Why medical residents are joining unions

Eighty-hour work weeks. Low wages. Near-constant pressure to learn and perform. These hallmarks of residency are challenging enough. Add a global pandemic into the mix, and the multi-year crucible became a pressure cooker.

And while the pandemic highlighted the need for reform, the changes residents seek have been a long time coming.

Swelling ranks

The Committee of Interns and Residents (CIR) is the biggest housestaff union in the US. It had 16,000 members as of late 2019, but membership has swelled to about 22,000 since, as Sunyata Altenor, CIR communications director, told MDLinx. The union has added two new chapters in Illinois and Vermont, now totaling 69 hospital/residency programs nationwide.

“Usually in an academic year we’ll have one, maybe two new campaigns running,” Altenor said. “Earlier this year, four residency programs voted to join CIR within a 2-month period.”

Across the country, unionized residents have called for better wages, benefits, and working conditions.^[] A 2022 Medscape report found that the average US medical resident makes $64,200 a year.^[] Among the residents surveyed, 27% felt they were fairly compensated. Half of all respondents carry more than $200,000 in medical school debt, and more than a quarter owe more than $300,000.

Of course, low wages and high debt were common complaints prior to the pandemic. So was the lack of ancillary benefits, such as childcare. Many residents are in their peak childbearing years during their training. Some delay having children because childcare is cost-prohibitive or difficult to arrange due to the long, sometimes unpredictable hours of residency.

Tremendous strain on a struggling system

Lena Carleton, MD, a resident in the emergency and internal medicine programs at the University of Illinois Chicago, said she’s seen interest in unions pick up among her fellow residents in recent years.

“While I can't speak for all residents who have joined unions recently, I think the COVID-19 pandemic put a tremendous strain on an already struggling health system,” Dr. Carleton said in an MDLinx interview. “Many residents realized that unless they had a unified, active voice with power, hospitals were going to continue making decisions that would negatively impact their working environments, educational experiences, and even their health.”

Nicole Kosmider, DO, and Grant Lin, MD, PhD, have seen the same. Dr. Kosmider is an anesthesiology resident at the University of Vermont Medical Center, and Dr. Lin is a child neurology resident at Stanford Medicine in California.

Dr. Kosmider even called her decision to join CIR somewhat surprising, telling MDLinx, “I never thought I would be a member of a union. I assumed unionized programs had something wrong with them."

Dr. Lin also noted systemic problems in residency—some of the same ones that plague medicine as a whole, and that may have been exacerbated by the pandemic.

“We have an epidemic of burnout in medicine, and the pandemic heightened so many of the factors causing burnout,” he told MDLinx.

Collective bargaining in the face of burnout, and other issues, is essential, Dr. Lin said. In December 2020, Stanford residents protested against an initial vaccine distribution plan that left out nearly all housestaff. The institution’s leadership apologized and revised its plan.^[]

“The collective housestaff response to having been left out of the initial COVID-19 vaccine distribution demonstrated the impact we can have when we come together,” Dr. Lin said.

These residents have some other ideas about how they’d like to use that impact, too.

Calls for reform

For Dr. Carleton, reform begins with collective bargaining, which will give residents in her program the ability to negotiate contracts, file grievances, and escalate them in the face of unfair labor practices or a lack of good-faith negotiations. Without a union, it’s up to individual residents and sympathetic program leaders, department chairs, or graduate medical education representatives to take up the issue on the individual’s behalf.

“None of these options represented a unified action representing all residents and fellows, and none had very much power or leverage,” Dr. Carleton said.

Dr. Kosmider saw union membership as a path to more humane medical training and better medicine. She said that while all doctors join the profession wanting to be the best they can be, the training process limits their potential.

“Residents are seen as this limitless resource, but we are only human and we have human needs,” she said. “When you work as much as we do, it can be easy to neglect families, our health, and our friendships. To become exceptional physicians, we need working conditions that are sustainable and wages that provide for us.”

Dr. Lin wants an end to the grueling hours of residency—80 hours a week with shifts capped at 28 consecutive hours—which he said put patients at risk.

“The history of residency programs is marred by abusive working conditions,” he said. “It's worth questioning if we truly want our doctors working over 24 hours at a time without sleep.”

If this trend of unionization continues, these reforms just might become the norm. According to Altenor, the CIR chapter at the University of Massachusetts just ratified its first contract in June, and four other hospitals that recently joined will soon be heading to the bargaining table, where they’ll join Dr. Carleton’s union at University of Illinois Chicago. She said that they’ve already achieved an important milestone.