WHEN INTERNS AND RESIDENTS UNIONIZE

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On May 2, 2022, residents and fellows (medical doctors in their first years of educational work after medical school) at Stanford University Health Care voted to unionize. In an email to medical staff, the Graduate Medical Education administration wrote: “Stanford Health Care (SHC) residents and fellows voted in favor of having The Committee of Interns and Residents (CIR), a local of Service Employees International Union (SEIU), serve as their collective bargaining representative. The votes cast in the election represent the sentiment of 1,049 residents and fellows who participated, out of the 1,478 employed by SHC. Ultimately, 835 voted ‘yes’ to unionization; 214 voted ‘no.’ . . . While we believe that the best relationship with our employees is a direct one without a union, we respect the results. . . . When the results are certified in the coming days, the first stages of the collective bargaining process will begin. . . . We will negotiate with the union in good faith to reach an agreement that reflects your priorities, while maintaining the best parts about training at Stanford.”

Stanford residents and fellows are not alone in choosing to unionize. A total of 1450 residents and fellows at UCSF (University of California San Francisco) recently voted to join the same Committee of Interns and Residents (CIR) union. The UCSF residents stated, “By joining CIR, UCSF residents will be able to negotiate their contracts for the first time, including bargaining for better salaries, benefits, time off, and other provisions that will improve resident life and well-being.” 

A total of over 20,000 residents and fellows at hospitals around the U.S. have voted to join this CIR union. What will this development mean to healthcare in the United States? I respect residents and fellows at the highest level. I spent five years as a medical resident, and I can empathize with the demands of their workload. From my current perspective as an attending physician at an academic medical center, how will this unionizing of housestaff (MDs who are residents and fellows) play out? 

First off, why form a union? The main reasons are a lack of bargaining power regarding:

  1. Burnout and staffing. Housestaff work up to 80 hours per week, a number that is twice the 40-hour workweek considered standard in the United States, and they do this for a duration of 3 to 7 years, depending on their specialty.  The rate of burnout is known to be high in medical doctors, and despite nods to wellness programs at most university hospitals, improvements have been slow in coming. An online survey of doctors finds an overall physician burnout rate of 42%, and the highest percentage of burnout occurred in these six specialties: urology: 54%, neurology: 50%, nephrology: 49%, diabetes and endocrinology: 46%, family medicine: 46%, and radiology: 46%.
  2. COVID. The long hours and risks of acquiring COVID while working with sick COVID patients from 2020 -2022 made many residents and fellows feel vulnerable and angry. While hospital administrators and many faculty returned to the safe havens of their homes each night, interns and residents staffed intensive care units, wards, and emergency rooms, caring for patients with this terrifying new contagious disease. When University of Massachusetts interns and residents joined the CIR union, they stated, “When the pandemic struck, securing better conditions became even more urgent, as the inequities in our healthcare system were laid bare — and in light of the rapid changes that left residents scrambling to keep up within traumatizing and sometimes dangerous practice conditions.”
  3. Higher pay. Residents and fellows are paid a salary. They do not earn an hourly wage. When their salary is divided by 80 hours of work per week, 50 weeks per year, most residents and fellows are making less than minimum wage. When University of Massachusetts interns and residents joined the CIR union, they stated, “UMass Memorial residents are willing to work 80 hours per week because we know exceptional care is critical to community well-being, but we are significantly underpaid for doing so.” 
  4. Better benefits. Residents and fellows will desire more vacation time, top-notch health insurance benefits, and perhaps even retirement contributions.

If residents and fellows don’t receive what they seek during negotiations with the administration, what consequence can residents and fellows turn to? Will they go on strike? In May 2019, interns and residents at UCSF staged a 15-minute “Unity Break” strike as a show of solidarity and power. The Committee of Interns and Residents, which represented 1,100 of UCSF’s resident and fellow population at that time, said that management had not properly recognized the contributions of their resident and intern members and offered a package that left them underpaid and underrepresented. “UCSF has failed to meet some of the very basic demands that we have been fighting for at the table,” said Kim Carter, director of the union. 

