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Janelle (not her real name) had just wheeled a patient into the recovery room at her Brooklyn, New York, hospital when an alarm sounded over the public address system. Another patient with COVID-19 was coding. The surgical resident rushed to the ICU to see if she could help, but all she had on was a mask, the same N95 respirator she had been using for days. She needed a gown, but the hospital had run out. Staff had resorted to wearing trash bags with holes cut out for their arms and heads. It was better than nothing. She spotted a roll, peeled one off, and began to yank it over her scrubs.

"Don't wear that!" said a clerk, who was watching her fumble with the bag. "I have to," she snapped. "We're out of gowns." But then she realized what he meant. Janelle was about to put on a body bag.

Even as residents are being lauded as heroes for their frontline work fighting COVID-19, they are also trainees who say they are being taken advantage of by hospitals in crisis mode.

In New York and New Jersey, where there have been more deaths than the rest of the United States combined, some residents are caring for COVID-19 patients with little to no supervision and minimal training.

"I had never touched a ventilator before this," says one first-year resident in New Jersey. "I have no clue how to change the tubing if something goes wrong, and I have no idea where the attending is most of the time," the resident says. "As an intern, I don't have access to all the medicines, so I can be in situations where a patient's blood pressure drops and I don't have any means to treat them." He has found himself looking after up to nine COVID-19 patients at once, more or less on his own. It's terrifying and exhausting, he says, and he is not only worried about himself, but also about the compromised care for his patients. "I'm doing my best, but half the time I don't know what I'm doing."

His hospital is also running out of N95s, so he's been reusing an ill-fitting N95 that makes his glasses fog up. The program coordinator that he would normally communicate concerns to isn't working because the position is considered non-essential.

Medscape spoke with nearly 20 residents working on the front lines of the COVID-19 crisis and found that, while some academic hospitals are going above and beyond to protect their trainees, others have fallen short. Residents face massive workloads in normal circumstances. Now, particularly in COVID-19 hotspots, they're overwhelmed and working longer hours for the same pay, often with inadequate personal protective equipment (PPE). They're doing jobs outside their scope of work and facing burnout and emotional and physical fatigue. And they're doing it all, in some cases, for little more than minimum wage.

"There is a very dark side to medical training," says Rachel Hughes, MD, an emergency medicine physician in Madison, Wisconsin. "Medical trainees are vulnerable and, in most situations, they cannot say no."

Trainees in Crisis

The current crisis has amplified all of the problems that residents faced previously, says Amy Plasencia, MD, chief medical resident at Brookdale University Hospital Medical Center in Brooklyn and executive vice president of the Committee of Interns and Residents, a union that represents more than 17,000 interns, residents, and fellows across the United States. Even during normal times, residents face grueling working conditions. But in the middle of the COVID-19 pandemic, the abuses have been egregious and, in some cases, life-threatening. Residents have been asked to take greater risks than their attending physicians. Some have been told to enter COVID-19 patient's rooms with inadequate PPE. Others are performing tasks they feel wholly unqualified to do.

In a recent paper, leaders of the American Heart Association write that "residents and fellows — whether due to lack of experience, poor preparation or lack of training — are particularly vulnerable." As a result, they're the ones most in need of protection during moments like this. "Protect medical trainees on the COVID-19 front lines or do not send them in," they write.

When abuses do occur, residents are wary of pushing back. Recently, numerous hospitals instituted gag orders to prevent employees from speaking to the media. Yet residents fear that even speaking up to their attendings could cost them their jobs — and that's a risk most feel they can't afford to take. Securing a new residency spot might require waiting for the next year's match, moving across the country, or changing specialties. And their departure — whether voluntary or not — serves as a red flag for other programs.

"While attending physicians can easily advocate for themselves, residents' futures rely heavily on the subjective evaluations of their colleagues," write three University of California San Diego Health hospitalists in a recent op-ed. "One negative report can jeopardize a resident's standing and letter of recommendation for future employment. Residents are forced to bear the burden of direct patient care without adequate protection or the power to advocate for their safety."

Fearful they could lose the careers they'd spent most of their lives working toward, most trainees Medscape interviewed requested that their names and, in some cases, even the names of their hospitals, be left out of the story. One resident who contacted Medscape to report dangerous working conditions wrote, "You know what I risk by writing this? Termination. Four years of university premed, a year of clinical research, a year of grad school, four years of medical school and five plus years of residency."

A Google Document identifying accounts of mistreatments in hospitals across the country has popped up on Reddit, but the complaints are anonymous. This desire for anonymity makes specific details difficult to verify, but many of the complaints echo those made by doctors, nurses, and other residents across the country. The residents are not just worried about protecting their careers. With unconfirmed accounts of more than one resident death swirling through the rumor mill, they are also scared for their lives.

