Tehmina Ahmad is a third-year Internal Medicine Resident at the University of Toronto.
The emergence of coronavirus disease 2019 (COVID-19), an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has shifted healthcare resources, changed hospital structures, and created unique working conditions for resident doctors. However, there are no national guiding principles to address training limitations and the consequent stressors faced by resident physicians during pandemics.
It was not until the AIDS epidemic in the 1980s that publications began to explore the vulnerability of trainees and challenged the ‘duty to treat’ in light of perceived risks. Although there have been several epidemics over the past few decades before COVID-19, including Severe Acute Respiratory Syndrome (2003), H1N1 flu (2009), Middle East Respiratory Syndrome Coronavirus (2013), Ebola (2014) and Zika (2016), scant literature exists to capture resident experiences during epidemics and pandemics and resident physicians – who are valuable and sometimes ill-protected frontline workers in times of crisis – remain under-recognized in the literature.
Residents are left particularly vulnerable when it comes to negotiating as a labor force. Our status as trainees limits our influence over the environments in which we are deployed to work during infectious disease outbreaks. As preparations for COVID-19 began across the country, with the first hospital case of COVID-19 in Canada on January 15, 2020, it became clear that, at any moment, patients with COVID-19 might overwhelm our hospitals. Many residents have been asked to assume roles and redeploy to departments that are not necessarily part of their specialty training. This has been characterized by on-the-job acquisition of skills in a time of dynamic uncertainty. Yet time spent providing COVID-19 care may not be credited by specialty programs, which had led to resident concerns about potential delays and extension of training when routine clinical duties resume.
Resident doctors play a dual role as students engaged in structured educational programs and as highly skilled professionals. However, as frontline workers, residents are placed in high-risk situations for COVID-19 exposure, particularly with the current landscape of changing personal protective equipment (PPE) requirements and potential PPE shortages. Most employees can refuse to do unsafe work without the danger of discipline if the employee has a reasonable basis to believe the work to be unsafe – this is enshrined in Ontario’s Occupational Health and Safety Act (OHSA). However, the Professional Association of Residents of Ontario (PARO) has made residents aware that under the OHSA “employees who work in hospitals are not allowed to refuse unsafe work if the danger is inherent in the work or the refusal directly endangers the life, health or safety of another person.” This has worrisome medico-legal implications. Our professional house staff organization has been pushing for solutions from our employers (that is, hospitals) to state that, if a hospital is unable to provide appropriate PPE and the resident physician feels that it is unsafe to provide care, even where the refusal to provide care endangers the life, health or safety of another person, that the resident will not be subject to any disciplinary measures. Currently, there are no firm assurances from our regulators or guiding principles regarding the outcome of any future complaints against resident physicians’ refusal to provide care when life or limb in imminent risk in unsafe situations without PPE.
Residents are at increased personal risk due to the hierarchical learning environment itself – even without the additional stressors of the pandemic. Although we are all physicians, not all physicians are equal. Inherent power differentials may foster overt and covert intimidation tactics that can lead to workplace mistreatment in residency. Bullying in residency can occur through unevenly distributing workloads, unfair assignment of administrative tasks, or the allocation of junior physicians to potentially hazardous situations. Residents often do not report this behaviour for fear of retaliation or lost career opportunities, and to protect their learning experience. With COVID-19 producing a unique set of physical, financial, and emotional stressors particularly from cognitive burdens of hygiene vigilance, there is a sense of increased risk-tolerance in our duty as professionals. This may lead to learner mistreatment going unnoticed. Junior residents may be expected to manage riskier COVID-19 situations based on orders delivered from the top-down. Given that programs across the country are rolling out different COVID-19 redeployment strategies, there is no standardized framework for who, and with what duties, should assume the brunt of the added risk.
Although we stand unified on the frontline for our patients, a national guideline to safeguard and empower residents responding to COVID-19 is much needed. Striking the right balance between education, clinical duties, and our vulnerabilities as students and professionals will be essential to future pandemic planning.