The Unionization of Doctors in Residency


It’s common knowledge that residents work long and challenging hours for relatively low pay, but is unionizing residency programs the answer to these problems? Or do the potential costs outweigh the benefits?

Residents joining unions is not a new phenomenon; however, it has been more prominent in the media in the wake of COVID-19. Throughout the pandemic, many residents were required to take on larger numbers of very sick patients without additional compensation or social assistance. In addition, significant increases in inflation and housing costs as a result of the pandemic have further highlighted the issue of resident salaries.

These factors have led many residents to advocate more vocally for issues like increased compensation and better work-life balance – and unionizing has the potential to help make these changes a reality. This is exactly what residents at Stanford hoped to achieve by unionizing.

For months, Stanford residents and fellow physicians negotiated with hospital leadership for increased compensation to help keep up with rising inflation and increased housing costs in California. In May 2022, however, they won a union election for representation by the Committee of Interns and Residents, or CIR, which is the largest resident union in the United States.

By June 2, 2022, the union had given official notice to the hospital of plans for a two-day strike starting on June 13, 2022. In response, hospital leadership met with the union the following day and the county presented a tentative salary and benefits proposal in line with the residents’ demands. As a result, the strike was effectively avoided and the residents achieved what they had hoped for.

Although many see this as a win for residents and are calling for other residency programs to follow suit, some are concerned that unionization may bring its own set of issues. Let’s explore both sides of the debate starting with concerns about the unionization of residencies.


Concerns About Residents Joining Unions

To start, many fear that if residents across the country begin joining unions and fighting for increased compensation, it may negatively affect the cost of care for patients. Although federal funding helps pay for residents’ salaries, hospitals often still contribute to residency expenses.

Although residents intrinsically contribute to educational costs through their labor contributions, many argue that they are also receiving a tremendous amount of training “for free.” In some fields, including many subspecialized fields of dentistry, trainees are required to pay tuition for their clinical training.

In contrast, resident physicians are not required to pay tuition and are instead compensated for their work. Some fear that if hospitals have to increase compensation for residents, these increased costs may end up being passed onto the patient.

In addition, if hospitals are paying each resident a higher salary, they may be incentivized to offer fewer residency positions and spread their current residents even thinner. This would put further strain on the already limited number of residency positions leading to more unmatched medical students each year.

Another concern is that the collective contractual agreements that unions fight for may limit flexibility. As it stands right now, resident requests are handled on a case-by-case basis. Programs look at each request one at a time and try to come up with an individualized solution tailored to that resident’s situation. In contrast, unions often fight for collective contracts which apply to everyone.

The problem with this is that residents in different specialties often have different needs. Surgical residents, for instance, are required to perform a certain number of procedures in order to qualify for board certification. As a result, they may not be able to take advantage of benefits such as additional time off as they need to work a certain amount to fulfill their case number requirements. On the other hand, these same surgical residents may benefit from improvements to hospital on-call rooms that other specialties don’t utilize.

During negotiations between unions and hospitals, compromise is often required on both sides. If a union negotiates to increase time off and improve on-call rooms, it’s possible that the hospital only agrees to one of these terms. In this scenario, only some residents would benefit from collective agreements whereas others would not – despite having to shoulder the other cons that come with unionization.

Threats of resident strikes, such as the one that occurred at Stanford, also have the potential to fray relationships between residents and hospital staff leading to animosity between the two parties. This, in turn, could have a significant impact on the dynamic between residents and hospital leadership.

Resident strikes may also undermine the trust that patients and communities have in resident physicians resulting in strain on the relationships that resident physicians form with their patients.

Lastly, there is some research that suggests unionizing residencies doesn’t dramatically improve the residency experience. In a 2021 article posted in JAMA, the authors evaluated the association of resident unions with working conditions and well-being.

They found that although vacation time and housing stipend benefits were improved at unionized programs, unions don’t appear to improve burnout, suicidality, job satisfaction, duty hour violations, mistreatment, or program educational environment. The authors conclude that these factors should be taken into account as residents and residency programs discuss well-being and contemplate unionization.