Can doctors strike? Is it ethically OK for doctors to strike? I think the answer is no. To leave patients without healthcare while doctors strike for better hours, wages, and benefits is a violation of the ethics of our healing profession. I don’t believe young doctors should be abused or squeezed into unacceptable hours, low wages, and/or poor benefits, but doctors staging a labor walkout would be a mistake. And if a union will never strike, will it ever have any real negotiating power? The CRONA (Committee for the Recognition of Nursing Achievement) nursing union at Stanford staged a strike beginning April 25, 2022, just days ago. Negotiations were successful after only one week of the strike, with the nurses gaining a tentative agreement for significant base wage increases of 5% on April 1, 2022, 2% on December 1, 2022, 5% on April 1 2023, and 5% on April 2024, in addition to other improvements in benefits, staffing, and scheduling. 

I have firsthand experience with strikes. I was a laborer during three United Steelworkers of America strikes in Northern Minnesota during summer employment in taconite mines while I was in college and medical school. Blue-collar strikes are not pretty. The picket lines were brutal, and no one dared cross them. Both sides lost money as the strikes wore on, and interpersonal conflicts simmered for a long time afterward. 

The idea of residents and fellows joining a union is not a new one. In 2001 The Los Angeles Times reported a story on this topic. The article stated, “Striking will disrupt the educational progression of classes, clinical practice and testing. A student wants to come in and have some certainty that his or her three-year residency will take three years. How would they feel if suddenly they were told they wouldn’t finish on time and, whether a strike is a good idea or a bad one, that they’re not going to be able to take a board exam?” One of the doctors who joined the union at that time stated, “Change won’t come overnight, but I think it will happen. We have to stop that cowboy attitude: ‘It’s always been this way, we’re tough, we don’t complain.’ Many residents want to complain, but they’re in an environment where if they do, they’re punished. Residents have to fight for all these things and, without a union, they don’t have any legs to stand on.”  

The ”cowboy attitude” refers an old-school medical education argument that sounds like this: “There’s no other way to educate doctors. It takes at least 80-100 hours per week. Even if you stay in-house every other night you miss half the good cases. When I was a resident, back in the (fill in the blank . . . 1950s, 1960s, 1970s, or 1980s), we slept in the hospital every other night and worked 120 hours per week. Now residents are complaining that 80 hours per week is too much.”

When I was an internal medicine resident in the 1980s, we stayed in the hospital on-call every third night and worked approximately 100 hours per week. My salary during my first year of residency was $16,000. On an hourly basis, this equated to $3.33 per hour. Adjusted for inflation, my 1980 salary would be $55,826, or $11.63 per hour, less than the current minimum wage. 

If medical centers shorten the workweek of interns and residents to 40 hours per week from the current limit of 80 hours per week, the medical center may need to hire twice as many interns and residents or other physician surrogates to do the workload. And if the union negotiates a 10-20% increase in annual salary, the cost for interns and resident would increase further. Where will all this money come from? Most of the salaries of residents and fellows are paid for by billions of dollars of federal tax money, as medical education is subsidized by the United States government. The publication Congressional Research Sources states, “Federal support for medical residency training (a.k.a., graduate medical education [GME]) is the largest source of federal support for the health care workforce. Although the health workforce includes a number of professions, the size of the federal investment in GME—estimated at $16 billion in 2015—makes it a policy lever often considered to alter the health care workforce and impact health care access.” 

Labor unions in the United States are organizations that represent workers in many industries. Labor unions grew afterCongress passed the National Labor Relations Act (NLRA) in 1935 to protect the rights of both employees and employers, to encourage collective bargaining, and to eliminate certain private sector labor and management practices which could harm the welfare of workers, businesses and the economy.

