Kaley Kinnamon, MD, still remembers the many challenges of being a new doctor when COVID-19 was raging through her hospital. “We were expected to do much more,” says Kinnamon, now a second-year neurology resident at the University of Vermont Medical (UVM) Center in Burlington. “We were having to take on a lot more patients — and a lot sicker patients.”
And though Kinnamon appreciated that the hospital was also battling tremendous challenges, she was disappointed that it failed to offer residents such supports as additional compensation and help with childcare.
“A lot that was happening during COVID made me want to advocate more vocally for what residents need. I saw unionizing as a powerful way to do that,” she says.
Many of her colleagues at UVM shared that sentiment, and on April 14, they voted to launch a residents union there.
These trainees joined a growing number of medical residents — sometimes known as house staff — who have unionized across the United States during the COVID-19 pandemic.
“Every year, we had one or two new organizing campaigns, but once COVID hit, that number pretty much tripled,” says Sunyata Altenor, communications director for the country’s largest house staff union, the Committee of Interns and Residents (CIR). “It was a massive wave, and we anticipate that it will continue to grow.”
Certainly, residents voiced concerns about their work lives even before the pandemic. They would describe three or more years of often grueling schedules, sometimes with 24-hour shifts and 80-hour workweeks. And they have bemoaned their salaries.
But others in medical education have pointed to the various nuances of their role as trainees.
“On one hand, residents work long hours and contribute significantly to the care of patients. For this they receive a stipend,” says Janis Orlowski, MD, AAMC chief health care officer. “On the other hand, they’re apprentices who are receiving very valuable training that is expensive for institutions to provide.”
And many experts — including some residents themselves — say that joining a union is not without risks.
For instance, some worry that unionizing can undermine the connections between residents and the physicians who train them. Others point to the threat of a strike, an issue that grabbed headlines last week when residents voted to authorize a strike against three Los Angeles County hospitals. Although a tentative contract deal was reached a few days later, averting a possible strike, the vote raised the specter of potentially dramatic consequences for hospitals that need to ensure adequate staffing.
“Clearly, hospitals are not actively interested in residents establishing unions, but when it happens, they are committed to making it work,” says Orlowski.
“The AAMC leaves it to each institution and its house staff to determine how to achieve the best possible education, working conditions, and patient care,” she adds. “Of course, the goals have to be meeting educational accreditation standards, providing high-quality care, and creating a nurturing learning environment.”
“We went into medicine for altruistic reasons, and that doesn’t change just because we join a union.”
Eduardo Fernandez, MD
Fellow, Keck School of Medicine
On their end, pro-union residents say there is little reason to worry about organizing efforts.
“We went into medicine for altruistic reasons, and that doesn’t change just because we join a union,” says Eduardo Fernandez, MD, who was active in organizing a residents union at the Keck School of Medicine in Los Angeles last month.
Paul King, MD, an academic leader who has long worked with unionized residents at his hospital, advises colleagues elsewhere not to panic. (King, who works for a large East Coast hospital, requested a pseudonym due to ongoing contract negotiations.)
“Things with a union sometimes can get uncomfortable,” he says. “But what in life doesn’t have some good and some bad? This is the same.”
The beginning of a movement
In the United States, residents unions stretch back at least to 1934 when the Interne Council of Greater New York organized around compensation (there was none), limited learning opportunities, and concerns about work conditions.
Over the ensuing decades, other residency programs unionized even as some faced legal battles over whether residents, as hybrid trainee-workers, had the right to unionize. In 1999, the National Labor Relations Board (NLRB) ruled in the affirmative, determining that medical residents should be deemed employees when it comes to federal labor rules. The agency indicated, however, that medical residents are also students — and therefore determined that it would not interfere in matters clearly falling within the educational sphere.
Today, roughly 15{e577f2e255613ded01a030e42bce2808ed901289218648e026d62c4ad00509a4} of U.S. house staff in more than 60 hospitals are represented by CIR, which is part of the Service Employees International Union. A smaller portion of residents have created their own local unions or joined one for health care providers more broadly, such as the Union of American Physicians and Dentists.
Those interested in unionizing their fellow residents face no small task.
Specific steps vary by state, but getting started usually involves residents indicating interest by signing union cards. If enough of them do so — a specific super-majority may be required — a next possible step is for the hospital involved to voluntarily recognize the bargaining unit. But that rarely happens.
Jason Sanders, MD, executive vice president for clinical affairs at the University of Vermont Health Network, explains UVM’s recent decision to decline recognition. “We had just a few days to respond, and this was not expected,” he says. “We wanted to give this our best thinking because a union is a third party in the room, someone who is not a physician. We also wanted to create a safe space for all viewpoints because not all residents supported having a union.”
If a hospital doesn’t recognize the union, the next step is a formal vote, overseen by the NLRB. Altenor says that once an effort gets this far, it rarely fails. For example, on April 14, 78{e577f2e255613ded01a030e42bce2808ed901289218648e026d62c4ad00509a4} of voting UVM residents checked “yes” to unionizing.
Last up are contract negotiations. King says his hospital’s current agreement has more than 20 sections, covering a broad sweep of topics from family leave and textbook allowances to parking fees and on-call rooms where residents can rest. Nothing in the contract covers academic issues such as standards for evaluating residents, he notes.
“We believe academics are an area of judgment that belongs to the school. Unions can do a lot of good, but these are not within their expertise,” he says.
At UVM, Sanders looks ahead to a year — or more — of contract talks since negotiators there will be building a new document. “We know residents doing this work are busy. They must balance their learning and clinical time, and we also want to make sure to be mindful of their wellness,” he says.
The upside of unions
Residents’ reasons for organizing often focus on such basics as pay and working conditions.
