As the COVID-19 pandemic unfolds, medical students are being conscripted into the frontline of the crisis. Specifically, medical residents are getting “field promotions,” taking on greater responsibility and more significant roles often without the usual adjustments in compensation, let alone additional hazard pay.

Thus far only one major hospital system has offered hazard pay. On April 7th one New York hospital, Mt. Sinai, announced $300 of weekly hazard pay for all residents and fellows.

Mother Jones reported that employees at “Partners HealthCare, the largest health care system in Massachusetts, received an email from the company informing them they would not be receiving hazard or crisis pay for dealing with coronavirus cases. The letter was signed by the CEO, who makes at least $2 million a year and perhaps up to $6 million.”

MPR reports that hospitals across Minnesota and the U.S. are making these cuts. In Minnesota, the state employment department indicates that 30,000 people who work in the health care sector had filed for unemployment as of last Friday.

Medical residents along with other health care personnel are struggling between an immovable object and an unstoppable force. The entire medical field is struggling with misleading statements by President Trump and surrogates of the administration along with the force of a highly transmissible virus without any known cure, vaccine and limited treatment measures. The inconsistency and delay of rigorous social distancing measures further complicates the general chaos.

Asking medical professionals to do pandemic related essential work, that’s made difficult by mixed messages about social distancing hasn’t worked. Even with assurances of best practices and proposed solutions, health care personnel are still struggling.

Emily R. Lowther, Communications Director for the Minnesota Hospital Association replied to questions around preparation for Minnesota hospitals,

Minnesota’s hospitals and health systems are preparing for a surge of COVID-19 patients and working to determine how to staff up to accommodate that anticipated surge. Yes, there is a shortage of PPE and it is very concerning. It is paramount that we protect the health and safety of our workforce, from environmental services workers to dietary aides to nurses and physicians. We are working around the clock in partnership with the state to obtain as much PPE as possible. To care for acutely ill COVID-19 patients, hospitals will need physicians and nurses who specialize in ICU level of care, as well as respiratory therapists. We will likely need more hospital staff than we currently have, and we have to take into account the health care workforce that may be exposed and become ill from COVID. Our hospitals and health systems are asking Gov. Tim Walz to issue an executive order that would waive the current health professional licensing process to allow any duly licensed health care professional to come to Minnesota. Upon notification, the Board of Medical Practice and the Board of Nursing could verify that the individual holds a license that is in good standing in their home state. This process could be done in 24 hours. We are only asking for this during the time of the declared emergency. We are also supportive of the state determining how to bring back retired nurses and retired physicians to respond to COVD-19. The state would also need to determine how medical students could care for patients during a surge. Gov. Walz issued an executive order postponing elective surgeries and procedures in order to conserve PPE and reserve hospital capacity for an expected surge of COVID-19 patients. That was the right thing to do and hospitals and health systems encouraged and support his action, but the reduction in revenues and significant costs to acquire an unprecedented amount of supplies and equipment, build out temporary spaces for a surge of patients and ensure we will have the right workforce in place to care for COVID-19 patients – particularly in intensive care – are having a significant financial impact on health systems throughout Minnesota, large and small, metro and rural. These financial impacts as well as the lower demand for clinic visits and elective procedures have unfortunately resulted in hospitals and health systems managing a present demand for fewer staff through furloughs, voluntary leaves and similar measures. This varies hospital by hospital depending on local needs. Hospitals and health systems are working to train some of these workers to be redeployed to care for COVID patients.

Reporting on this subject is challenging since desperation is high and workers are fearful about speaking out publicly, even though their lives are at risk. They fear endangering their career as medical professionals under the yoke of hundreds of thousands of dollars in medical school debt.

Vanity Fair reported on the fear doctors are experiencing as many in their profession have been fired for speaking out.

“One New York City doctor treating COVID-19 patients told me that accounts of doctors afraid to speak out for fear of retribution are ‘absolutely true on a large scale.’ The doctor added, ‘We have specifically been told not to speak to the press without the express consent of the hospital leadership system. This is to ensure the proper messaging, even at the cost of placing their health care workers’ lives at risk.’”

Many medical residents have taken to Reddit to describe their experiences and seek support and understanding as they head into medical facilities with worsening patients and a lack of protective gear.

Reddit user shponglenectar is a postgraduate year two anesthesia resident at a large Manhattan hospital. In late March they described the emerging toll of the pandemic.

“Walking down the hall now I can barely tell the difference from patient to patient. Everyone is tubed and RASS -5. Everyone looks grey and barely alive. It’s beyond unsettling how similar every patient looks, whether they’re 50 or 80, man or woman.”

They stated rather prophetically, “This is only the beginning of the outbreak and the suffering we’ll witness because of it. I hope we can all maintain compassionate care in the face of this pandemic. Please take care of yourselves as you go through this. If you ever need someone to chat with and decompress, I’m happy to talk. Stay safe fam.”

Residents are beholden to their attendings and obedience is high. Without completing these residencies, the years of prior training and debt that could easily reach over 300k will have been for nothing if they refuse and lose their jobs.

According to an OP-Ed in Forbes, “Many residents and fellows log 80 working hours or more in any given week. Those hours are spent doing everything from answering telephone calls from patients and operating to administrative tasks, and they see much more face time with patients than those who supervise them. At the major academic hospitals in this country, trainees are the workhorses that keep them running.”