At Framingham Union Hospital in Massachusetts, residents report that they are being asked to see COVID-19 patients to conduct daily physical assessments on their own while attending physicians minimize direct contact. "We're cheap labor," one resident says. "We are 100% being used as cannon fodder." Framingham Union denies these allegations.

"We're being pushed to see these patients with minimal PPE and being made to feel that we're crazy for asking for more PPE," says the resident, who asked to remain anonymous. Even residents with underlying health conditions that would put them at greater risk for severe illness from COVID-19 are not exempt from these requirements, the resident says. What's more, the hospital's parent company, Tenet Healthcare, has decided to postpone funding for their 401(k) match program, reducing the already minimal compensation that residents are receiving.

In New York City, another resident experienced similar pressures and was left to make life or death decisions without the guidance of an attending physician. "I had five thoracic emergencies on my COVID patients last night, and all five required that I go in the patient's rooms," he says. "I was in there and my attending was not."

Even at hospitals where residents feel relatively well-supported, the stress is intense. One radiology resident at Stony Brook University Hospital in Stony Brook, New York, recently had to insert a chest tube into a patient whose lung had collapsed. The man was about the same age as the resident and had been on a ventilator for 25 days. Most hospital rooms are bare because visitors are prohibited, but this particular patient's walls were plastered with pictures of his wife and kids, snapshots of his family on vacation, notes scrawled in crayon. Just before the resident began the procedure, a photo of one of the children floated down off the wall. That evening the resident was driving home from work when his own child called him. The resident started crying. "I couldn't even speak to him, I was sobbing so much," he says. "I had to pull over on the side of the road for a minute because I was afraid I was going to wreck."

"Taking care of sick people is part of the job," the Stony Brook resident says. But he never could have predicted this tsunami of severely ill and infectious patients. "It's just constant paranoia and stresses heightened beyond a level that I've never experienced," he says.

Falling Ill

Back in March, one hospital in New York asked its residents to start working in the COVID-19 screening tent. One resident fell sick, and then another and another. One of the chief residents pushed administrators to put the residents on a "float" schedule that would reduce overlap, fearing that residents working in the screening tent might be contracting the virus and infecting other residents in the halls or residents' lounge. "We were some of the first people deployed to that tent," the chief resident says. Eight residents got sick in seven days before the hospital finally agreed to change the schedule.

When residents do fall ill, they're not always tested for COVID-19. Testing guidelines keep changing, and even residents who are exhibiting symptoms of the disease can't always get a test, say both Plasencia and Chidi Ugwu, MD, regional vice president of New York for the Committee of Interns and Residents and a pediatrics resident in Brooklyn.

Additionally, many hospitals do not have clear policies about what will happen if a resident contracts the virus. At a hospital in New York City, the policy keeps shifting, says one resident. She says the current policy states that staff with COVID-19 symptoms must stay home until they have been symptom-free for 3 days and are cleared to come back to work. But residents only get 5 days paid sick leave, and she has heard that some have been cleared while they're still spiking fevers. "There's not even an effort to pretend we're taking care of the workforce," she says.

One resident in New Jersey tested positive for COVID-19 in March and missed 5 days of work. His paycheck, when it came, was short those missed days. When he followed up to ask about the discrepancy, he was told that the money would need to come from Workers' Compensation. He did get the funds — but not until a week later, after his rent was due. And he says at least two other residents at his hospital are in similar situations.

In Chicago, Rush Medical College fourth-years who indicated a willingness to volunteer if needed were sent a volunteer waiver on Thursday, April 2. The waiver includes an indemnity clause, and signees assume responsibility for the cost of any transportation or treatment required if they fall sick themselves while volunteering.

"I'm angry and frustrated about this," one fourth-year student says. "I want to help, but it sounds like the contract will not cover us at all. The implied support you are getting from the institution is going to be pretty much zero, and if you get sick you're screwed." Intense discussions in a fourth-year GroupMe chat led to lawyers looking at the contract and advising students not to sign.

"I like working in the critical-care setting," says another fourth-year medical student at Rush. "I'd be willing to do it but not if the only way to do it is signing that document. I would hope that even though a person is considered a volunteer and this doesn't count for credit that we would still be protected. Medical students are an eager bunch and this document preys on that."

Rush Medical College's Senior Associate Dean Elizabeth Baker, MD, says that 35 medical students have returned completed waivers, but none of them have been called in to volunteer yet and that it would only happen if Chicago were to see a maximum surge. "We don't want to put our most vulnerable people — students — into harm's way," Baker says. "I would not call students in unless safety conditions were being met, including appropriate PPE, and they would be working under close supervision, not above their level of competency."

These provisions are not included in the waiver, but Baker says the strongly worded waiver is coming from the legal team and not indicative of her intentions for students. Rush Medical College is not the only one calling on fourth-year medical students to volunteer — Harvard recently came under fire for recruiting students to volunteer at a recently opened COVID-19 recovery center.

