The following is an editorial in the American Journal of Bioethics, March 2022 issue. It can be found here: https://www.tandfonline.com/toc/uajb20/current
As face shields are dusted off and conferences go virtual again, Omicron reminds us how the once-novel coronavirus ruptured our collective idea of medical training. For nearly 2 years, social media and press depicted house staff grappling with the privilege—and burden—of responding to crisis standards as physicians-in-training. While this surge in the COVID-19 Pandemic continues to highlight the positive inclinations of residents to serve, it also raises important questions regarding their safety and agency that should be revisited.
The initial outbreak of the virus in March 2020 occasioned a crisis response among academic medical centers, necessitating emergent deployment and reassignment of available clinicians across all levels to meet dire need. House staff constituted a significant portion of this ad-hoc response, with many programs invoking Pandemic Emergency Status through the ACGME, allowing substantial institutional discretion in determining the roles of residents (ACGME 2020). As the inpatient burden subsided in the following months, hospitals moved toward more sustainable staffing methods.
The current surge, which is expected to linger, raises the familiar dilemma of how to best meet the needs of a rapidly climbing in-patient population. Residents once again represent a seemingly ready workforce. In recognition of this impulse, the ACGME has sought to enact certain safeguards (ACGME 2020). While important, such safeguards alone may prove insufficient if those in academic leadership fail to consider what constitutes a just (and not merely efficient) utilization of house staff.
Justice is one of the central principles of medical ethics and can be succinctly defined as “rendering [to others] what is due” (Pellegrino and Thomasma 1993). Its practice is coupled with the presence of relational vulnerability (Have 2016). For example, the inherent vulnerability of the sick grounds the need for justice in the patient-physician relationship, whereby the physician must act in unconditional accordance with the patient’s good.
By virtue of their social and economic standing, physicians are typically understood to be a population with relative power; however, within the hierarchy of academic medicine, resident physicians occupy a position of relative vulnerability. Residents are subordinate to attending physicians, program directors, and institutional leadership with little opportunity for role negotiation or recourse in the face of inappropriate demands. Moreover, resident physicians have limited ability to exit a program that they deem unjust. This vulnerability is simultaneously coupled with competency and significant instrumental value. As licensed physicians sufficiently trained to make diagnostic and therapeutic decisions with some degree of autonomy, residents are a valuable clinical resource, particularly in moments of increased strain on health systems.
During typical times, the combination of relational vulnerability and instrumental value embodied in the resident is generally held in balance. Labor expectations and accrediting body guidelines are clearly delineated and cannot be manipulated arbitrarily by those in positions of authority, protecting residents while ensuring the efficient use of their skills. Yet in moments of extreme medical need, both the vulnerability and the value of residents are significantly increased to a degree that renders them uniquely susceptible to unjust use.
The current COVID-19 surge is a clear instance of such extreme need. As staffing considerations arise, decision-makers should acknowledge and attempt to ameliorate three prominent vulnerabilities that may compromise the just utilization of residents.
First, the infrastructure of residency situates house staff as an especially capable workforce for deployment during a crisis. Residents are versatile clinicians, accustomed to working long and irregular hours; they are conditioned to accepting directives rather than questioning their validity or fairness. House staff can be mobilized rapidly at the discretion of their supervisors and lack forceful institutional mechanisms for refusing or appealing unjust demands. This differentiates residents from autonomous physicians or advanced practice providers (APPs), for whom varying degrees of volition are preserved and alternatives (including outright refusal) are generally available.
Second, preferential deployment of residents to care for patients with COVID-19 reduces the already limited training time dedicated to clinical roles specific to their future practice. Unlike APPs or attending physicians, residents do not function solely as clinicians. Residency serves the purpose of preparing trainees for autonomous practice in a predetermined specialty area. Utilizing house staff in clinical roles that contribute minimally to their future practice detracts from time necessary to develop the skills required for that future practice and undermines the educational mission of residency. This consideration requires increased weight when a crisis persists over an extended period of time.
Finally, house staff salaries are predetermined and do not admit the possibility of subsequent negotiation. This means that residents are generally ineligible for hazard pay or other incentives potentially available to attending physicians or APPs caring for patients with COVID-19. During normal times, the fixed salary is generally regarded as fair, since residents benefit from the costly educational offerings of a residency program and are exposed to relatively stable and known risks. However, during a crisis that simultaneously corrodes educational opportunities and presents elevated and uncertain risks, maintaining a fixed salary exposes residents to uniquely unjust use. While institutions can deploy residents at minimal cost, the resident pays a threefold cost in lost hazard pay, lost educational opportunity, and increased risk.
To ensure the just use of residents during crises, we must consider what they are “due,” given the unique demands of each particular crisis. It is challenging to propose specific prescriptions for such a complex question, but the three aforementioned vulnerabilities correspond to principles that should guide the utilization of house staff during the COVID-19 Pandemic in order to ensure their just use.
First, house staff should be provided an explicit, legitimate right to refuse reassignment if such refusal is available to other nonresident clinicians. Providing this option to some clinicians but not others, without compelling justification, is unjust, and it is particularly unjust if those that are denied the opportunity to refuse occupy positions of relative disempowerment.
Second, given residents’ educational commitments, a higher threshold should be required when considering their reassignment relative to attending physicians and APPs. While clinical responsibilities for all medical practitioners may increase during a crisis, this does not mean that the degree or type of increase among distinct categories of clinicians should be equivalent. Several months caring for COVID-19 patients constitutes a small portion of a career for those who have completed formal training, but a similar length of time represents a substantial impact on trainees in the midst of limited and finite training periods.
Finally, if academic medical centers deem it necessary to financially incentivize APPs and attending physicians for staffing patients with COVID-19, then residents should similarly benefit from enhanced compensation. Though the degree of such incentives may vary, it is incongruous and unjust to provide these benefits to clinicians who can reasonably refuse and are not losing educational opportunities while withholding the same benefit from residents.
These considerations may be met with opposition from those responsible for clinician reassignment. In such instances, transparency is critical. Documentation of such decisions will ensure that retrospective review is possible, allowing institutions to identify and address injustices that inadvertently occurred due to exigent circumstances.
Residency during the COVID-19 pandemic has been described as a “terrifying privilege” (Salari 2020)—one which accords sick and fearful patients the competent and compassionate doctoring they are due. But the just care of patients should not and need not come through the unjust use of resident physicians.