complete our residency requirements, leaving most of us feeling we have no choice or voice.”
Other residents interviewed expressed their fear and a feeling of being viewed as “disposable” by health care systems.
During residency, you lack many basic employee rights. For instance, you cannot negotiate your salary, and your job location is determined by The Match system, another nonnegotiable process that places doctors at their residency home for three to six years. If a physician terminates their residency, the path to becoming a board-certified doctor meets an unceremonious end.
Medical residents are arguably the most financially undervalued employees of the health care system. The average U.S. medical student debt is $190,000, and tens of thousands of dollars of interest will accumulate on these student loans during residency. Residents spend the most hours in the hospital, with the greatest amount of patient contact, being paid similar hourly wages to big-box store cashiers. In contrast, stores like Walmart are compensating their employees with hazard pay during the pandemic.
As an alternative to hazard pay, an internal medicine residency program in Denver revoked its residents’ annual stipend increase, stating, “This was a very difficult decision but one that is in alignment with the entire hospital system.” At Denver Health, a hospital staffed by these same residents, executives were given six-figure bonuses in April.
Contrary to their financial compensation, residents are the foundation and backbone of major hospital systems throughout the United States. And during the COVID-19 pandemic, we need strong policy to protect these physicians in training.
In 2003, the Accreditation Council for Graduate Medical Education instated work hour restrictions for resident physicians of 80 hours per week. These restrictions were created after the death of 18-year-old Libby Zion, as the result of a medical error made by a resident working a 36-hour shift. The girl's father wrote a New York Times op-ed stating, "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life and death."
Enforce resident work hour limits
Resident work hour restrictions must be strictly enforced during the COVID-19 pandemic.
Other considerations that should be discussed include using residents to cover hospital services outside of their medical specialty and creating the opportunity for residents to opt out of aerosolizing procedures, which throw the virus into the air. Institutions should have further stringent precautions for residents who are immunocompromised or pregnant.
Residents must be given adequate daily personal protective equipment. They should not be required to use reduced protections. They must be given sterile N95 masks, gowns, face shields or powered air-purifying respirators for aerosolizing procedures. If hospitals do not have the correct protective equipment for residents, they should not allow trainees to work with COVID-19 patients.
In most states, workers’ compensation requires front-line health care workers suffering from COVID-19 to provide proof the virus was contracted at work, which is nearly impossible. Residents need comprehensive workers’ compensation coverage for any COVID-19 related illnesses, including mental health, incurred during the pandemic.
Equip whistleblowers to come forward
Finally, residents need anonymous and nonretaliatory means of submitting whistleblower information specific to the pandemic, to be investigated immediately by the Accreditation Council for Graduate Medical Education.
Taking steps to care for residents during the pandemic will result in superior patient care and protect the moral integrity of our health care system. We have lost resident physicians to COVID-19. There will surely be further loss of resident life during this pandemic, and these young doctors deserve every protection we can afford them in this battle.
A current resident and previous Air Force captain, who served in Afghanistan, drew similarities between his residency and his time in the military. When describing ideal hospital leadership during the pandemic, he told me of how his favorite superior officers led from the front, which included recognizing that a dedicated recruit would never say “no” to an order
Health care systems and residency programs across the country must lead from the front, creating increased protections for our physician trainees during this pandemic. They are the future of health care in the United States and without them, we are lost.
Dr. Ashely Alker is an emergency medicine physician, serving on the front lines of the COVID19 pandemic in Northern Virginia, and a past president of the American Academy of Emergency Medicine Resident and Student Association. Follow her on Twitter: @aalkerMD