By Daniel A. Gross

As a child in Southern California, Nicholus Warstadt spent a lot of time in emergency rooms on account of his severe asthma, and he often wondered how doctors knew how to make people feel better. After college, he went to Stanford Medical School and decided to specialize in emergency medicine. This past spring, Warstadt was a second-year resident at N.Y.U. Langone Health. “My favorite thing about my specialty is that I take care of everyone, regardless of their ability to pay,” he told me. His own pay, when he began the residency, was a little more than sixty thousand dollars per year, roughly the median household income in Manhattan. He often worked sixty hours in a week, meaning that he was making about twenty dollars per hour. He will be able to earn many times that in a few years, as a board-certified emergency physician, but only after completing more than a dozen years of higher education and accruing about three hundred thousand dollars in student loans. The average debt for medical-school graduates is about two hundred thousand. “So much of your life is delayed, a lot of it due to finances,” Warstadt said. “I wouldn’t want this for my kids, because of the stress.” Medical residents suffer from unusually high rates of depression, anxiety, and suicidal ideation.

When the coronavirus came to New York City, in mid-March, Warstadt was redirected from a pediatrics emergency room to a covid-19 respiratory unit, where he worked about four twelve-hour shifts per week. By April, hundreds of New Yorkers were dying from covid-19 each day; medical residents and fellows were working new and expanded jobs, which reduced the time they spent learning. “I think the hardest part was not knowing if or when it was ever going to end,” Warstadt said. Some private hospitals began offering hazard pay. N.Y.U. Langone Health—a private, nonprofit, multibillion-dollar hospital system with dozens of locations in New York and a few in Florida—did not. Many of N.Y.U. Langone’s nearly seventeen hundred trainee physicians spend part of their time at the city-funded Bellevue Hospital. Some of them are technically employed by the city and are unionized; Warstadt is a union delegate at Bellevue. In early April, a handful of residents drafted a letter asking for hazard pay, increased life and disability insurance, and protections for those who contract covid-19. “As the demand placed on our hospital systems skyrockets, our risk of hospital-acquired infection increases,” the letter said. “We are honored and willing to take on these greater clinical responsibilities. But along with this comes an increased risk for disability and death.” They shared the letter with trainees across the hospital system, initially by text message. More than five hundred trainee physicians, including Warstadt, signed it.

While the letter was circulating among residents and fellows, it leaked to Michael Ambrosino, the associate dean for graduate medical education, and to Steven Abramson, a vice-dean and chair of N.Y.U. Langone’s Department of Medicine. Ambrosino and Abramson e-mailed residents on April 9th, declining their requests. During a pandemic, Ambrosino and Abramson wrote, insurance companies were unwilling to increase their coverage, and, “given the increasing financial uncertainties for all of our institutions, ‘hazard pay’ is not feasible at this time.” Abramson told me that administrators were focussed on averting layoffs and furloughs for the hospital system’s employees. “We understood how hard these residents were working in very difficult circumstances,” Abramson said. “What we did in response was to give them our reasons.”

After responding to the letter, Abramson exchanged e-mails with hospital leaders as they prepared a more detailed statement. N.Y.U. Langone was losing money at an alarming rate, and was facing a potential billion-dollar deficit if the coronavirus outbreak did not improve by June. The letter from residents had argued that all front-line workers deserved increased compensation—but, even so, Abramson proposed a response that emphasized the unfairness of giving hazard pay to one group of hospital workers and not others. He also circulated an e-mail that one of the medical chairs had sent to his department. “Now is the time to accept the hazards of caring for the sick . . . rather than focusing on making a few extra dollars,” that e-mail read. “I am not indifferent to your anxieties but personally feel demanding hazard pay is not becoming of a compassionate and caring physician.”

Later that day, these e-mails were sent to medical residents by mistake. “I can’t even express how deeply wounding it is to have my compassion, caring and maturity called into question by my leadership,” Colleen Farrell, then a third-year internal-medicine resident, wrote on Twitter, after reading them. (Farrell had not signed the letter from trainee physicians.) Warstadt told me, “We felt like we were just being gaslit, like we were crazy for thinking about these things.” In one of the accidentally forwarded e-mails, a director asked which of his department’s fellows had signed the letter—which struck Warstadt and others as threatening. (Abramson, who told me that he saw the letter before it had any signatures attached, disagreed, saying that the director had simply wanted to understand the fellows’ concerns.) Some signatories asked the organizers of the letter to remove their names, for fear of retaliation. In the end, the list of names, which included almost a third of the hospital system’s residents and fellows, was not sent to senior leadership.

