Resident Physician Abuse: Are Unions the Answer?

Lexi Krupp

August 04, 2020

After rationing three N95 masks for more than a month at her hospital, Victoria Kalawur, MD, contracted COVID-19 at the end of April. She suspects she got sick from her own mask. A week after testing positive, the internal medicine resident physician still hadn't fully recovered, but her institution, Rutgers New Jersey Medical School, told her to return to work anyway. "I spent every day [during recovery] fighting with my employer for another day off," she said.

Angered by interactions like this, as well as inadequate hospital staffing and scant PPE, hundreds of residents at Rutgers signed a petition to the university. They requested hazard pay, disability and life insurance, added protections for immunocompromised and pregnant physicians, expanded PPE supplies, and changes to their allotted sick leave.

The group responsible for the petition was the union of resident physicians at Rutgers, a local chapter of the Committee of Interns and Residents (CIR), which represents more than 17,000 residents at nearly 60 hospitals across the country. Across the nation, resident unions have sought a guarantee of workplace protections in the wake of the pandemic. Some campaigns have been more successful than others.

Residents, inherently, are a vulnerable population. Still in training and without the professional standing or institutional resources to advocate on their own behalf, they are susceptible to abuse. The pandemic has exacerbated problems related to safety and well-being, prompting many to consider joining unions that advocate on their behalf. "The union has come to be one of the things that residents constantly talk about now," said Kalawur.

Resident unions are not universal. Their existence depends on state and local laws, whether hospitals are public or private, and the administrative culture at each institution. And they have one major limitation: Strikes, the most powerful collective bargaining tool available, can jeopardize patient care. Yet many residents feel unions represent the best means of securing things like safe working environments and fair pay.

"COVID was a big awakening for a lot of residents," said Lola Mudgistratova, MD, an emergency medicine resident at the University of Washington and a leader of the medical center's union, the University of Washington Housestaff Association. "We can't count on these institutions [hospital systems] to stand up for us," she said. "It feels like it's the white coats against the suits. And that's a terrible feeling to have."

Unions Have Made Headway

Resident unions typically negotiate years-long contracts with medical centers to secure adequate compensation, benefits, and working conditions. They are funded through annual union dues, which range from a few hundred dollars at some institutions to 1.5% of salaries at others.

These organizations do more than negotiate for pay and benefits. They fight against out-of-title work, oppose unjust evaluation systems, advocate for access to mental health services, and provide legal counsel. "Even with the nicest, most responsive administration, there are reasons that residents need unions," said Sudipta "Nila" Devanath, MD, JD, an internist in Virginia who just completed her hospitalist residency at Yale School of Medicine, which does not currently have a resident union.

During her tenure as a member and co-president of the Yale Resident Fellow Senate, Devanath heard from numerous residents who were put on educational probation or remediation — or even kicked out of their programs — without representation by an attorney or an independent investigation outside of Yale Medical School. "I can't even count on my hands how many times residents have been referred to me [for this reason]," she said.

A representative for Yale explained that residents are involved in the review and approval of all graduate medical education policies. Yet, Devanath says Yale's Senate has limited power to change the grievance policy. "That would really take a union," she said.

Many residents turn to unions after experiencing frustrating environments or outright abuse. Amy Plasencia, MD, an internal medicine resident in New York City and vice president of the CIR, first became involved with the group at her hospital after learning the organization was working to decrease the amount of phlebotomy work for residents. After numerous meetings between the union and the administration, the hospital invested in phlebotomists on every medical floor. "Seeing the tremendous impact that had in my day-to-day life really inspired me to become more involved," Plasencia said.

At medical centers in high-cost cities like San Francisco and Los Angeles, resident unions have negotiated generous housing stipends of $12,000 or more, on top of starting salaries of over $60,000 for first-year residents — almost $5000 more than the national average.

Unions have wrangled other benefits for residents, too. At the University of Michigan, the 3-year contract ratified in June included 6 weeks of paid parental leave and extra pay when residents work on their birthdays and holidays.

More recently, during the pandemic, unions such as the University of Washington Housestaff Association have established agreements with their institution to provide proper PPE, training for removing contaminated gear, and a guarantee not to assign residents who are pregnant or immunocomprised to work with COVID patients. "[The pandemic] has really put a magnifying glass on the impact that being a unionized resident makes," Plasencia said.

Another factor in the rise of resident unions is a change in demographics. Increased diversity — in genders, economic backgrounds, and races — among younger doctors has required new considerations for financial compensation and benefits, such as childcare. "If we're going to promote diversity, then we need the culture of residency to change," Mudgistratova, of the University of Washington, said. "We have to do that advocating for ourselves."

