At 27, Dr. Nathan Wood, a first-year internal medicine resident at Yale New Haven Hospital, is prepared to die for his patients.
The young doctor has asthma. If he contracts COVID-19, the disease caused by the novel coronavirus, there’s a possibility he may need a ventilator to help him breathe. And that, even though he is young and otherwise healthy, he, like many he treats, might not survive.
“I had to have a very introspective journey at the beginning of all this, where I really reflected on my faith and mortality and had to come to grips with the fact that going to work might end up killing me, and that it was still worth it," Wood said.
Resident doctors, like Wood, finished with schooling and training for specialized medical careers, are on the front lines of the coronavirus crisis gripping the nation. Their jobs were notoriously punishing long before the pandemic began. Residents frequently log 80-hour weeks for little more than minimum wage, once all their working hours are tallied, while carrying mountains of student loan debt. It’s a system designed to test the physical and mental limits of the next generation of health care providers — and to instill an ethic of professional sacrifice, for when sacrifice is required.
In the hospital hierarchy, medical residents and fellows occupy the lowest rungs, with first-year residents, or interns, at the very bottom. The culture of residency is often likened to the hazing process that fraternity prospects endure — grueling and, at times, belittling, but necessary for membership in the medical elite. While many trainees, galvanized by a soldierly sense of duty, feel grateful for the opportunity to care for sick patients in this crisis, others fear they could buckle under the increasing demands of their jobs, if they’re not stricken with COVID-19 first.
”I think this coronavirus pandemic has put incredible stress on an already stressed group of workers," said Dr. Rose Olson, 29, a first-year internal medicine resident at Brigham and Women’s Hospital. “Residents are some of the most overworked doctors at the hospital and we have some of the most inpatient time ... and we don’t know the true occupational risk yet that health care workers face in contracting the coronavirus disease.”
Residents’ anxieties — some new, and others longstanding — run the gamut, from concerns about disruptions to their education to fears of exposure to the virus due to widespread shortages of personal protective equipment, or PPE. At teaching hospitals across New England, residents say their specialized training and education have taken a necessary back seat in order to care for the influx of coronavirus patients. At several hospitals, research opportunities and elective rotations have been canceled, as residents have been deployed to staff COVID-19 floors.
“Normally, residents, for our educational benefit, will cover the infectious disease floor, will cover the liver floor, will cover the kidney floor to learn about all these acute pathologies,” Wood said. “At some point, the decision was made that the residents would get pulled from all those floors ... and instead, residents would basically just care for COVID patients.”
The cancellation of elective procedures and shift to telemedicine have also translated to a loss of training time for residents, who need to learn critical skills and meet graduation requirements. That’s a source of anxiety among junior trainees, in particular, who haven’t been able to rotate through certain specialties and now fear they may fall behind, said Dr. Fiona Malone, a third-year radiology resident at Brigham and Women’s Hospital.
“We have competencies we need to acquire and skills we need to master on top of the actual day-to-day work we’re doing, and so across the board, this has turned on its head,” Malone said.
At many institutions, caring for coronavirus patients has fallen largely on the backs of residents, new doctors who work under the supervision of attending physicians. Their attendings, however, are not always in the hospital, though they are just a phone call away. Since the pandemic began, residents who normally wouldn’t take care of patients with severe respiratory illnesses, such as those training to be psychiatrists, podiatrists, or orthopedic surgeons, have been asked to volunteer to work in COVID-19 wards. And like all clinicians, they’re learning to treat patients infected with a deadly new virus based on rapidly evolving protocols and research.
“I think, overwhelmingly, it’s been a very positive experience in terms of the camaraderie, and the feeling like we want to do this and want to do this in the best way possible," said Dr. Yannis Valtis, a second-year internal medicine and pediatrics resident at Brigham and Women’s. According to Malone, 40 percent of radiology residents at Brigham and Women’s volunteered to serve on COVID-19 floors. Malone said she “responded within five seconds” of receiving an e-mail from hospital leadership, asking for volunteers.
”This is what we signed up to do — to help with our community and our hospital," she said. Malone said she and her co-residents who also volunteered were motivated to “contribute and especially lessen some of the immense burden of many of [their] colleagues on the front lines.”
But that sentiment isn’t universally shared. Privately, some residents told The Boston Globe that the call from their superiors to volunteer to work in COVID-19 wards felt coercive. Others worry they’re at undue risk of contracting the disease because they spend so many hours in hospitals. Meanwhile, fears of speaking out about their working conditions abound.
