Grant Lin was asleep — just off a night rotation — but waking up every few hours that morning to check his phone for progress.
Meaghan Roy O’Reilly was checking the group chat for updates during her Maui vacation.
It had been a year of organizing, juggling their residencies, their personal lives, and one-on-one meetings with as many of the 1442 residents and fellows at Stanford Medicine as they could connect with.
Together, about 20 organizers had done the leg work. And they were ecstatic but not surprised when Stanford house staff last month overwhelmingly voted to unionize by 81% of the 1049 votes cast.
Stanford was one of three hospitals to ratify a local chapter of the Committee of Interns and Residents (CIR) within the past two months. The other resident unions were formed at Keck School of Medicine of USC in Los Angeles and University of Vermont Medical Center (UVM).
A recent uptick in medical trainee unions across the country as documented by CIR comes during a lull in the pandemic that allowed residents and fellows to come up for air after serving on the oppressive front lines. They are seeking improved working conditions and higher compensation to protect themselves from overload, according to O’Reilly, a PGY-2 adult neurology resident, and other union leaders.
Eduardo Fernandez, a PGY-5 hematology and medical oncology fellow at Keck, said the “bare minimum we want is parity” with the residents working at the nearby public hospital associated with USC, LAC + USC Medical Center.
Dr Eduardo Fernandez
The county hospital unionized several years ago, and the residents and fellows there get better pay and benefits for serving the same populations as Fernandez and his colleagues, he said. The Keck union will soon start negotiating for the same educational stipends and bilingual bonuses.
Even with better pay and benefits, the CIR chapter at LAC + USC and two of LA’s other large hospitals voted this week to strike over unfair labor practices and bad faith bargaining conduct by the county. CIR reported Thursday that the strike, planned for June 13-15, would be the first time its resident physician members have gone on strike since 1990; that strike occurred in New York.
“A Captive System”
The problems faced by residents are not new: Salaries that come out to minimum wage, unaffordable housing, and work beyond their scope of practice, such as assuming the additional role of a phlebotomist, courier, or nurse in an understaffed hospital. But as overwhelmed hospitals battled COVID, residents became more keenly aware of how vulnerable they really were.
Dr Rebecca Merrifox
Fixing difficult working conditions for these trainees is not easy. “Residency is this captive system,” said Rebecca Merrifox, a pediatric PGY-2 resident at UVM. Because residents are placed by the Match process, changing residencies is extremely difficult. And with excessive debt and time invested in their medical training and their ability to practice medicine in the hands of the hospital and supervisors, residents are disincentivized to push back against or leave a challenging work environment, she said.
“Residents don’t have much power or leeway to demand more or better,” said Sunyata Altenor, communications director at CIR. Many hospitals have committees where residents chair and advocate for better conditions, but the hospitals can effectively “drag on the issues” and wait out the resident’s 4- to 6-year tenure, she said.
At Stanford, union organizing dated back to the hospital’s vaccine rollout, said Lin, a child neurology PGY-2. The algorithm used by the hospital to give out the first rounds of vaccines completely left out residents and fellows — even though they were on the front lines. It became very clear “how little importance” the hospital viewed the work residents were doing and the risks they were taking, he said.
A rally by residents and fellows followed. The Stanford algorithm made headlines. And after the residents staged a walkout, the administration started to respond. Union leaders saw “how much that collective voice can have an impact,” Lin said. And that’s when a core group of house staff started working together to hang onto their newfound agency by unionizing.
As O’Reilly met with fellows and residents at Stanford, she was surprised by their needs. “I knew my reasons for wanting to unionize. [But] the more I talked to people, especially our fellows, there are so many things that people were hopeful a union might be able to help with.” Parental leave was huge at Stanford. And guidelines about moonlighting — whether extra hours were paid or volunteered — was of major interest to some.
At UVM, a “housing stipend was a huge interest,” Merrifox said. In her conversations with other residents, she learned of colleagues who’d lived in their cars, hotels, or in apartments unable to afford furniture. Some had seen rent hikes as high as $1000 in the last year. Because many residents are required to live near major teaching hospitals in increasingly expensive cities, housing stipends are a frequent focus of resident unions, Altenor said.
The new crop of resident unions across the country is a reflection of months and years of work on the organizer’s part, according to Jennifer Curry, JD, an employment attorney in Baltimore who specializes in working with employers in the healthcare field.
In the past, “the reason why you really didn’t see it all that much is that residency traditionally is a pretty short-term employment situation,” Curry said. “By the time anybody organized enough to get a union up and going those residents that started the union campaign would have been graduated.” Since they often didn’t personally benefit from unionizing, many students lost motivation.
Part of the reason unions are gaining more traction now is because of outside organizations such as CIR, Curry said. These, in many ways, have streamlined the process. They know what it takes to successfully unionize, they can advise house staff, and they can push for these effects to last well beyond a single class of residents or fellows.
CIR spent years fighting the idea that residents are students. “Once we’ve established residents are not students, but are employees, there are very clear federal protections around them unionizing,” Altenor said. And CIR has successfully argued this point with the National Labor Relations Board enough times that it has moved beyond the issue in the last few years.
But unions still face other forms of opposition.
“I was surprised that there was a lot of advertising or messaging from our hospital that was quite negative,” O’Reilly said. Some schools push back more than others. Stanford and UVM presented strong anti-union campaigns.
At Stanford, the administration sent mailers instructing residents how to vote “no.” And sent emails detailing how disappointed they were in trainees. At UVM, the hospital “hired a team of lawyers and spent quite a bit of money” to push the antiunion messaging, Merrifox said. Residents were even required to attend anti-union lectures during their education time, she said.
But landslide votes at Stanford and UVM confirmed that residents were still in solidarity, even after the administration’s counter.
Fernandez said that’s partially because of the connections they formed amid the pandemic. In the last 2 years, Fernandez worked in New York City and Los Angeles County. At both locations, he said residents and fellows stepped up to help patients regardless of the conditions. “It showed some unity, all these different specialties you don’t really interact with coming together,” he said. Now that some of the pandemic strain has been lifted, residents are redirecting their collectivism to improve their work environment and earnings, he said.
Still, Curry doesn’t know whether unionizing will totally solve residents’ concerns. “The problem is residents are overworked,” she said. “Residents will continue to be highly motivated people who have years of training behind them and a lot of debt. They won’t want to jeopardize their future practice by seeming like complainers, or like they are shirking their responsibilities.”
Unionizing, however, is a step in the right direction, she said. Any further reform “requires a change in the culture of medicine.”
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