Limitations and Drawbacks

For residents seeking immediate help at institutions in which there are no unions, organizing one will not provide speedy solutions. Forming a union is a years-long process, according to a representative at the CIR. Resident physicians who begin the organizing process are almost certain to finish their training by the time the group is recognized. And once a group is established, there is a constant turnover in membership, requiring a new cohort of committed members every few years.

Although the pandemic may be driving interest, it is a difficult time to start a union, Placencia said. "The current political environment is not very friendly towards unionization." To establish a union at a private institution, residents must go through the National Labor Relations Board. This federal agency is composed of five positions, only three of which are filled — all by officials who have been called antiunion and were appointed by President Trump.

In the public sector, a 2018 Supreme Court case limited the ability of unions to secure funding by preventing the organizations from collecting "fair share" fees from nonmembers, according to Paul Mirowski, JD, legal counsel for the San Diego House Staff Association, who represents residents and fellows at UC San Diego School of Medicine. "It's created a huge problem for us," he said. Because funds can only come from members, groups must divert time and energy away from advocacy and into marketing and recruiting. "If we don't get people to join our union, we're gone," Mirowski said.

Even for established unions with widespread participation, negotiations with institutions need not be smooth or successful. In part, this might be because physicians are typically unwilling to initiate complete work stoppages, because full-on strikes could severely compromise patient care.

As an alternative, resident unions have in particular favored minimally disruptive walkouts, dubbed "unity breaks." They have also appealed to elected officials and have created public outreach campaigns to pressure hospital administrators into providing better working conditions.

At the University of Washington, Mudgistratova became involved with the Housestaff Association when she learned that hospital leaders initially refused to meet with residents outside of the hours of 9:00 AM and 5:00 PM to negotiate their contract, hours when most residents were working with patients. "It was really mind-boggling. It was pulling teeth," she said. At the time, residents were calling for higher wages, expanded childcare benefits, and guaranteed access to reimbursed cab fare for residents who work overnight shifts — some as long as 28 hours.

After months of negotiations, the union organized a 15-minute unity break of hospitals in September. This didn't secure the University of Washington residents an offer they wanted, and the pandemic further delayed negotiations, Mudgistratova said. In May, the union took out a full-page ad in the Seattle Times to demand a fair contract and gained endorsement from the Seattle City Council.

The union ultimately signed a contract with the university in June that included a 2% annual salary increase for the next 3 years and a housing stipend of $2400 per year. The union's website points out that Seattle's cost of living typically rises 3% each year. Timothy Dellit, MD, the University of Washington's chief medical officer, said that, given financial challenges at the institution that were exacerbated by the pandemic, "we believe this is the best offer that we could make."

Overall, union members were unhappy with the final agreement. "This remains a deal we have, not a deal we want," residents wrote. "We didn't get the result we hoped for," admitted Mudgistratova.

Critics of resident physician unions point to other concerns beyond a lack of effective negotiations. Some within medical education have argued that unions lead to "inevitable conflicts" that pit the needs of residents against the needs of patients, especially when resources are scarce.

But the idea of choosing between patient and resident well-being is based on a false dichotomy, union supporters say. Denying residents living wages and fair benefits doesn't help patients; rather, it "perpetuates the abuse that residents have had to endure," said Mudgistratova.

Better Than Nothing?

Although the pandemic has brought increased attention to some of the worst abuses residents face, these are not new problems, emphasized the CIR's Plasencia. "Nothing that happened during COVID wasn't happening before," she said. Even after pandemic-specific concerns have faded, resident physicians will have to keep fighting for fair compensation and protection. "There's still a need," said Yale's Devanath, "coronavirus or not."

In mid-July, more than 3 months after Kalawur and her fellow residents at Rutgers made their demands, their hazard pay arrived. The $450 — before taxes — was a small fraction of what they had requested. In early June, the university declared a financial emergency, and residents learned they would not receive their salary increase of 3% at the start of the fiscal year, as stipulated in their contract. "It was a real slap on the face," Kalawur said.

When asked for comment, representatives from Rutgers acknowledged ongoing disputes and stated that "any further discussions regarding the terms and conditions of employment will take place at the negotiating table with the medical residents."

Despite setbacks and challenges, many residents acknowledge that unions are a privilege for those who have them. "I'm really glad the union exists, especially after talking to residents at hospitals where there are no unions," said Ravi Upadhyay, MD, an internal medicine resident at Rutgers. "If the union didn't exist, many of these benefits would be reduced or not exist at all."

Lexi Krupp is a journalist who covers science and health stories for audio and print. Her work has appeared in Science Vs, Popular Science, Audubon Magazine, public radio, and elsewhere. You can follow her on Twitter @KruppLexi.

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