Unions Not a 'Silver Bullet' to Improve Resident Well-Being

Lucy Hicks

September 20, 2021

Although unionized surgical residency programs offer more vacation time and housing stipend benefits, membership does not necessarily improve resident well-being, research suggests.

In a study published September 1 in JAMA Network Open, residents in both unionized and nonunionized programs reported similar levels of burnout, job satisfaction, and suicidality. Duty hour violations and mistreatment also did not differ between the two groups.

Dr Brian Brajcich

"When you're looking at ways to really address burnout and some of these issues in [residency] programs, contrary to what we've sometimes seen in news articles, forming a union doesn't seem like it's going to solve everything," Brian Brajcich, MD, a fourth-year surgical resident at Northwestern University Feinberg School of Medicine, in Chicago, Illinois, told Medscape Medical News.

Physician burnout has become increasingly common in medicine, and residents are at higher risk because of long hours and concurrent educational requirements. Resident unions, which negotiate with medical centers for improved compensation, benefits, and working conditions for their members, are sometimes advocated as means to improve resident well-being, Brajcich noted, but there were no recent data to support this.

To find whether resident unions do improve well-being, Brajcich and colleagues administered a survey to general surgery residents who completed the 2019 American Board of Surgery In-Training Examination (ABSITE). ABSITE is an annual 5-hour computerized exam taken by all residents at general surgery residency programs accredited by the Accreditation Council for Graduate Medical Education. The survey was administered immediately after the ABSITE in January 2019, using the same software that was used for the examination. Participants were asked how often they experienced the following:

  • Symptoms of burnout, such as depersonalization and exhaustion

  • Duty hour violations (working more than 80 h/wk, receiving less than 1 day off per week, or taking in-house call more than once every 3 days)

  • Discrimination, harassment, or other mistreatment due to gender, sexual orientation, race, ethnicity, or religion

Residents also reported whether they had considered suicide in the past 12 months and their satisfaction with their educational and work environments.

The authors collected data on residency programs' salaries, vacation time, and availability of stipends for housing, relocation, childcare, and technology using FREIDA, the American Medical Assosciation's residency fellowship database, as well as publicly available employment contracts and program websites.

Responses to the survey came from 5701 surgery residents in 285 programs. Of the respondants, 56.5% were men, 66.3% were White, 17.7% were Asian, and 5.0% were Black. Thirty residency programs (10.5%) were unionized; of those, 25 (83.3%) were affiliated with the Committee of Interns and Residents (CIR), the largest house staff union in the United States.

Researchers found no significant difference in the prevalence of burnout between unionized and nonunionized residents; 43.0% and 43.4%, respectively, experienced at least one symptom of burnout on a weekly basis. Suicidal ideation within the past year was reported by 3.8% of unionized residents and by 4.7% of nonunionized residents, but this difference was not statistically significant. The team found no difference in reported duty hour violations (44.5% vs 42.3%), discrimination (54.6% vs 53.5%), or bullying (66.0% vs 67.1%) between unionized and nonionized residents.

Unionized programs were more likely to offer 4 weeks of paid vacation; 93.4% of members received this benefit, compared with 30.6% of nonunionized residents. Unionized programs were more than twice as likely to provide housing stipends. There was no significant difference between the salaries. The average salary for unionized first-year residents was $61,932; their nonunionized counterparts took home $57,798 annually.

Dr Eva Gillis-Buck

"The purpose of the union in my eyes is to negotiate my contract with the hospital and help me make more money so that I can live comfortably and also be safe in the hospital," said Eva Gillis-Buck, MD, a second-year surgery resident at the University of California, San Francisco (UCSF), in an interview with Medscape. She was not involved in the study and is a CIR member. Although the study did not find a difference in income between unionized and nonunionized residents, housing stipends essentially translate to higher pay, she said. She noted that the housing stipend provided by UCSF, which is more than $13,000, allows her to afford housing and childcare in San Francisco.

Gillis-Buck also noted that paid parental leave is a huge bonus to joining unions, a factor that was not examined in the study. CIR has won its members 6 weeks of paid parental leave in addition to vacation, she added. In other unionized residency programs, however, maternity leave can be unpaid. "The fact that unionized residents make more money, have more paid vacation time, and have parental leave means that the union is doing its job really well," she said.

Gillis-Buck thinks subjective factors such as burnout may be outside of the union's control. "Unions can advocate for our wages and work environment but cannot change the culture of surgery, which attracts individuals (myself included) who value self-sufficiency and hard work without complaint, which may make us less likely to seek help and more susceptible to burnout," she wrote in a follow-up email.

Taking the survey immediately after having taken a long and stressful test may have affected participants' responses, she added.

Although Brajcich agreed that the study did show some benefits to unionizing residency programs, "there's not a clear signal that just going out there and forming a union is going to reverse a lot of these outcomes that are important for residents in terms of their well-being, in terms of their work environment, and in terms of the educational environment," he said. "Unions, in an of themselves, don't seem to be a silver bullet."

Brajcich and Gillis-Buck have disclosed no relevant financial relationships.

JAMA Netw Open. Published Online September 1, 2021. Full text

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