“We are in an extremely difficult situation across the country where residents are seeing egregious things happen within their hospitals, they are being put at risk, and then are being threatened when they try to speak up about an issue,” said Dr. Linda Alvarez, national secretary and treasurer of the Committee of Interns and Residents, an affiliate of the Service Employees International Union that represents more than 17,000 medical trainees, including residents from Boston Medical Center and Cambridge Health Alliance. As trainees, they also have little recourse, she said, if they feel, for example, they can’t care for their patients safely.
“When you are matched [as a resident], that’s a binding contract," Alvarez said. "So a resident can’t say, ‘I am not happy with where I’m working. I’m going to leave.’ They are contractually bound there for their education.”
Nationwide, these stresses have triggered a groundswell of activism from residents, many of whom have called on the federal government to cancel their student loan debt or have organized efforts for collecting PPE donations. According to Jonathan Paz, a Massachusetts contract organizer for CIR, interest in unionizing among medical trainees has also spiked. Paz said he fields “one to three inquiries a week from non-CIR residents about the union and its benefits.”
At Massachusetts General Hospital, Dr. Dan Chonde, 35, a second-year radiology resident, started a Change.org petition, asking the state of Massachusetts to extend first-responder death benefits to health care workers. Chonde, who shares a small apartment in Salem with his wife and 2-year-old, said his family lives “paycheck to paycheck,” and he can’t risk leaving them swallowed with debt. The average resident salary in 2019 was $61,200, according to a MedScape survey, and nearly half owed more than $200,000 in student loans. Attending physicians, by comparison, can make five times as much or more depending on their speciality.
“They’re able to saddle us with so much debt because we have so much earning potential. But when we die prematurely, all of that earning potential goes away,” Chonde said.
At Yale New Haven Hospital, Wood wrote an op-ed for The Washington Post, arguing that front-line health care workers, several of whom have died of COVID-19 complications, deserve hazard pay for risking their lives caring for sick patients. Yale New Haven Health has since agreed to offer residents and clinical fellows a one-time bonus of $1,800. (Vin Petrini, a Yale New Haven Health spokesman, said the decision to give trainees a “special COVID-19 achievement award” predated Wood’s column and was made “to recognize the extraordinary work they’ve undertaken in the midst of the pandemic.”)
Residents at Partners HealthCare hospitals, including Mass. General and Brigham and Women’s, also have inquired about hazard pay, but those requests were “quickly shut down," according to Olson, the first-year Brigham and Women’s resident. In a statement to the Globe, Rich Copp, a Partners spokesman, said the hospital system has “opted to provide our workforce a wide range of financial support,” including access to reduced-rate child care, behavioral health assistance, hotel rooms for patient-facing providers, and guaranteed wage protections through June 30.
“We regard serving patients in need as a professional responsibility that we fill as individuals and as a community, even as we recognize that individuals have different reactions about working in different environments,” Copp said, in response to questions from the Globe about the added demands being placed on residents. Copp said resident reassignments are made in order to “avoid excessive fatigue among caregivers" and are based on “patient care needs, provider capabilities, and the caregivers’ other ongoing clinical responsibilities."
Before the pandemic, the risk of depression was high among residents, and feelings of burnout were not uncommon. Residents at several hospitals in the region told the Globe that morale has dipped since the coronavirus crisis upended their lives. Taking care of so many sick patients in the face of so much uncertainty is exhausting. Dr. Eden Almasude, 27, a second-year psychiatry resident at Yale New Haven who reluctantly signed up to work on a COVID-19 floor, said she feels “tired and used.”
“I think around the country, we’re seeing the way that residents are being objectified in a different kind of way, that our bodies are just put out there and they’re using all this heroism rhetoric as a way of avoiding responsibility for the risks of what we’re doing,” Almasude said. “The veil has been pulled back,” she added.
For residents, the emotional burden of tending to fatally ill patients and their families is also heavy. As hospitals crack down on visitors due to the risk of contagion, residents are often their dead and dying patients’ only connection to their loved ones. During a recent 12-hour shift in the intensive care unit, two of Wood’s patients died of COVID-19 within 30 minutes of one another. He had to call their families and gently break the news, steeling his resolve not to cry.
At Boston Medical Center, the staggering death toll from COVID-19 is unlike anything that Dr. Tara Bylsma, 30, a second-year internal medicine resident, has ever seen, with “dozens of patients” dying in the ICU a day.
“It’s so fast and it just happens over and over and over,” she said. “You get numb until you leave the building.”
Bylsma tries to imagine herself from the perspective of her patients, hooked to tubes and wires, while she hovers above them dressed in armor and looking “like an alien." The mask over her mouth garbles any words of comfort she can offer.
“It’s a terrifying, solitary, dehumanizing death that these people go through, and it’s going to leave wounds in our society for a long time,” she said. “That’s one of the hardest things for me.”