One unexpected consequence of the COVID-19 pandemic was the exacerbation of the financial disparity between resident physicians (residents) and allied healthcare professionals (i.e., nurses and non-physician practitioners). By 2020, the American Medical Association (AMA) released guidance and expectations for the well-being of residents as the pandemic began systematically disrupting the American healthcare system. The AMA acknowledged specific financial responsibilities including hazard pay equitable to other healthcare workers. At a time when resident physicians were needed on the frontlines, too often hospital systems excluded residents from equal compensation under the premises of the current student-employee model, the nature of residency as an “apprenticeship,” and the inherent duty to patient care. This posed significant financial vulnerability concerns for residents at a time when other frontline healthcare workers received inflated hazard benefits for providing patient care.

In a survey of 429 U.S. Internal Medicine Program Directors (PDs), only 19.5% of PDs reported hazard pay provisions for their residents.Hazard pay occurred more commonly where PDs supported hazard pay (74.5% vs. 22.1%, p=0.018).Of the PDs who opposed, the most common reason was professional obligation.Even asking for hazard pay was taboo. An exposé published in The New Yorker described the tense situation between residents who circulated a letter in support of hazard pay and the administration at New York University (NYU) Langone.In the article, residents were genuinely worried about retaliation for bringing up their hazard pay concerns. NYU Langone eventually offered a compensation package, but it excluded residents and fellows. My program had a similar response to resident/fellows, offering a 3% salary increase and bonuses to guarantee staff retention but excluded doctors-in-training. Similar exclusionary stances led to a profound dissatisfaction with current salaries according to a Medscape survey of resident physicians. Nearly 6 in 10 residents felt they needed to be adequately compensated and did not believe their salaries reflected the number of hours worked or was comparable with what other medical staff were paid.Could you blame them? Travel nurses were making, on average, $3,000-8,000 per week (more than a month’s salary for a doctor-in-training) while working fewer hours. Interestingly, at the height of the pandemic (2020-21), residents and fellows experienced the lowest percent change in their salary, a 0.6% ($358) increase from the previous surveyed year (see table).4

Hospitals were overwhelmed with patients and hemorrhaging money to retain staff; yet doctors-in-training saw the smallest change in salary in greater than 50 years? This demonstrated that the Medicare Graduate Medical Education (GME) system wrongly presumes that GME payments for claims made by hospitals will pass through to the residency programs. The Coronavirus Aid, Relief, and Economic Security (CARES) Act funds were set up to defray losses in health care to hospitals but did not specify any assistance to the GME; thus, the funds likely were used to meet non-GME shortfalls instead of boosting resident wages or funding hazard pay.The only GME funding proposed by Congress was the 2021 Consolidation Appropriations Act which acknowledged the physician shortage with funding for future expansion in residency program positions but did not address an increase in salary per resident.

Fortunately, resident physicians did not have to worry about loan repayment. The CARES Act temporarily put federal loans into forbearance, and interest rates froze. This helped thousands of residents count $0 monthly payments towards their Public Service Loan Forgiveness (PSLF). On August 24, 2022, President Biden announced student debt relief that would grant up to $20,000 in debt cancellation to borrowers with annual income during the pandemic of under $125,000 or under $250,000 who received a Pell Grant in college. While the debt relief bill continued into litigation, the COVID federal loan forbearance remained in effect, extending beyond its initial expiration date.

The COVID-19 pandemic led to significant financial well-being concerns for resident physicians. The healthcare system relied heavily on residents and fellows to be frontline workers, but they were often excluded from hazard compensation. The 2021 Consolidated Appropriations Act will only expand the number of residency spots but it’s unlikely to see any increase in residents’ salaries. Further reform must address the wage gap between training physicians and other allied healthcare workers. With the pandemic exposing vulnerabilities within the student-employees model, a growing interest in unionization has come into the limelight. It will be interesting to see the exact impact, if any, these financial concerns have on GME funding over the next few years.

References

  1. Uthlaut B, Catalanotti J, Kisielewski M, et al. Hazard pay for internal medicine resident physicians during the COVID‐19 pandemic: A national survey of program directors. J Hosp Med. 2022 Feb;17(2):104-111. doi:10.1002/jhm.12784.
  2. Gross DA. What happened when medical residents asked for hazard Pay. The New Yorker. https://www.newyorker.com/science/medical-dispatch/what-happened-when-medical-residents-asked-for-hazard-pay. Published October 8, 2020. Accessed May 15, 2023.
  3. Martin KL. Medscape residents salary & debt report 2020. Medscape. https://www.medscape.com/slideshow/2020-residents-salary-debt-report-6013072?faf=1#1. Published August 7, 2020. Accessed May 15, 2023.
  4. Resident Stipend Survey Staff. AAMC survey of resident/fellow stipends and benefits. AAMC. https://www.aamc.org/data-reports/students-residents/report/aamc-survey-resident/fellow-stipends-and-benefits. Published November 2020. Accessed May 15, 2023.
  5. Keneally RJ, Frazier HA, Berger JS. COVID-19 and graduate medical education trainee protections and finances. J Grad Med Educ. 2020 Dec;12(6):647-650. doi:10.4300/JGME-D-20-01295.1. Epub 2020 Dec 18.

Issue

Topic

COVID-19, Health Policy & Advocacy, SGIM

Author Descriptions

Dr. Kahn (Cameron.kahn@jax.ufl.edu) is a PGY-3 internal medicine resident at the University of Florida College of Medicine, Jacksonville, FL

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