The Ailing Labor Rights of Medical Residents, by Sarah Geiger, published in 2006, describes the legal history of medical resident labor law and the attempts to legalize unionization among medical residents. I quote the following excerpts directly from Geiger’s paper: 

“From 1947 to 1974, hospital staff members did not have the right to unionize. . . . Congress then amended the NLRA in 1974 to include non-profit hospitals. The Committee on Labor and Public Welfare report on the amendments stated that it could find no acceptable reason why 1,427,012 employees of these non-profit, non-public hospitals, representing 56% of all hospital employees, should continue to be excluded from the coverage and protections of the Act. . . . One source of confusion involved the dubious supervisory status of professional health care providers. . . . health care professionals exercised supervisory roles and were thus excluded from the right to unionize. . . .

In Cedars-Sinai Medical Center, the NLRB held that the residents, interns, and clinical fellows of Cedars-Sinai were not ‘employees’ within the meaning of the NLRA. Thus, they had no right to unionize. . . . The Board thus concluded that interns, residents, and clinical fellows were primarily students, noting the relationship between residents and Cedars-Sinai was primarily educational, and not an employment relationship. . . .  The decision remarked that interns ‘participate in these programs not for the purpose of earning a living; instead they are there to pursue the graduate medical education that is a requirement for the practice of medicine. This statement implies that residents do not actually ‘practice medicine,’ but merely are training to do so. . . . 

“In response to staunch legal criticism, the Board reversed Cedars- Sinai.  Boston Medical, an oft-quoted case, involved a unit of housestaff at the Boston Medical Center (BMC) that attempted to unionize. . . .  The Board overruled its precedent in Cedars-Sinai and held that medical interns and residents were both students and employees and thus were entitled to unionize. . . . The NLRB recognition of housestaff’s plight has done little to encourage unionization among medical interns and residents. . . . The residents’ dual roles, however, present extra-legal barriers to unionization which are not present in other industries. Residents spend an inordinate number of hours in the hospital and often are directly serving patients for twenty-four hours at a time. . . .  the fears of Congress (and earlier fears of the American Medical Association) that unionization may compromise the doctor-patient relationship or the quality of health care residents adds another layer of complication. . . .   

“The Association of American Medical Colleges (AAMC), the representative body of all accredited medical schools in the United States and Canada, as well as over 400 teaching hospitals, vehemently opposed all resident unionization efforts. . . . Offering more labor rights to medical residents would cost academic hospitals inordinate amounts of money. The cost of replacing one surgical resident with a “physician extender,” or other physician, is $210,000 to $315,000 a year. . . . the federal government is by no means an objective observer in the matter of medical residency funding and regulations. Currently, the federal government is the main financier of graduate medical education, ‘contributing $6.8 billion through Medicare, plus additional sums through the Departments of Defense and Veteran Affairs.’ The federal government is constantly looking to reduce the cost of medical care. Offering residents more control over their working conditions would likely lead them to demand more money, money that would have to come from the federal government or from private university hospitals. Thus, the government and academic hospitals are appropriate bedfellows in opposing resident labor rights. 

“The Boston Medical decision made it clear that little legal basis exists to deny medical residents unionization rights or any NLRA specified rights for that matter. Thus, unless Congress amends the NLRA, no legal barriers exist to housestaff unionization.  Many other internal barriers, however, hinder medical residents from acquiring labor rights. Unionization takes more effort than residents have time for and many fear unions will compromise their goals as physicians. A national survey of residents found that residents’ willingness to get involved in forming a union or serving as a member of union management was inversely proportional to the difficulty and amount of time their specialty required them to be in the hospital. Residents are accountable to their superiors for their future careers and would rather endure a few years of grueling working conditions than do anything which might compromise their careers. . . . Hospitals should give residents a real opportunity to unionize. . . . An informed, inclusive dialogue will serve to clarify legal and extra-legal barriers to accomplishing these congressional goals as well as to alleviate medical residents’ labor burdens.”

