When Gaelen Stanford-Moore, MD, MPhil, was an otolaryngology resident at the University of California, San Francisco, hospital administrators decided to make a change that would have had residents paying for overnight parking. Patients with airway emergencies, however, might suffer indirectly from this, and so resident union representatives, including Dr. Stanford-Moore, made hospital administrators aware.
Explore This IssueNovember 2023
“By discussing how crucial it was for residents to have parking provided while on call overnight in order to drive in from home and not look for cheaper parking farther from the hospital, we could take better care of patients with life-threatening emergencies,” she said. “This provided the hospital representatives with new context for what our jobs actually entailed.”
Currently a facial plastic and reconstructive surgery fellow at Oregon Health & Science University in Portland, Dr. Stanford-Moore said that the need for safe, easy, and free parking for on-call residents became much more apparent to the hospital when residents in multiple fields shared their experiences. “Ultimately, the hospital chose to continue providing free parking to on-call trainees overnight,” she said.
Thousands of medical residents nationwide have unionized in recent years or are currently voting to do so. Last spring at the University of Pennsylvania in Philadelphia, a large majority of residents and fellows filed to unionize with the Committee of Interns and Residents (CIR), a union that represents resident physicians nationwide. According to National Public Radio, insiders said that the existing House Staff Governing Council was extremely limited in what they could accomplish on behalf of residents and fellows and that concerns were often brushed aside. Similar efforts have occurred since the pandemic at the University of Vermont Medical Center in Burlington, the Keck School of Medicine of the University of Southern California in Los Angeles, George Washington University in Washington, D.C., Montefiore Hospital in New York City, and Mass General Brigham in Boston. According to WBUR radio in Boston, Mass General Brigham has one of the largest residency programs in the country, and unionization was supported by 75% of those voting, despite a campaign of emails and video messages from hospital leaders urging them to vote no.
What does this mean for the future? Sunyata Altenor, communications director for the CIR, the country’s largest house staff union, was quoted in an article in the AAMC News: “Every year, we had one or two new organizing campaigns, but once COVID hit, that number pretty much tripled. It was a massive wave, and we anticipate that it will continue to grow” (www.bit.ly/ResidentUnions).
Michael J. Ruckenstein, MD, MSc, an otorhinolaryngologist and director of residency training and education at the Hospital of the University of Pennsylvania in Philadelphia, believes that while otolaryngology residents were generally in favor of unionization, the process last spring was driven primarily by residents in programs larger than otolaryngology, such as internal medicine, anesthesia, and pediatrics.
“Many of them were quite heavily put upon during the COVID-19 crisis and perhaps didn’t feel heard or didn’t feel there was a mechanism by which they could make themselves heard,” he said. “I think that’s a lot of what drove the process, because one thing a contract does is provide a stipulated pathway to launch a grievance and have an advocate there for you at the table to help address it.”
Dr. Ruckenstein didn’t think the hardships of the pandemic impacted otolaryngology residents as much as other specialties but rather that they were sympathetic to their colleagues.
Residents at the University of California, San Francisco School of Medicine (UCSF) have been enjoying union benefits since 2017 and are now paid more; additionally, their meal stipends are significantly higher than at other medical schools, and being unionized has generally been helpful for residency recruiting, said Steven D. Pletcher, MD, director of the residency program in the department of otolaryngology–head and neck surgery.
While Dr. Pletcher was not involved with union negotiations, he recalls that money was the biggest issue, along with parking, resident lounges, and available and affordable food. (As far as hours worked, resident unions at UCSF have not impacted that issue beyond the Accreditation Council for Graduate Medical Education (ACGME) requirements that max out at 80 hours per week and stipulate no more than 24 hours of continuous scheduled clinical assignments).
“In some ways it makes my job easier,” said Dr. Pletcher. “When residents come to me and say, ‘We really need help with parking,’ or ‘We really need these other issues solved,’ I can tell them to speak to their union representative.”
UCSF otolaryngology resident Jacqueline Harris, MD, said that programs with unions were toward the top of her rank list. After a union representative came to speak at her residency orientation, she became a union representative herself. “In my first year of residency, my class started the year with a new contract that had just been bargained for and won by the union,” she said. “It detailed all of the new additions to our contracts that would enhance our day-to-day experiences, and I felt grateful for the changes that had been fought for.”
In Dr. Harris’s view, unionization efforts represent a larger collaboration among peers having a voice in spaces where historically they did not. “As otolaryngology residents who are frequently outnumbered by residents from other programs, it’s important for us to be participants because oftentimes our opinions and perspectives are unique,” she said.
In addition to salary increases, higher meal allowances, and parking reimbursement, the resident union at UCSF has bargained for longer parental leave and fertility coverage as part of resident healthcare insurance.
“Unionization continues to challenge the traditional residency model to ensure that residents are cared for holistically—spiritually, emotionally, physically, and mentally,” Dr. Harris said. “It serves to remind the institutions that we are employees and more than just the backbone of the workforce of the hospital. In the future, the union will continue to fight for higher wages in consideration of inflation and rising costs of living, plus resources to enhance our education along the way.”
