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  • 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?

  • Let’s find out.

  • Dr. Jubbal, MedSchoolInsiders.com.

  • 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, the significant increases were seeing 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 balanceand 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 resident 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 residentsdemands.

  • 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.

  • 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 residentssalaries, 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 trainingfor 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 for their training and instead

  • receive a salary 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.

  • I talk about this topic in depth in my Surprising Facts About the 2022 Match video over on the

  • Kevin Jubbal, M.D.

  • channel - link in the description.

  • 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 notdespite 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.

  • 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 shift, it wouldn’t

  • have been nearly 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 physicianand residency spots aren’t necessarily easy to come by.

  • If youre 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 work that they are doing.

  • 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 thatthis 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, I believe that 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.