As described above, a crucial issue which complicates union negotiations for medical residents and fellows is that their jobs are part work and part education. Each intern or resident is a medical worker, a student of the specialty he or she is training in, and a teacher to the interns and residents who are junior to them in the hierarchy. Residents and fellows are learning as they are paid to work. Their learning is both valuable and necessary for progression to their eventual career. The U.S. News and World Report’s listing of the “Best Paying Jobs in America” lists specialties of Medical Doctors as 7 of the 10 highest paying jobs in the United States. 

No discussion of intern and resident salaries would be complete without a disclosure of the average debt these young doctors carry. Because of the high costs of medical school and college tuition, the average medical school graduate owes $241,600 in education debt. The average medical school graduate owes six times as much as the average college graduate. You can’t blame student doctors for wanting to maximize their income as medical interns, residents, and fellows.

If there’s a silver lining in all this, it’s best described in this anecdote from my training years: After completing a 3-year residency in internal medicine, I applied for and was accepted to a second 2-year residency in anesthesiology, a field I was passionate to learn about. In the first weeks of my anesthesia residency, a former chairman of the Stanford anesthesiology department gave us a lecture and tutorial on how to intubate the trachea of a patient with the highest level of skill and ease. I hung on every word he said. I was getting a lesson from a legend, and I was collecting a salary while I was learning this craft. Image a young golf professional getting paid while he received a lesson from Jack Nicklaus. I was earning a salary while I bettered my education and became more marketable in the medical marketplace. Could I have been paid more as a resident? Perhaps. But the primary gain I made during five residency years was the investment of my time in the labor and learning which made it possible for me to work as a board-certified anesthesiologist for the past 36 years . . . and still counting.

I’m confident Stanford Healthcare and the CIF union will negotiate a successful compromise agreeable to both sides. Until that time, stay tuned, as the intersection of physician labor unions and academic medical centers will generate headlines in the days ahead.

I offer this question to my readers: Do you think it’s acceptable for unionized doctors to strike?

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13 thoughts on “WHEN INTERNS AND RESIDENTS UNIONIZE

  1. The idea of a unionized doctor going on strike and depriving patients of needed medical care is appalling.

    1. Compassion doesn’t put food on the table, and no organization raking in massive profits is just going to hand out a higher salary because residents are doing a good job. The idea of a hospital systems making hundreds of millions in profit (not income, profit) and saying there’s nothing to pay residents is appalling. Ask yourself, with the cost of medical school, inflation, downward pressure on salaries, scope creep, and higher cost of living if your generation would have “made it”.

    2. I believe striking in the way of withholding required medical care should only be done in the most dire circumstances, however, one can strike in different ways, like not filling a review of systems in notes, making them unbillable. In anesthesia, one could not electronically log into cases, making them unbillable while still providing care.

  2. This is a challenging issue. Americans want free healthcare and don’t understand or care that this attitude is not consistent with free market principles. This has a direct impact on backlog of care.

    Additionally, the best minds are drawn to other fields with better pay.

    Further, an expert needs 10000 hours to begin to become proficient. As work hours are cut this should lead to longer residencies, but who wants to add 2 years to each residency?

    Add into this equation that free healthcare needs to be matched some tort reform.

  3. “To leave patients without healthcare while doctors strike for better hours, wages, and benefits is a violation of the ethics of our healing profession.”

    Yeah ok, so would you do your job for free? What if tomorrow, admin told you they were reducing your salary by half? You’d probably search for a new job, which is something a resident can’t do. Or maybe you’d just retire? The world is your oyster, you’re not trapped in 3-7 years of obligatory training that is necessary to even have a job after (and pay off the $220,000 of debt that we appreciate you even mentioned).
    This take is archaic and hypocritical. As you mentioned in the next sentence, nurses went on strike last week, successfully. Are they immoral villains who want patients to suffer?
    How about if residents go on strike, the hospital forces attendings to cover call and floor work? Come on, you’d have to. It’d be immoral to let the patients suffer. Just pick up the extra shifts. It’s your calling.