Although maximum allowable work hours are covered by the Accreditation Council for Graduate Medical Education, salaries are not. First-year residents earned just under $60,000 on average in 2021, according to AAMC data.
“Residents work up to an 80-hour week, and they see other staff who work less and get paid more,” says Glenn Ault, MD, physician director of graduate medical education at Keck. “At 80 hours, one could calculate that they could be earning less than minimum wage.”
Other resident concerns vary but often connect to more control over their unusually intense work lives.
At the University of Washington, for example, the Resident and Fellow Physician Union-Northwest (RFPU) won pregnant residents the right to reject 24-hour shifts. At the University of Miami Leonard M. Miller School of Medicine, CIR negotiated additional pay and better planning for the extra demands residents face when hurricanes hit.
Hope for a more powerful voice drew Meaghan Roy-O’Reilly, MD, a second-year Stanford Health Care resident, to union organizing. At the Palo Alto, California-based Stanford, unionizing efforts got rolling after leaders there omitted residents from the first batch of staff to receive COVID-19 vaccines.
“They were using an algorithm to decide,” says Roy-O’Reilly. “That was well intentioned but not fair in the end. Including residents in the process — people with the lived experience of the front lines — might have avoided this problem.”
Some say that unionizing can have upsides for hospitals as well.
King notes that having a union sometimes simplifies matters for him. “Having a detailed contract means I don’t need to debate a range of requests and helps ensure consistency between departments. I can say, ‘This is the rule for everyone. We can’t deviate from it.’”
“In order to take good care of others, we need to be able to care for ourselves. … We love being residents and caring for patients. But we can’t do that well if we neglect ourselves.”
Kaley Kinnamon, MD
Resident, the University of Vermont Medical Center
Unions can also help enhance patient care, say some observers.
“CIR has a lot of initiatives to support patient safety and quality care,” says Joan St. Onge, MD, MPH, senior associate dean for graduate medical education and faculty affairs at the Miller School of Medicine. “They also have an outreach effort that helps residents address concerns, such as racial justice, within our local community. We collaborate very well with them on that work.”
Brandon Pepliniski, MD, RFPU’s immediate past president, says unions can also promote patient care by helping support diverse individuals in the physician workforce.
“With a union, you can short-circuit traditional channels for change that can be quite slow moving or downright performative,” he said. That’s significant, he notes, because “people who have historically been systematically excluded from medicine are often those who need the better protections and benefits a union can offer,” such as increased stipends for housing. He adds that unions can provide such services as counseling about options for how to respond to discrimination.
Kinnamon describes another possible patient benefit.
“In order to take good care of others, we need to be able to care for ourselves,” she says. “We love being residents and caring for patients. But we can’t do that well if we neglect ourselves.”
The costs of unionizing
Of course, residents unionizing is not without its downsides, say some involved.
For hospitals, money is certainly an issue. Although federal funding helps pay residents’ salaries, the lion’s share of training expenses comes from hospitals’ coffers. And in many instances, those coffers have been depleted during the pandemic, notes Orlowski.
“Hospitals raise the question of whether compensation should be calculated only by hours worked,” she says. “They think about the tremendous amount of education they’re providing. Residents don’t pay for their apprenticeship as others, like oral surgeons, do. Are hospitals going to have to start charging tuition for that training?”
Another major concern for hospitals is the threat of a residents’ strike — even though it has been decades since the last one. In fact, in a recent dramatic move, unionized residents with Harbor-UCLA Medical Center and two other Los Angeles training sites voted to authorize a strike following a month-long deadlock in contract negotiations. A few days later, a tentative agreement was reached, averting a possible strike before it was set to launch.
Some residents also worry that going on strike — or unionizing at all — could undermine patients’ and communities’ trust in them. “The relationship between us as doctors and society should be that of providing service. That should be the case irrespective of our personal interests,” says Sriram Rangarajan, MD, a surgical fellow at Brown University in Providence.
“Hospitals raise the question of whether compensation should be calculated only by hours worked. They think about the tremendous amount of education they’re providing.”
Janis Orlowski, MD, AAMC chief health care officer
Beyond a major move like a strike, UVM’s Sanders worries that a collective contractual agreement could limit flexibility in graduate medical education (GME). “For us, GME is one resident at a time, but with a union, we will now have a contract detailing conditions that apply to everyone,” he says.
Residents training in different specialties have interests that are “massively different,” adds David Harmon, MD, a fourth-year resident at a West Coast hospital who requested a pseudonym because his peers are negotiating a new contract. “If a union gets more leave time, for example, surgical residents can’t use it anyway because we have to work a certain amount and perform a certain number of cases to qualify for board certification.”
Harmon also believes contract talks can fray relationships between residents and hospital leaders. “When residents hear about setbacks, there can be an almost unconscious animosity,” he says. “They may have exactly the same benefits as residents elsewhere, but if they ask for something and don’t get it, they are likely to feel unsupported.”
King adds another concern that comes up. “Those with a loud voice sometimes use the union as a bully pulpit for issues that maybe 90{e577f2e255613ded01a030e42bce2808ed901289218648e026d62c4ad00509a4} of rank-and-file residents don’t even care about.” The union urging purchase of a specific type of online medical education platform is one example, he says.
In fact, research suggests that unions don’t dramatically improve the residency experience. One 2019 study of surgical residents found that while some benefits were better at hospitals with a union — four weeks of vacation instead of two or three, for instance — levels of burnout were about the same.
Still, residents seeking to join a union articulate very real concerns, and Sanders urges educational leaders to focus on that bigger picture.
“Whether or not residents have a union, their concerns exist,” he says. “The question we leaders need to ask ourselves is, how are we going to address them?”
This article first published on June 7. It was updated on June 8 to reflect developments in contract negotiations between the union representing some UCLA residents and several Los Angeles hospitals.