On April 10th, N.Y.U. Langone held a virtual “town hall” to discuss the concerns of trainees. The meeting was tense. “Not a single resident felt comfortable asking a question,” an internal-medicine resident told me. Instead, participants texted the chief residents who supervised them and who could raise questions anonymously. That same day, the leaked e-mails were posted anonymously on Reddit, where they drew tens of thousands of views and dozens of critical comments. Abramson told me that whoever leaked the e-mails had “unscrupulously weaponized internal documents on social media, out of context, to shame and defame other devoted physicians.”

Three days later, in a follow-up e-mail to the trainees, Abramson and Ambrosino announced that a previously planned pay increase for trainee physicians, which was scheduled for July 1st, would be implemented retroactively from April 1st. In other words, medical residents would receive between thirteen and twenty-two hundred dollars in extra pay, depending on their year; some senior fellows would receive more. Abramson told me that the pay increase was a way to compensate trainees for the added responsibilities of the covid-19 crisis but that it was not hazard pay. “Philosophically, we had trouble with the term ‘hazard pay,’ ” he said.

A few days after the additional pay was announced, an eighteen-year-old journalism student at N.Y.U. published an opinion piece in a college paper, the Washington Square News, criticizing the hospital system’s media policy—which bars employees from speaking to the media without authorization—and arguing that its trainees deserved hazard pay on top of the retroactive raises. The Times, Bloomberg, and the Intercept had already reported on these topics, but the piece was thinly sourced and contained inaccuracies, and, three days later, the Washington Square News received a letter to the editor signed by Kenneth Langone, the billionaire and benefactor who serves as a board chairman of the hospital system. It was also signed by Abramson and five other top administrators. “We believe this ‘opinion piece’ ironically is ‘FAKE NEWS’ and an egregious misrepresentation that actually harms the efforts of heroic individuals working tirelessly to care for our patients,” they wrote, demanding its retraction. The newspaper published the letter and issued a correction, but responses continued to pour in. At the request of an N.Y.U. Langone spokesperson, about thirty hospital administrators sent their own critiques to the paper. Meanwhile, about half a dozen trainees e-mailed the paper in support of the piece. “I was happy that the student was trying to stand up for us, and it seemed to me like she was in tune with the sentiment among the residents,” Warstadt told me. “It’s just a very surreal response to a student newspaper article.” On April 24th, the Washington Square News retracted the piece.

The term “resident physician” stems from the nineteenth century, when trainees often lived in the hospital and were seen as in-house workers, or “house staff.” Today, when medical-school graduates start a residency program, they begin receiving a salary. But incoming residents don’t have the opportunity to negotiate or weigh competing offers: at the end of medical school, they arrive at a career-defining juncture known as the Match. In order to complete their training, they must submit a list of preferred residency programs to a private nonprofit called the National Resident Matching Program, which assigns each successful applicant to a single residency that will last at least three years. “On the same day, every medical student across the country opens an envelope, and that’s where you’re going,” Warstadt told me. “Individually, every resident doesn’t have a lot of power to make a change.” Because residents cannot easily pick up and go somewhere else, residency programs have less incentive than they might otherwise to compete with one another on pay or benefits, or to place limits on the twenty-four-hour shifts and eighty-hour work weeks that they are allowed to assign.

“Physicians have recognized that The Match inculcates a culture of disenfranchisement, and the resulting lack of bargaining power sets the stage for abuse,” Ajay Major, an oncology fellow at the University of Chicago, wrote in a recent opinion piece. Too often, Major told me, residents and their more experienced counterparts, fellows, are labelled unprofessional if they demand better conditions. “Residents and house staff don’t feel like they can advocate for pay, basic necessities, benefits—where you would be able to in any other workforce,” he said. Major believes that a broader house-staff union movement could help trainees regain their bargaining power.

But calls for structural change come at an exceptionally difficult time for hospital finances. According to one estimate, U.S. hospitals were losing fifty billion dollars per month at the start of the pandemic, in part because covid-19 halted so many profitable, non-urgent medical services. (Through the end of July, N.Y.U. Langone had realized operating losses of $1.4 billion across its hospitals and medical school, according to a spokesperson. It has received $570.1 million in government support, which covers less than half of the deficit.) The Resident & Fellow Physician Union — Northwest, a union for residents and fellows, was trying to negotiate for cost-of-living raises when, early in the pandemic, U.W. Medicine projected potential losses of half a billion dollars. “We certainly lowered our sights once covid happened,” Brandon Peplinski, the union’s president, told me. Still, Peplinski believes that covid-19 could bolster nascent organizing efforts by making the struggles of health-care workers more visible. He said that, in the past year, his union has been in touch with trainees from at least two dozen programs, and he expects many of them to unionize in the future. Other medical workers, such as nurses and medical technicians, have launched or accelerated union campaigns in response to the pandemic.

