key: cord-0976028-nlrjcixo
authors: Ruhnke, Gregory W.; Detsky, Allan S.
title: Should medical residents who care for COVID‐19 patients receive hazard pay?
date: 2022-02-14
journal: J Hosp Med
DOI: 10.1002/jhm.2779
sha: 520ebecb7ff540bc446470287398f9a0a4b7a913
doc_id: 976028
cord_uid: nlrjcixo

nan

Hazard pay compensates employees for work-related risks. 1 Typical labor markets establish hazard pay premiums to entice people to do risky jobs. Free market forces create these pay differentials to fill such jobs when workers are both aware of and averse to hazards, and have alternative employment opportunities. 1 Most hazard pay is established before a person agrees to a job. In special circumstances, employers may offer hazard pay when risks increase or even retroactively. In the former case, they may do so to keep their employees from quitting. In the latter, they may be motivated by a sense of fairness or to make sure employees do not quit should the risk recur.

Hazard pay has been proposed as a way to ensure the adequacy of physician supply without coercion during the COVID-19 pandemic. 2 In this issue, Uthlaut et al. report that 20% of institutions provided their residents with hazard pay, and that hazard pay was offered more frequently in institutions where program directors supported it. 3 These findings also suggest that program directors and residents alike became advocates for hazard pay in areas with early local epidemiologic intensity. This advocacy, in combination with greater resident involvement in COVID-19 patient care, may have influenced institutions to provide hazard pay.

The following arguments favoring hazard pay often arise. Contrary to popular belief, physicians' social contract does not obligate them to take unlimited risks, 4 a perspective solidified by the 2003 SARS outbreak. 5 Physicians are distinct from soldiers, who receive automatic hazard pay for excessive risk burden when refusal is not an option.

Many overburdened residents were pressed into service without adequate personal protective equipment (PPE) and outside their scope of expertise, both of which increase their risk of COVID-19 exposure.

Without the ability to make informed choices, residents were rendered essential workers whose education was compromised, 5 a view expressed by program directors in favor of hazard pay. 3 In the short term, residents could not easily say no to redeployment, but COVID-19 will be here for a while. Thus, failure to provide hazard pay retroactively may well lead to more organized residents, who are prepared to say no with a better script when the next wave hits. In the long run, even retroactive hazard pay may ensure future resource availability. Finally, hazard pay would prevent professional conflicts among residents competing for low-risk assignments, while perhaps matching exposure risk preferences with desire for rewards. 2 On the other hand, there are multiple arguments against providing hazard pay for residents. Residents are employees who have contracts for a specific period of time. Unlike restaurant workers, they are not a mobile workforce-lack of job portability prevents them from moving easily to another employer. They could quit, but would likely experience considerable professional consequences, including interruption of training. This dilemma highlights the unique dual role of residents as trainees and employees. In the short run, programs are largely shielded from labor market forces that would pressure them to provide hazard pay. The large debt burden of many trainees also accentuates the implications of job forfeiture, although debt relief may simultaneously justify hazard pay. 2 However, concurrent ethical concerns arise because hazard pay may serve as a coercive incentive to accept excessive risks. Furthermore, some would argue that physicians already internalized health risks when they chose their careers. 4 Another reason, cited by program director respondents, 3 is that the unnecessary provision of hazard pay to residents (who would work without it) leaves less money for PPE and hazard pay to other frontline personnel, including hospitalists. Finally, since PPE mitigates transmission risk, 4 most infections among healthcare workers are likely derived from the community, making hazard pay unnecessary.

There are many economic and professional justifications to argue for and against hazard pay. 1-3 Although we believe that providing hazard pay for residents is the right choice both ethically and professionally, we recognize that institutional politics, financial factors, and labor needs are more likely to drive this choice.

Hazard pay in unsafe jobs: theory, evidence, and policy implications

Physician supply during the coronavirus disease 2019 (COVID-19) crisis: the role of hazard pay

Hazard pay for internal medicine resident physicians during the COVID-19 pandemic: results of a national survey of program directors

Limiting patient autonomy: mandatory COVID-19 diagnostic testing

The impact of severe acute respiratory syndrome on medical house staff: a qualitative study

The authors declare that there are no conflicts of interest.