COVID-19: Residents, fellows need physical and financial protection

With more than 135,000 residents and fellows in the workforce, physician trainees make up a large portion of those on the front lines fighting against COVID-19. It’s also a segment that has unique vulnerabilities in terms of its limited autonomy within the health care system.

Taking those vulnerabilities into consideration, recent AMA guidance offered key points to protect residents and fellows on a number of fronts during the pandemic, including physical safety, financial and emotional well-being and the preservation of their education.

“As part of their training, residents and fellows across the country are being heavily relied upon as essential front-line care givers during the COVID-19 pandemic—often assuming roles that aren’t typical to residency training. It is vitally important that residency programs and sponsoring institutions are taking action to ensure these physicians-in-training are kept safe and supported personally and financially throughout the course of the pandemic,” said AMA President Patrice A. Harris, MD. “We encourage residency programs to look to this guidance and put measures in place that will protect residents and fellows as they care for patients on the front lines of the pandemic and simultaneously complete their medical training.” 

The AMA has also offered guidance for protecting medical students during the COVID-19 pandemic.

With residents from all disciplines being pulled into the emergency departments and intensive care units to treat patients who have contracted the COVID-19 virus, they are at high risk for exposure.

“We have heard anecdotal reports of residents being asked to see patients who haven’t been screened [for COVID-19] or to evaluate patients in the absence of adequate personal protective equipment,” said John Andrews, MD, the AMA’s vice president for GME Innovations. “It’s a concern residents have, so we need to articulate clearly that it is our expectation that they have appropriate access to personal protective equipment and instruction in its use.”

Other key points related to resident and fellow health and safety include:

• Residents must be free to raise concerns about their personal safety and the safety of those around them without recrimination or consequence to their employment and training.
• Residents deployed to clinical areas unfamiliar to them must receive appropriate training and supervision for the tasks they will be asked to perform.
• Residents who become ill as a result of their participation in the COVID-19 response must not be required to use vacation or personal time off while ill or quarantined. Residents who require leave under these circumstances must continue to receive their salary and benefits.
• Residency programs must continue to comply with the Accreditation Council for Graduate Medical Education (ACGME) requirement to provide access to confidential, affordable mental health assessment, counseling and treatment.

The day-to-day activities of just about any trainee have changed. Residents from all specialties are being called upon to work on wards and in emergency departments, while some fellows are being asked to work as attending physicians. Because of that, residents and fellows are left wondering how the pandemic will affect their ability to train.

“We want to be sure that the contribution that residents and fellows make in the care of patients in responding to COVID-19 is seen as valid experience toward their certification and independent practice,” Dr. Andrews said. “It’s important that’s considered. We also recognize that in many disciplines access to relevant clinical experience like elective surgeries, out-patient clinical visits and consultations may be limited. To the degree possible we hope that disengagement from those experiences during the pandemic response doesn’t delay or unnecessarily prolong the period of training for those residents and fellows.”

Among the key training-related guidance the AMA is calling for:

• Clinical work that residents perform during the pandemic response should be considered in assessments of a trainee’s qualifications for program completion. Where possible, credit should be given for the work residents are doing during this time.
• That bodies overseeing certification requirements, in light of the pandemic, should allow flexibility in assessments of the competence of trainees. Where possible, these assessments should not delay program completion nor eligibility for certification.
• Residents should be permitted to remain in their programs to complete necessary requirements that qualify them for board certification. They must continue to receive salary and benefits and have access to necessary clinical experiences.

The economics of training to be a physician are complicated. Medical school creates a significant debt burden for physician trainees—federal loans are being temporarily put in forbearance under the CARES Act—and relative to the vast majority of the health care workforce, residents and fellows are undercompensated.

Factoring in the financial obstacles many trainees are facing, the AMA calls for:

• Residents to be candidates for hazard pay in a way that is equitable to other health care workers.
• Residents to be granted forgiveness or forbearance for all or portions of their student loan debt to ease the financial stress they may experience in caring for themselves and their families.
• Fellows who assume attending physician roles in core disciplines in which they are licensed and certified to receive pay and benefits commensurate with these roles. The impact of this activity on progress toward completion of the training program must be openly discussed with fellows prior to them assuming these responsibilities.
• The Centers for Medicare & Medicaid Services (CMS) to ensure flexibility in GME reimbursements to hospitals to accommodate variations in training due to the COVID-19 response. This flexibility should lengthen the initial residency period (IRP) for residents to allow them to extend their training, if necessary, to meet program and board certification requirements.
• In the event of program contraction or closure that may result from the pandemic response, disruptions to resident education may be mitigated through active planning for resident relocation. In the event of closures, the AMA stands with other organizations ready to assist should the need arise.

The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time.