Three resident physicians died last week from COVID-19 and are the first known deaths of medical trainees in the United States. Dr. Chris Firlit, a 37-year-old oral surgery resident from Detroit, died from complications of COVID-19. He leaves behind his wife Sylvie and three children, Alexander, Viktor, and Katerina. Sadly, we know residents like Dr. Firlit will not be the only ones to lose their lives in this pandemic. Unbeknown to many, young doctors are among the least powerful and lowest compensated healthcare workers in America and face an alarmingly high risk of exploitation.

When you are a patient in a hospital, it can be difficult to distinguish between your doctors by level of training. You might be surprised to learn that the doctor you interact with most is a resident. Residents are physicians who have completed an undergraduate degree followed by four years of medical school and are undergoing on-the-job training before they can practice independently. They are responsible for the majority of direct patient care in academic hospitals, with oversight by attendings. Attendings have completed their residency and are independently practicing board-certified physicians. Residents routinely work 80 hours per week and receive a stipend of about $60,000 per year, equaling roughly $14 per hour. Residency training can last anywhere from three to seven years, depending on specialty. During this time, doctors make close to minimum wage, accrue interest on hundreds of thousands of dollars of student debt, and lose significant earning potential compared to peers in other fields. In our current system, completing residency is the only path to practicing medicine independently in America.

So why do hospitals sign up to provide on-the-job training for residents? Simply, they are cost-efficient labor. They are the workhorses of the hospital, working the longest hours for the lowest pay. Numerous studies have demonstrated that replacing residents with attendings would significantly increase cost to hospitals. Even reducing the number of hours that residents work from 80 to 60 hours per week would cost a hospital millions of dollars in additional staffing.

Prior to COVID-19, a resident would not be expected to take care of infectious patients without proper protection. They would not treat someone with active tuberculosis without wearing an N95 mask, nor would they perform an invasive procedure on an HIV positive patient without gloves. During this pandemic, however, hospitals are no longer providing essential safety equipment. Residents are expected to care for these patients without N95 masks (the gold standard per CDC guidelines) and instead are given single-use droplet masks, which may not provide adequate protection. Often, they are forced to wear these masks for days when the manufacturer recommends a maximum of four hours.

To make matters worse, in many hospitals, healthcare workers are “reported” for wearing their own protective equipment during the pandemic. While attending physicians can easily advocate for themselves, residents’ futures rely heavily on the subjective evaluations of their colleagues. 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.

While some attending physicians are choosing not to work amid dire supply shortages of personal protective equipment (PPE), residents do not have the freedom to make this decision without severe personal and professional repercussions. An extreme power differential exists. If a resident chooses to leave a training program, even because they feel unsafe or unprotected, the process to find a new program can take months or years. Leaving a residency program is generally seen as a “red flag” to future programs. If a resident decides to leave residency all together, they will be saddled with insurmountable debt and no clear path to future employment as a physician. For many, this makes residency feel more like indentured servitude than true apprenticeship.

When doctors complete medical school, they take an oath to care for the sick, and they take this oath very seriously. For most doctors, medicine is a calling. It is this drive to care for the most vulnerable that fuels them to endure one of the most difficult and costly professional training programs in existence. Throughout this pandemic, residents have been reminded that it is their “duty” to care for these patients. Having sacrificed their income, relationships, and even health to care for patients, these young doctors are deeply committed to this duty. If they choose to opt-out of caring for COVID-19 patients, because of risks to themselves or their families, it can take a significant psychological toll. They are made to feel like they’ve broken a sacred oath, calling into question their identities as young physicians.

People who maintain that residents should abide by their oath regardless of protection conveniently forget an essential part of that oath: “First, do no harm.” Caring for COVID-19 patients without adequate protection can cause harm. You run the risk of contracting the virus and unknowingly infecting others. You transform from healer into a vector of disease. While residents take an oath to care for the sick, caring for patients infected with a highly virulent pathogen without adequate protection does not reflect the spirit in which that oath was written – in fact, it does the opposite.

Residents are being sent to fight a war with no protection, no power, and no voice. They are fighting this war diligently but invisibly. The general public is largely unaware of these soldiers and how they are used on the frontlines. We are exploiting our lowest paid and hardest working doctors and asking them to shoulder the greatest risk without adequate protection. We are sacrificing our youngest, most vulnerable physicians without their consent and calling them heroes. As talk circulates of graduating medical students early so that they too can care for COVID-19 patients the moment the Hippocratic Oath leaves their lips, we must ask ourselves, is this how we treat our heroes?

This article represents the authors’ opinions about a national problem and does not reflect their personal experiences at their home institution. For additional reference, see the article published by the American Medical Association.

Constance Chace, Supraja Thota, and Milla Kviatkovsky are internal medicine physicians.

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