As Covid-19 surges in some cities and across the country, it has subsided in New York City, where we live and work. Here, health care workers breathe collective sighs of relief, though we continue to do so through masks and behind face shields.
Hospital hallways are empty, yet heavy with the sadness of lives lost.
For doctors in training like us, often heralded as “soldiers” and “heroes,” the coronavirus “war” feels far from over. Though we are relieved that cases have decreased in New York, feelings of fear and anxiety remain. Not being acknowledged for the work we did and the trauma we faced leaves us feeling used and forgotten.
A few months ago, we were asked to put our health and well-being on the line for our patients. And that’s what we did.
While sacrifice is expected in the culture of medicine, the psychological and physical harm that has come with Covid-19 is unprecedented. We don’t derive satisfaction from being idealized as battlefield heroes. And many residents like us received no concrete benefits or compensation for the work we did with minimal protection and support.
Not only does it feel that our recent sacrifices have been forgotten, but we wonder if we will again be called to duty during a second wave of Covid-19, once again without the necessary personal protective equipment or support for our lingering exhaustion. We just don’t know if we can recover for another round with Covid-19.
Researchers from Columbia University surveyed health care workers in New York City during the peak of Covid-19 in April to explore the psychological symptoms of physicians, residents, fellows, nurses, and advanced practice providers. They discovered that 57% of those surveyed reported symptoms of acute stress, 48% reported symptoms of depression, and 33% reported symptoms of anxiety.
Most impressive was the overwhelming concern for risks outside of the clinical space. A whopping 74% said they were worried about transmitting Covid-19 to family members and 71% worried excessively for the health of their family and friends. Slightly more than half of the health care workers surveyed showed interest in individual or group counseling.
So during the peak of the pandemic in New York City, and other cities as well, health care workers were not only battling a deadly virus but also substantial mental health issues. Managing them is complicated by the fact that the culture of medicine encourages physicians to just “suck it up,” and that there is no confirmed end to the pandemic: Healing emotionally feels impossible when you fear facing the same trauma all over again.
The survey echoed what we felt as residents working in a public hospital in New York City: Concern for our loved ones compounded our fear for our own health. Lack of personal protective equipment and administrative disorganization needlessly heightened our anxiety. We scrambled to get personal protective equipment, sometimes having to beg for it. We lost cherished colleagues to Covid-19, and were angry knowing that they did not have adequate protection themselves.
We both fell ill at a time when testing was not yet available. We were faced with terrible uncertainty: Was it Covid-19 or something else? It felt as though we did not have a right to know if we had the illness we were treating. One of us (G.H.) had Covid-19-like symptoms twice and then tested negative for antibodies, which caused chronic confusion and self doubt. The other (A.E.S) was very ill, and tested positive for Covid-19 antibodies, but the fear that the titers might not last meant that there was still no peace of mind.
The psychological impact of Covid-19 on health care workers has been significant. Yet residents — doctors in training — are particularly vulnerable to it. In the hierarchy of hospitals, residents are at the bottom, with little autonomy. They are expected to take on a disproportionate chunk of the workload caring for patients in exchange for liability-free training. They are compensated at a rate just over minimum wage. While dangerously long work hours came under scrutiny just after the turn of the century (see the Libby Zion case), residents remain among the lowest-paid clinicians by the hour.
The response to the pandemic increased the already overflowing responsibilities of residents and extended their work hours. Their direct contact with patients was higher than that of supervising physicians due to their long on-call shifts and the reliance on residents to provide most of the face-to-face physician-based care care when necessary.
Some have opined during this pandemic that, as physicians, we should have known and accepted the risk of working in a hospital. That might hold true for attending physicians, but it’s essential to note that residents have little choice in the work they do.
During the pandemic, many residents were redeployed to other specialties to meet the needs of a burdened health care system. One of us (A.E.S.), a psychiatry resident, was deployed to a Covid-19 unit, managing patients on ventilators and prescribing medications with an extra dose of prayer. That wasn’t unusual. Residents training for a range of specialties — from pediatrics to dermatology to radiology — suddenly found themselves in overcrowded intensive care units caring for patients with Covid-19.
We may have received some appreciated applause and freebies for the hard and extra work we did, but we didn’t receive financial compensation for it.
Most residents, struggling financially under the massive burden of student loans, were barely making do before the pandemic. On a resident’s salary, renting a car to ensure safe transportation to and from the hospital is impossible. Taking public transportation puts us and our patients, colleagues, and family members at risk daily. Many residents are still paying out of pocket for child care as they spend hours at the hospital meeting the country’s health care demands. The cost of psychotherapy is exorbitant, leaving many residents unable to process their trauma and ongoing anxiety.
In an effort to support health care workers through this challenging time, some hospitals offered hazard pay. The U.S. Department of Labor defines hazard pay as “additional pay for performing hazardous duty or work involving physical hardship.” Work that causes extreme physical discomfort and distress “which is not adequately alleviated by protective devices is deemed to impose a physical hardship.” That pretty much sums up the work residents have been doing in hospitals since the pandemic began.
Residents training in hospitals with limited resources, like the public hospital we work in, did not have the same support as residents working at private hospitals. Wealthier hospitals were more likely to provide some semblance of hazard pay, in addition to providing resources such as transportation and food.
Covid-19 has illuminated the inherent health and financial disparities rampant in our communities, which are directly reflected in a hospital’s ability to provide for its employees. In New York City alone, several private hospital systems gave their residents hazard pay throughout April, from an extra $1,000 to $2,000 to bumping up residents early to their next salary level. Residents working for public hospitals, who cared for some of New York City’s most ill and impoverished citizens, were not supported like that.
Hazard pay would comprise only a small part of helping pandemic health care workers heal. While the unequal distribution of financial support excluded many health care workers, even those who were compensated received little compared to the magnitude of the sacrifice they made and continue to make.
The expectation that health care workers should give endlessly to their communities because they chose a career in medicine is a dangerous one. These workers are already burnt out and are in danger of becoming completely depleted.
If one goal of medicine is to prioritize patient safety, we must acknowledge the harm that has befallen health care workers and recognize it as a barrier to optimal patient care. Wounded clinicians cannot care adequately for their patients, especially facing an illness as taxing as Covid-19.
Although clinicians like us are often expected to be infallible — something we strive to achieve — we are human. We need help overcoming trauma just like anyone else, though few resources have been offered to help us heal. As a country, we need to acknowledge the mental health symptoms that Covid-19 is leaving in its wake and find solutions to revitalize Americans — including health care workers — while we still can. Without the proper support, residents and other clinicians cannot be expected to sacrifice so greatly for an indeterminate amount of time. Our healing must be prioritized too, so we can continue to provide the level of care our patients deserve.
Alex El Sehamy is third-year psychiatry resident at SUNY Downstate Medical Center. Gali Hashmonay is a fourth-year psychiatry resident at SUNY Downstate Medical Center.