    “I was getting a lesson from a legend, and I was collecting a salary while I was learning this craft. Image a young golf professional getting paid while he received a lesson from Jack Nicklaus. I was earning a salary while I bettered my education and became more marketable in the medical marketplace.”
    What a gaslit point of view. Like what GME falls back on to tell residents instead of paying an actual living wage. “Oh, but what a privilege it is! You are so lucky to even be here!” Meanwhile as you mention, it takes $250-300k in other (appropriately paid) staff per year to replace a resident. Does that tell you anything?
    It’s easy to call medicine a “calling” and that you should be “grateful to even be here” when you’re making $400k per year and make your own schedule. Residents are in an incredibly vulnerable position and it shows in the ways they’ve been abused for so long. This gaslighting, implying residents should take each punch with a “please sir can I have another” attitude is disgusting.

    1. The above comments from Mark show how strong emotions can be when it comes to interns and residents feeling abused with their current job situation.

    2. I was getting a lesson from a legend, and I was collecting a salary while I was learning this craft. Image a young golf professional getting paid while he received a lesson from Jack Nicklaus. I was earning a salary while I bettered my education and became more marketable in the medical marketplace.

      all other professions you get paid a full salary while getting on the job training and use this skill set to be more marketable on the marketplace. Just look at the nurse practitioners. They go to online nurse practitioner school and gets hired in a specialty knowing absolutely nothing and get paid 2-3x a resident salary and working only 50% as hard as residents. (no call, no weekends, only taking care of 4-5 easiest patients waiting for placement with all medical issue already addressed. God forbid a new minor issue arises they waste precious resources consulting every specialty under the sun outside their Narrow scope of practice.

      1. Perhaps unions will be able to negotiate higher salaries. If they do,, great. I’m not opposed to interns and residents getting paid more money.

        I share the public perception that doctors walking off their jobs and striking while sick patients get inadequate healthcare is simply wrong. Doctors have always been healers, not bystanders, to sick patients.

  4. Nurses are at least as essential as doctors and can strike. They only utilize strikes as a last ditch effort when administration fails to support or listen to them, which is embarrassingly frequent. We residents should absolutely have the right to do the same given how overworked we are. Hospitals can make do covering work during nursing strikes, and they can do the same for residents if they actually do value us.

    What is missing from this story (or maybe I missed it) is that collective bargaining agreements for resident and fellow unions often outright prohibit striking, even strikes that are in solidarity with, say, nursing unions. This includes my hospital’s program and I honestly can’t believe that was ever agreed to. Hopefully that right will be restored after the next scheduled negotiations. And yeah, I plan to advocate for that. Preventing strikes is just a blatant attempt to disempower unions, and with the renewed vigor of the labor movement in the US, I’m hopeful this will change at least in some places.

    Also, nationalized healthcare (not just universal, nationalized) and free higher education need to happen as soon as possible.

    1. The above comments from TC demonstrate that some interns and residents passionately want some new and fair way to negotiate with their employers.

  5. “Can doctors strike? Is it ethically OK for doctors to strike? I think the answer is no. To leave patients without healthcare while doctors strike for better hours, wages, and benefits is a violation of the ethics of our healing profession.”

    I think this thinking is deeply flawed. First of all, doctors certainly perform a job that is critical for society and that has life-or-death stakes, but they are far from the only job where this is true. This description can also apply to police officers, firefighters, nurses, paramedics, and EMTs among others, who all can and do go on strike. These groups are also usually represented through collective bargaining. A profession being critical to society is not an excuse to rob its most vulnerable members of their agency and bargaining power.

    Second, there are far more benefits to a union than strikes or the threat of strikes. Unions can amplify the voices and concerns of those they represent, and can advocate and negotiate long before the prospect of a strike is raised. For example, unions often negotiate labor deals that guarantee no strikes for a given period of time. So residents and fellows being represented by a union would merely more evenly distribute the responsibility to ensure continued care between the employees and the employer.

    Third, residents are almost uniquely vulnerable to being taken advantage of. They are matched to a program and do not have a free market to take their services elsewhere if they are mistreated. An application for transfer is possible but not guaranteed, can be frowned upon, and can cost the resident training time. Residents who speak up individually also clearly risk professional retribution, and therefore collective representation is even more important. Most workers in civilized countries at least have the possibility of power through both collective bargaining and through the free market – most residents today have neither.