Doing Better

Even amid the chaos in COVID-19 hotspots, some hospitals are striving to keep their residents safe and supported. At California-based Stanford Medicine, the stated policy is to protect residents from COVID-19 exposure in a way that still optimizes medical education. "The attending faculty physician limits house staff examination of COVID-positive patients to only what is required," says Neera Ahuja, MD, division chief of hospital medicine. Often that means the attending physician will see COVID-19–positive patients independently.

At NYU Langone Health, interns and residents were officially bumped up to their next year's pay level as of April 1 to show appreciation for the extra hours and responsibilities they've been asked to assume due to COVID-19. Steven B. Abramson, MD, executive vice president and vice dean for education, attributes this to strong leadership from nationally renowned epidemiologists and infectious disease specialists at the hospital, along with the emotional connection that program directors have with residents. "Our program directors are committed to their emotional well-being and development as people, and that was before this crisis. We aren't just training them as doctors and throwing them into the fire."

However, not all NYU Langone residents feel protected. Internal medicine resident Colleen Farrell recently posted on Twitter that residents are "working longer hours, caring for more patients, with less supervision than ever before." Yet when some of her co-residents petitioned for hazard pay, they were shamed.

Leaked emails revealed that one department chair "accused us of 'focusing on making a few extra dollars' and said it's 'not becoming of a compassionate and caring physician' to request adequate compensation for our work," she wrote. One fellowship program director requested names of fellows who had signed the petition. Farrell noted that she was speaking out despite NYU Langone's threats of disciplinary action — including termination — for speaking to the media.

https://twitter.com/colleenmfarrell/status/1252241169758773250

While other hospitals in New York City have provided hazard pay for their residents, NYU has not. An undergraduate pointed this out in an op-ed in the university's independent, student-run paper, the Washington Square News, writing that "NYU's medical workers deserve fair compensation through hazard pay, which is the very least NYU can do considering the sacrifice these workers are making."

The response was swift and came from on high: The medical school's top leaders took time to write a letter to the editor slamming the freshman for her opinion and citing factual inaccuracies. (The op-ed has since been retracted, but many have spoken up, anonymously, on behalf of the writer and her claims.)

The Accreditation Council for Graduate Medical Education (ACGME), the body responsible for accrediting graduate medical training programs, including residencies, has given hospitals flexibility in how they use their residents but still expects residents to be limited to 80 hours of work a week, averaged over 4 weeks. And it demands that residents and fellows have proper PPE and supervision.

Yet again, however, compliance depends on the culture at the institution. Trainees may be hesitant to report violations because they don't want to get their employer in trouble. "You don't want to ever say 'no' to the person that is going to write a letter of recommendation for you," Ugwu says.

The pandemic presents an opportunity to rectify problems that should have been addressed years ago. That's why Plasencia, Ugwu, and the rest of the Committee of Interns and Residents recently launched a Resident Bill of Rights demanding a living wage, an 80-hour cap on working hours per week, sick and parental leave, the right to unionize, and access to mental health services, among other things.

Beyond the overarching Resident Bill of Rights, residents are also looking for solutions that can be implemented more immediately. Jocelyn Fitzgerald, MD, a fellow in Washington, DC, created a petition asking ACGME for hazard pay for residents and fellows that garnered more than 21,000 signatures by the time she submitted it. "Many companies including Target and Walmart have offered their employees hazard pay, while physicians, with at least 12 years of training on the riskiest front lines, receive nothing," she writes in the petition.

All of the demands have so far gone unanswered. "It is beyond disappointing that we don't have these kinds of established protections," Plasencia says. Residents are "willing to step up. But we want to know we have someone in our corner to protect us."

Janelle, the resident who nearly donned a body bag in lieu of a trash bag, doesn't feel protected. She feels exposed and frustrated that patients are dying while she rummages through supply closets for a donated Yankee rain poncho to cover her scrubs.

There is a lot Janelle doesn't want to think about these days: The tragedies unfolding in the ICU; the people who are her age on ventilators; the hundreds of thousands of dollars in student loans that her family, who co-signed the documents, will have to pay back if she dies. So each night when she lays down in bed, her mind racing, she tries to forget. She pretends it's a normal day and that her only problems are the ones she had 2 months ago — buying a car, finding a new apartment, hiring movers. She fixates on the mundane until sleep overtakes her and her mind goes blank. If she's lucky, she sleeps straight through until morning and doesn't remember her dreams.

Amber Gibson is a Chicago-based journalist whose work also appears in Forbes, USA Today, and NBC. She can be found on Twitter @ambergib and Instagram @amberyv. Cassandra Willyard is a freelance science journalist based in Madison, Wisconsin, whose work has appeared in The New York Times, The Atlantic, and Nature. She can be found on Twitter @cwillyard.

Do you have information on treatment of residents, gag orders, PPE shortages, or other related issues? Has anyone you know faced disciplinary measures for speaking out? Write to us at: news@medscape.net.

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