In short, if the goal of unionizing is to improve resident well-being through addressing issues like burnout, depression, and suicide, the data suggests that it may not yield the result that residents and programs are looking for. Instead of focusing our efforts on these issues, many argue that our focus would be better placed on other factors that are more effective in improving resident well-being.


Benefits of Residents Joining Unions

Now let’s explore the other side of the argument and talk about the benefits of residents joining unions.

Perhaps the most obvious benefit is that by unionizing, residents are able to participate in collective bargaining. When everyone is on the same page and fighting for the same cause, they have more leverage to get what they want.

We can see this in the case of Stanford. If it was only a handful of residents threatening not to show up for their shifts, it wouldn’t have been near as concerning for the hospital compared to a significant portion of their residents refusing to show up.

The value of this cannot be understated as residents, even relative to most employees in the U.S., are often in a position of powerlessness. After medical school, you need to complete residency training in order to practice as an attending physician – and residency spots aren’t necessarily easy to come by.

If you’re unhappy with your program, it’s not easy to leave and find another spot at a different program. Leaving residency is often perceived negatively and makes it incredibly difficult to find another position. As such, many residents are forced to endure much more than they would otherwise because the only other alternative puts their entire career as a physician in jeopardy. By coming together and unionizing, these residents are on a more equal footing with hospital leadership and have a much better chance of achieving their goals without risking their careers.

According to Medscape’s 2021 Resident Salary & Debt Report, approximately 57% of residents are dissatisfied with their compensation and 87% don’t feel that it reflects the number of hours worked. In addition, 81% report dissatisfaction regarding their compensation relative to other members of the medical staff such as physician assistants, nurse practitioners, and nurses.

Despite still being in training, resident physicians and fellows are second only to attending physicians in terms of their level of knowledge and expertise, yet their salaries don’t reflect this. Newly graduated nurses, NPs, and PAs are still training when they begin employment and have far lower levels of expertise but they earn substantially higher salaries per hour than the average resident.

According to the American Medical Association and Medscape, the average first-year resident physician makes around $60,000 per year and works greater than 50 hours per week. It is not uncommon, however, to hear of residents working upwards of 70 to 80 hours per week in many specialties.

If we use a modest estimate of around 60 hours per week on average, that comes out to an hourly rate of just $19 per hour. It is important to keep in mind that by this point in their training, resident physicians have over 8 years of post-secondary education and over $200,000 of student loan debt on average.

In addition, resident physicians perform many of the same duties as their attending physicians despite making only a fraction of the salary. Although resident salaries vary by state and program and increase by a few percentage points with each additional year of training, they are still several times less than the $260,000 per year that the average primary care physician earns and the $360,000 per year that the average specialist earns. As such, many resident physicians feel that their compensation does not come close to reflecting their level of knowledge and training or the value that they are providing.

By joining unions, residents may also be able to improve their working conditions. The majority of residents work more than 50 hours per week with nearly a quarter reporting working more than 70 hours per week. Although duty hour regulations exist that limit residents to 80 hours per week and require them to have at least one day off, this is averaged over 4 weeks. And even then, many programs violate these restrictions. As such, there are many residents working in excess of 80 hours per week, which translates to an average of 13 hours a day, 6 days per week.

Many residents argue that these long hours take a toll on them emotionally, physically, and psychologically and negatively impact their ability to provide care for their patients. As such, unionizing and improving resident work-life balance has the potential to improve patient care as well. Residents need to be able to put their own oxygen masks on first and take care of themselves before they can effectively take care of their patients.

Lastly, unionization can be beneficial for hospitals as well. By having a contract that applies to all residents, hospitals don’t need to spend time debating a broad range of requests from each individual resident. Instead, they can say that “this is the rule for everyone, and we can’t deviate from it.“

For too long, residents have been hazed, overworked, and poorly treated. As a consequence of this, we have concerning levels of burnout, depression, and suicide among resident physicians. Although unionizing residency programs is likely not going to be the end-all, be-all solution to these issues, it is a step in the right direction.

That being said, even as resident unions fight to improve pay and work-life balance, we still need to take a critical look at the system as a whole to address these other deeply-rooted issues. Only then will we be able to produce a generation of happier, healthier, and more effective future doctors.

If you enjoyed this article, be sure to check out America’s Doctor Shortage Explained or Burnout in Medical Students and Residents.


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