    “Housestaff work up to 80 hours per week”

    This is simply incorrect. Residents are required to work no more than an average of an 80 hour week over a four week period. I know many residents who work 100 hour weeks regularly. I also know that the 80 hour average per period is not usually regularly enforced, so many exceed even that average.

    “If medical centers shorten the workweek of interns and residents to 40 hours per week from the current limit of 80 hours per week, the medical center may need to hire twice as many interns and residents or other physician surrogates to do the workload. And if the union negotiates a 10-20% increase in annual salary, the cost for interns and resident would increase further. Where will all this money come from?”

    The argument that the current business model cannot support paying the most vulnerable employees fairly is especially grotesque coming from someone in the same business who receives an exorbitantly high salary. I am not aware of a reason why resident compensation should only be paid for directly through tax dollars, other than “we’ve always done it that way”. The economic model of a hospital in America is a whole other can of worms, but to start you could imagine reducing attending and administrative pay by 20% and putting that into increased resident compensation and more resident slots. That would leave the former group still very well compensated and go a long way towards addressing these problems. To be clear, the issue is not that you should be paid less, but the backloaded pay structure gives residents no freedom – with high loans and low pay initially they are trapped in the career, and have no choice but to endure every obstacle put in their way.

    I believe you are making arguments in good faith, so I implore you to reconsider. The archaic and abusive system we have in place directly contributes to well-documented mental health issues among residents (residents experience clinical depression at a rate of 3-4 times their peers, and 23% of first-year residents reported suicidal thoughts. Source: https://www.psychiatrictimes.com/view/beneath-the-wheel). It also is bad for society – if working conditions for residents were not so poor we would likely see many more young people with other options choosing to become doctors. Preserving the status quo is great for those in your position, but let’s not pretend there’s anything good about it for anyone else.

    1. Sam,
      I believe it’s valuable for my readers to see your input. Medical training is a rough and long road, as you’ve voiced. I believe that if unions position themselves as forces for negotiating a better work situation, then both sides will win in the long run, with less burnout, and certainly less suicides. I do believe there is room for improvement and compromise in the future of resident education.

      Regarding your statement that residents are working more than 80 hours, this should be kicked upstairs to the Accreditation Council for Graduate Medical Education (ACGME) as a grievous complaint.

      What the general public does not want to see is a reality in which they are bringing their acutely ill child, spouse, or parent to an academic hospital, and instead of compassionate care from interns and residents, they instead see doctors carrying picket signs and there is no one to care for their loved one.

      I still believe we’re all lucky to be doctors. Medical school admissions have never been more competitive. Here’s some food for thought: If an applicant was asked at their medical school interview whether they’d consider striking as a fair behavior for young doctors, and they answered in the affirmative, I would bet that applicant would never be admitted to a single medical school.

      I believe the debate on your grievances is healthy, and if talks between unions and medical training programs can hammer out solutions short of calling for strikes, then unions will be valuable.

      1. I think that CIR and residents have done a good job of balancing the need to put pressure on hospitals without impacting patient care. The reality is that if residents are more learners than anything else then a hospital should be able to function with half if us on strike i.e. good programs should be able to withstand a resident strike because the attendings and other staff would pick up the slack in an adequateky staffed hospital. The other reality is that at one of the hospitals above you discussed a lot of issues were safety related. For example, female surgical residents not having access to good fitting lead and residents not having access to lead glasses in the or. Another example, is 1 senior medicine resident covering 30 icu beds on their own at night (including having to do admits and codes in the whole hospital) at the height if the pandemic. Or attendings refusing to see covid patients and just waving from the window while residents were repeatedly at risk and have really bad health insurance. These are just some of our issues. The reality is that there is a lot of pressure that can be put on hospitals without having to strike (especially about the issues that we care about most -health and safety).

        Current resident at one if the above programs

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