Dr. Pletcher believes that there’s probably an evolution of unionization. “Even though we’re five plus years in, I don’t know that we really know the long-term impacts, but my experience so far is that it really hasn’t changed the traditional resident model,” he said. “It has just made our residents’ transition to San Francisco a little bit easier by decreasing some of the financial stress.”
While some residency directors like Dr. Pletcher haven’t experienced downsides to having residents who are unionized, even after several years, there are some who have. Mark Wax, MD, program director for the otolaryngology residency program and microvascular reconstructive surgery fellowship at Oregon Health and Science University (OHSU) in Portland, does believe unions serve a vital role in society and the economy. In a healthcare setting, however, he believes that unions often represent the interests of a broader group of residents and isn’t so sure that smaller departments, like otolaryngology, and the residents in them necessarily benefit.
“Sometimes the interests of the broad group may adversely affect certain constituencies,” Dr. Wax said. “The union may be negotiating for something that benefits a majority of their members but that’s detrimental to a select group of their other members, which are in a minority.”
Dr. Wax described having had a great system for recording and monitoring duty hours for otolaryngology residents, one that was individualized with a login and logout system that was pre-populated and easy to use. This system also enabled the department to take into account variability with on-call differences in shifts and proactively look ahead, predicting potential problems with duty hours in upcoming weeks or months. This system, however, didn’t fit the overall institution’s view.
“They wanted a system for the larger programs, and we were forced to adapt to that, which is suboptimal for our program,” he said. “Otolaryngology is a small piece of the pie. Over the last two decades, I’ve found that our program has always had collateral damage from overall decisions made by the GME office, the institution, and multiple other large national organizations when they make decisions or enact protocols that affect medical residents in the broader school of medicine.”
Dr. Wax said that another pitfall of unionization has been the fact that otolaryngology cannot offer some of the perks and benefits that they did in the past, such as various outings and purchasing books and loupes for residents, although he doesn’t think this has adversely affected residents from an educational perspective.
Dr. Ruckenstein anticipates some of the same once residents at Penn Med are unionized, even though he trained in Canada where residents were unionized 25 years ago, and he said that he never encountered a union issue or even a union rep.
“What it’s going to change is the discretion of program directors and other leaders in the department to address things at a departmental level,” he noted. “We’ll be governed by a contract—the same contract that governs all the residents in the health system, and we’ll be obliged to follow the rules and regulations stipulated in that contract, which diminishes our personal ability to address issues and provide benefits,” he said. “It just makes it much more official.”
A lot will depend on how the contract at Penn Med is written and whether it provides individual departments with latitude that allows them to bestow certain benefits on their residents. For example, in the past, otolaryngology residents could come to the otolaryngology department to request an increase in their cell phone benefit because they couldn’t get a cell phone at the benefit level provided. The request, and the phone, could then have been decided at the departmental level.
“Now, if the contract stipulates a certain cell phone benefit to the entire residency body, then that’s what we have to adhere to,” Dr. Ruckenstein said. “We can’t give a better benefit because we can’t have an internal medicine resident go to their PD and say, ‘Otolaryngology is giving $100 a month, and we’re only getting $50.’ It has to be equitable. Again, it could be that the contract will be written to allow certain levels of leeway to individual departments. But, in general, now we’re going to have to go back and check the union contract to see how something like this is supposed to be handled.” He added that this isn’t necessarily a bad thing—it’s just different.
Effects on Institutions
Are practicing physicians worried about unionization at other institutions? Last summer at Loma Linda University Health in California, residents and fellows voted to unionize, but the university pushed back against these efforts, citing its status as a religious educational institution and filing a lawsuit against the National Labor Relations Board. A federal judge dismissed the case in April, and Loma Linda has appealed. Prior to the vote, they argued against unionization efforts, stating that residents and fellows are students rather than employees as defined by the National Labor Relations Act.
“I think the answer is yes,” said Dr. Pletcher. “Change often brings concern and anxiety, and I think the traditional sense of a union is that it creates antagonism between the workers and the employers.” From a program director to resident standpoint, however, this hasn’t been Dr. Pletcher’s experience; he believes the relationship between residents and faculty is the same as it was in the pre-unionization days at UCSF.
“I think the special thing is that otolaryngology residents overall are interested and invested in their training,” Dr. Pletcher said. “While they want to be able to afford rent, food, and all of the basics, they’re still very committed to their position as residents and the same clinical care partnership they currently have with their faculty mentors.”
Dr. Stanford-Moore considers her residency at UCSF to have been a very positive experience: She received a great education and valued her mentorship. “The union wasn’t an angry place,” she said. “There was a general sentiment that we were grateful for opportunities to learn, but any job needs to evolve with time. Residencies nationwide have been shown to be very slow to change and adapt. The union serves as a positive way to have representation on a university level.”
Renée Bacher is a freelance medical writer based in Louisiana.