Guiding principles to protect resident & fellow physicians responding to COVID-19

This article is part of a series of COVID-19 articles and resources on medical education.

There are over 135,000 residents and fellows (“residents”) working in graduate medical education (GME) programs in the United States. They are participating in supervised clinical experiences that will qualify them for certification and independent practice in a wide array of medical specialties. While acquiring this experience, residents are the frontline physician workforce in the health systems that employ them.

During the response to the COVID-19 pandemic, residents are experiencing personal, physical and economic stresses. Many of these stresses are common to all health care workers affected by the pandemic; some are unique to their status as employed trainees. These include the following:

• Residents are on the front lines during the COVID-19 response and like other health care workers, such as first responders and ED nurses, experience some of the highest risk situations for exposure and have the same need for personal protective equipment (PPE). They are at personal risk, and their work creates a risk to family members. Residents themselves may become ill and/or require quarantine while caring for COVID-19 patients, and residency program leave policies may not adequately account for these unplanned absences during the pandemic response.
• During the response to COVID-19, many residents are being asked to assume roles that are not a prescribed part of their specialty training, being deployed to medical units and emergency departments from their roles in operating rooms and outpatient clinics. Their preparation for these roles is variable, and residents may be compelled to acquire skills on the job that were not an expectation when they began residency. Furthermore, time spent providing these services may not meet the requirements for graduation and certification in their discipline, leading to concerns that their training may need to be extended when routine clinical duties resume.
• Some subspecialty fellows are being asked to serve in attending physician roles in their core disciplines (e.g., gastroenterology fellows serving as general internal medicine attending physicians). While they may be board certified in these specialties, their compensation and malpractice coverage may not be commensurate with the role.
• Resident salaries are low compared to those of other health care workers, particularly on an hourly basis. Given average resident salaries and an 80-hour work week, resident salaries equate to approximately $15 to $20/hour. In addition, residents carry significant debt loads related to their undergraduate medical education. The average student loan burden at medical school graduation exceeds $200,000.
• Residents are particularly vulnerable in their negotiating ability as a labor force. Although they are employed health care workers, their status as trainees makes them dependent upon their employer for their professional development. As such, their influence over the environment in which they work is limited.

In managing the engagement of residents during the response to COVID-19, the AMA Council on Medical Education strongly supports observance of the following principles by programs, sponsoring institutions and national organizations:

1. Residents must be actively engaged in COVID-19 response planning regarding deployment of health care workers, including field promotion of fellows to attending roles, in order for the specific interests of trainees to be considered.
2. 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.
3. Residents must have access to, and instruction in, the use of adequate personal protective equipment (PPE), as should all health care workers.
4. Residents deployed to clinical areas with which they are unfamiliar must receive appropriate training and supervision for the tasks they will be asked to perform.
5. Residents who become ill as a result of their participation in the COVID-19 response must not be required to use vacation and/or personal time off while ill and/or quarantined. Residents who require leave under these circumstances must continue to receive their salary and benefits.
6. Sponsoring institutions and 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, including access to urgent and emergency care 24 hours a day, seven days a week.
7. The clinical work that residents perform during the pandemic response must 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.
8. The ACGME review committees (RCs), the American Board of Medical Specialties (ABMS) specialty boards and the American Osteopathic Association (AOA) specialty boards should consider their program and certification requirements, in light of the pandemic, to allow flexibility in assessments of the competence of trainees. Where possible, these assessments should not delay program completion nor eligibility for certification.
9. Residents must 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.
10. Residents should be candidates for hazard pay in a way that is equitable to other health care workers.
11. Residents should be granted forgiveness and/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. This is particularly important during this time of compromised access to opportunities to supplement their income, such as moonlighting.
12. Fellows who assume attending physician roles in core disciplines in which they are licensed and certified should 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.
13. The Centers for Medicare & Medicaid Services (CMS) should 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 addition, CMS should expand the residency funding cap at institutions where residents must extend their training, in order to support an increased number of residents, as new trainees begin, while existing trainees remain to complete their programs.
14. As hospitals and health systems confront the economic impact of the pandemic response, we urge early consideration of effects on the training environment and the sustainability of GME programs. Health systems should also proactively manage opportunities for residents to continue their professional development.
15. 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.

• AMA guiding principles to protect learners responding to COVID-19 
• Medical education COVID-19 resource guide 
• COVID-19 resources for medical educators

The AMA is an active member of the Coalition for Physician Accountability (CPA), a group of national organizations who oversee accreditation of programs and licensure & certification of physicians throughout their medical career. The CPA has tasked workgroups to urgently address the disruptions that have occurred in medical education, training and credentialing as a result of the pandemic response. The AMA will work to advance the principles in this statement through its engagement in that effort.