According to many trainees I spoke with, the calls for hazard pay were not an end in themselves but a reflection of structural inequality in the medical profession. The N.Y.U. Grossman School of Medicine no longer charges tuition to the hundred medical students it admits each year, but, for most aspiring doctors, medical school may cost a quarter-million dollars over four years. This helps explain why a quarter of incoming medical students come from the top-earning five per cent of households, and only thirteen per cent come from the two-fifths of families that earn the least, according to the Association of American Medical Colleges. The A.A.M.C. also found that Black, Hispanic, and indigenous doctors are badly underrepresented among active doctors.

One N.Y.U. Langone resident, a union delegate on the Bellevue payroll, who spoke on the condition of anonymity, described the particular predicament of medical workers during covid-19. When the city’s crisis was at its worst and workers were most in need of support and protection, they had even less time and energy than usual to advocate for better working conditions. At the time, the resident was completing twelve-hour shifts at 7:30 p.m. each evening, getting home at 8:30 p.m., and then spending an hour catching up on messages from other residents, who did most of their organizing between 9 p.m. and midnight. The effort sounded impossible to sustain, and perhaps it has been—several trainees told me that they were tired of fighting and eventually moved on to broader causes not specific to their work, including the nationwide protests for racial justice.

There was one moment, however, when the weariness disappeared from the resident’s voice, and he sounded hopeful that change might be coming. He talked about building solidarity with other front-line workers, from nurses to environmental-services staff—and with other public institutions, from Lincoln Hospital, in the Bronx, to Coney Island Hospital, in Brooklyn. “It can’t be business as usual anymore,” he told me. “I think this moment makes that clear. If we are not well, and we are not cared for, then we can’t do our job.”

Later in the summer, I spoke to a current resident who had helped to write the letter. As he walked home from a shift at the hospital, he told me that the administration’s response had left him feeling dejected and fearful. “All of us were exhausted,” the resident, who also spoke on the condition of anonymity, said. “It’s a scary place to be, when you’re a trainee and you’re trying to stare down the leadership of a giant corporation.” The letter had led to some changes—N.Y.U. Langone eventually agreed to double its life-insurance coverage for non-unionized residents and fellows, for instance. (“We were trying to be responsive—and ultimately were,” Abramson told me.) But then the hospital system offered front-line staff a “recognition program” that paid two weeks of extra vacation, or a minimum of twenty-seven hundred and fifty dollars in cash, and residents and fellows were excluded from the benefit. “We all felt sort of betrayed again,” the resident told me. “They literally contradicted themselves by giving everybody else the thing they said they couldn’t give us.”

Residents also said that they were bothered by graduation remarks that the C.E.O. of N.Y.U. Langone, Robert I. Grossman, had made. “You are physicians and as such benefit from the respect of the public,” Grossman had said. “It’s important to continue to earn that respect throughout your career. Transactional behavior—driven by self-interest and/or ulterior motives—demeans you and our calling.” The resident turned this criticism back on N.Y.U. Langone, calling the hospital system a prime example of corporate medicine. The hospital system operates as a tax-exempt nonprofit, but its annual earnings are usually in the hundreds of millions of dollars; in 2017, Grossman received just over ten million dollars in total compensation. “It’s a business disguised as a calling,” the resident told me. (The N.Y.U. Langone spokesperson said that, in response to the pandemic, hospital executives had taken a forty-per-cent pay cut.)

In September, I called Warstadt at home. He was cooking dinner. Compared with the last time we had spoken, he sounded upbeat. He is now a third-year resident, and his salary has risen to about seventy-five thousand dollars per year. Morale among the house staff has improved, he told me, and he felt proud of the care that N.Y.U. Langone and Bellevue have provided in response to the coronavirus. Still, he described a dissonance between his pride in his work and his experiences as a worker. The reaction to the letter, he said, left him with a lingering feeling that house staff don’t matter to N.Y.U. Langone. “The administration’s response is the one thing that doesn’t really sit right,” he told me. I thought back to my conversation with Steven Abramson, the hospital administrator, and his objection to the concept of hazard pay. “There is something to be said that this is the obligation of the doctor, to take care of the patient,” Abramson had said. “You can either be part of the profession or not.”