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As the coronavirus epicenter has slowly moved around the world—first in Wuhan, then in Italy, now in New York City—Americans have had the slight benefit of watching other countries try to handle the worst as we prep for our hospitals to be flooded with patients. The Italian government, for example, has taken extraordinary steps to mitigate the spread of COVID-19 and to support its ailing health system. Among them was a bold decision to graduate final-year medical students early. Reuters reported that students there would be staffed at outpatient clinics, so the more experienced could surge toward hospitals in hot spots to care for patients with COVID-19.
It seems that now some of America’s medical schools are planning to do the same. Last Wednesday, Brief19 broke the story of New York University’s plans to graduate its fourth-year medical students early to work in its emergency departments and wards. The next day, Albert Einstein College of Medicine, based in the Bronx, announced similar plans for students to staff its hospitals as stand-in residents. By the end of the week, more schools in New York joined them, along with Uniformed Services University (the military’s medical school) and most medical schools in Massachusetts.
As a fourth-year medical student myself, I felt a turbulent mix of emotions when I first heard this news. Pride interspersed with worry, for my colleagues who may now find themselves on the front lines of a pandemic sooner than we all expected, but with dwindling access to personal protective equipment. Empowered that, if I were to receive the call, I would be able to rise to the challenge and help the patients in our hospitals who need it most right now. Anxiety that I might fall short of what may be asked of me. Fear for our society, knowing that fourth-year medical students have to be among the last untapped reservoirs of health care workers left to keep our hospitals running. A friend of mine privately compared the news to conscription. I thought they may have been overreacting, until I learned that Gov. Andrew Cuomo of New York actually used the word draft when describing his plan to call medical and nursing students, alongside retired medical professionals, into action.
Frustration, however, seeped into those emotions too, as I read into the details of what some medical schools were asking of their students. Other than what Italy has done just weeks ago, the decision to graduate medical students early has no obvious modern precedent. All bets, it appears, are off. NYU’s ask, to take an example, seems reasonable: It is offering its students pay that is typical of a first-year resident, alongside benefits like health insurance, while making the request entirely voluntary. Students there, famously, also don’t pay tuition. Einstein’s ask, on the other hand, was tone-deaf at best and exploitative at worst. In an email to students, it announced that fourth-years are expected to return to clinical duties on April 6 and to work effectively as residents on either a COVID or non-COVID ward. None of its students would actually graduate early. Nor would they be paid. Instead, they’d actually be paying tuition to work in their hospitals in the middle of a pandemic.
To its credit, Einstein walked back part of its demand after facing significant criticism, making it voluntary. But the taste of the initial request still lingered. The school still has not waived or prorated tuition, nor has it offered any pay for students. Any discussion of benefits or assurances of adequate health insurance were conspicuously absent (although Einstein, according to its website, does require its students to carry basic health insurance). School officials said PPE would be available, but it’s difficult to ignore the warnings issued by political leaders in New York that suggest it’s rapidly running out. In digital communities like r/medicalschool on Reddit, unverified rumors abound of schools in places like California and Michigan following Einstein’s initial lead, forcing their students into the wards before they leave for their residency programs, without repaying their tuition or figuring out how to pay them.
And yet I can imagine that many medical students would still consider these offers. It’s in our nature. For the past few weeks, the vast majority of medical students have been dismissed from hospital rotations, per the recommendation of the Association of American Medical Colleges. Outside the hospital, however, many have found ways to help in the fight against COVID-19. Students have translated fact sheets about the virus into dozens of languages, organized to provide child care for resident and attending physicians on the wards, manned telephone hotlines to answer questions about COVID-19, collected public donations of personal protective equipment, and published briefings that distill the findings of the vast research literature on COVID-19 for front-line health care workers. At my institution, students have volunteered with our local public health department to help perform the grinding, necessary tasks of epidemiology to counter COVID-19, like contact tracing and calling patients to notify them of test results.
I can even sympathize with the leadership of our medical schools and hospitals. What we’re facing right now is an unprecedented all-hands-on-deck situation. The latest recommendations offered by the accrediting body of medical schools, published last week, also reflect the increasingly dire situation and leave the door open for schools to take this step with their blessing. But to conscript or “voluntell” medical students to work as residents without pay and while hospitals themselves struggle to find enough personal protective equipment for their employees is reckless. I’m honestly struggling to find an analogy to any other context. Even in our wars in which there were drafts, conscripted soldiers were guaranteed armor and earned a salary.
Perhaps muddying the waters here are the awkward roles of medical students in the hospital during their clinical years. The second half of medical school functions like an apprenticeship, in which students learn on the job. In that role, we often skirt the line between employee and learner—performing necessary tasks on the wards and assuming some patient care, but always under heavy supervision and with little ultimate responsibility.
COVID-19, however, changes that equation; what medical schools are asking of us now is far more substantial. Asking us to act like residents, in the middle of a disaster, means that we should be treated like residents. That means we ought to be earning a fair salary and getting adequate health insurance coverage that unfortunately some of us will inevitably need. It means that we’re no longer students, and we shouldn’t be paying tuition to risk our lives. It also means leaving the final decision to enter the workforce prematurely in the hands of students themselves. Some may not be mentally or emotionally ready to make such a leap; some may be immunocompromised. Others may wish to continue the valuable work they are doing outside the hospital right now to support our system.
In Ed Yong’s tremendous Atlantic piece on how this pandemic may end, he introduced the idea of a generation of people whose lives will be irrevocably shaped by this crisis: Generation C. I worry that there will be a Generation C of medical professionals, too, but that we might be older than the generation Yong envisions. It could certainly include the health professionals on the front lines right now—forced to work themselves to the bone in a global health disaster, while making decisions of life and death that weigh so heavily on psyches. And it may also include graduating medical students, possibly forced to enter the workforce. They will remember the unavoidably abrupt transition from student to doctor, marked by Match Day celebrations over Zoom and being minted in the midst of a pandemic. And they will also remember the cognitive dissonance of how society is handling its front-line health care workers—soon to be them—at this very moment. Private businesses and citizens are offering generous displays of public support for their doctors and nurses, cheering for them every evening, buying them dinner in hospital wards, and thanking them profusely for their service. But institutions, at the same time, are letting them down. The Centers for Disease Control and Prevention is constantly revising down recommendations of adequate personal protective equipment, now actually suggesting that bandannas are enough to keep COVID-19 at bay. Stories surface of hospital administrators yanking masks off of nurses’ faces. All while our president accuses our future colleagues of hoarding masks and wanting to wreak economic havoc on our country. The notion that now some of our medical schools may be willing to, in the words of a physician on Twitter, offer us up as “unpaid meat shields” only compounds the psychic trauma.
Fourth-year medical students are now in a unique position to help in the war against COVID-19. Many of us are willing to enter the trenches. But we deserve respect, remuneration, and protection. That’s not much to ask.