As reported by the American Medical Association, stress and the toxic work culture has led to high sucicide rates even before COVID,

“Two in five physicians screen positive for depression and mental health issues, and burnout and other stressors are prominent across the continuum of physician education and practice. Medical students, meanwhile, are three times likelier to die of suicide than their counterparts in the general population.”

During this crisis, the stress is compounded by a lack of acceptable personal protective equipment.

Claims and concerns from residents about a severe lack of protective equipment are further affirmed by findings produced by the Inspector General for the Department of Health and Human Services (HHS). Released Monday April 6th and described by NBC News, the findings confirmed previous media reports and warnings from health workers that the medical system is under unprecedented strain. The report was based on interviews with administrators from 324 hospitals and hospital networks of varying sizes.

Hospitals reported that they face dire shortages of vital medical equipment including testing kits and thermometers — and fear they can’t ensure the safety of health care workers needed to treat patients with COVID-19.

Equipment provided to hospitals from the federal government fell far short of what was needed and was sometimes not usable or of low quality, said the report.

For example, the report describes how one hospital received two shipments from the Federal Emergency Management Agency with protective gear that had expired in 2010. Elastic on N95 masks were found to have been dry rotted and another delivery was half filled with children’s masks.

Residents are also being asked to provide care outside of their field of training. One day they are training in dermatology and the next they are accelerated to the front lines in a COVID-19 ward. There they are expected to operate complicated and delicate ventilators with which they have no experience or training.

A ventilator requires near-perpetual management. Pulmonologists work with respiratory therapists and nurses to diagnose, intubate, medicate, and manage patients hooked up to the devices.

“That’s why it’s the ICU,” said Joshua Denson, an assistant professor and associate director of pulmonology at Tulane University School of Medicine. “It’s all very intensive, between the nurse, the doctor who is looking at the bloodwork, making changes to the patient’s meds, and doing procedures on the patient.”

The LA Times reported on April 7th that, “The federal government is quietly seizing orders.” As the LA Times article explained, “Hospital and health officials describe an opaque process in which federal officials sweep in without warning to expropriate supplies.”

Adding to the difficulty in reporting on these subjects is that hospital administrators appear to be loath to speak out, afraid of retaliation and not getting access to desperately needed supplies. This fear comes as the Trump administration is providing equipment and supplies using an unclear logic for distribution. Reporting from Talking Points Memo explained the process further saying that, “the White House seizes goods from public officials and hospitals across the country while doling them out as favors to political allies and favorites, often to great fanfare to boost the popularity of those allies.”

Speaking to the dearth of equipment and the feeling of being expendable, one resident on Reddit madresident commented from New York,

“Frustration at the government, politicians, administrators for being in the comfort of their homes and insisting I risk my life with bare-bones equipment to protect myself. Administrators that promise you shipments of things that never come, yet the one isolated time you see them in the hospital, it’s never without a shiny new n95. Frustration that you will never be compensated for this. You are a resident. They don’t care about you. You knew that before, but now you see just how far that goes. You can literally die, and they do not care. All these discussions about overtime, hazard pay, humane working conditions, none of that applies to you. This has come and it will go. And if you survive it you will get absolutely nothing for it – save an empty thank you email, or a half-assed pat on the back by someone who has no idea just what you’ve been through. Life will just go on and no one will ever remember what happened.”

Residents have expressed frustration that they have not been included in many of the recent scheduling decisions and have been put at risk unequally compared to their senior counterparts. In one case explained to Workday, attending physicians have disappeared from the physical space, leveraging their preferential treatment as established physicians to be able to interface remotely to avoid being in harm’s way. As one person Workday spoke to described, “Leadership is out of the blast radius.” Residents have explained that some of their attending physicians had received preferential choice to cover non-COVID services, leaving residents and fellows more exposed.

On April 9th Congresswoman Carolyn B. Maloney announced that she will be introducing legislation to alleviate the burden of student loan debt for frontline health care workers and help attract medical professionals in various specialties to lend their expertise to the response to COVID-19.

“The least we can do to recognize their service is to forgive their graduate student loan debt so that they are not forced to worry about their financial wellbeing in addition to their health and the health of their families while they respond to a public health emergency. That is why I will be introducing the Student Debt Forgiveness for Frontline Health Care Workers Act. I hope my colleagues will join me in making this a bipartisan priority.”

The Student Debt Forgiveness for Frontline Health Care Workers Act will eliminate graduate school debt for health care workers who are providing direct patient care in response to the COVID-19 pandemic. This would include recent graduates as well as more experienced providers who are still paying off their student loans.

“Eligibility would extend to nurses, doctors and other health care professionals who have already been treating COVID-19 patients or have shifted from other specialties to support the effort.”

The Accreditation Council for Graduate Medical Education (ACGME) has a petition asking for hazard pay for residents.

“Residents are, per hour, the lowest paid employees in the hospital, who work the longest shifts and take the biggest risks. At this time, we should be pushing for hazard pay.”

If a subspecialty fellow is being redeployed to work in the capacity of an attending physician, they must be paid attending wages for moonlighting for those hours worked. To continue fellows at their trainee pay tier without compensation for attending work is frankly abuse of a vulnerable population.