Should Surgical Residents Unionize?

Is resident unionization the strongest form of advocacy for a vulnerable population, or is it an inappropriate mode of self-protection with an erosive effect on the medical profession?

“This polarizing debate has become even more intense in the setting of the COVID-19 pandemic,” said Julia R. Coleman, MD, MPH, a general surgery resident at the University of Colorado Denver Anschutz Medical Campus.

Surgical residents have long faced a number of stressors, including job market uncertainty, work–life imbalance, medical school debt, and salaries that don’t keep up with the cost of living. The coronavirus pandemic has added new concerns, such as access to personal protective equipment and adequate sick leave.

“Residents are asking themselves again, ‘What is our best mechanism for advocacy?’” said Dr. Coleman, the chair of the Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS), who introduced a debate on the topic at the virtual 2020 ACS Clinical Congress.

Pro: Unions advocate for residents and ensure employer accountability.

Why would residents want to form a union today? In 1999, when the American Medical Association (AMA) House of Delegates voted to form a union, Physicians for Responsible Negotiation, it was largely to protect physicians from unreasonable demands. In the case of residents, these could be requests for unreasonable working hours or conditions, said Susan Adelman, MD, a former professor of surgery at the University of Michigan in Ann Arbor.

“Now the reasons might be related to electronic health records [EHRs], fallout from hospital mergers, lack of protection for resident physicians who are pregnant, and issues of patient safety,” she said.

The Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to maintain a house staff association to advocate for residents, but some trainees believe those groups are not adequately positioned to effect change, Dr. Coleman said.

In addition to the house staff requirement, the ACGME has a number of other requirements of residency programs designed to protect residents; programs that fall short of meeting these requirements risk loss of accreditation. That may be a powerful motive for a program to follow ACGME guidelines, but it’s not clear how an actual loss of accreditation would benefit residents, Dr. Adelman noted. “This would not be what residents want.”

She acknowledged that unionizing can create an “us versus them” relationship with administration, which is why it should be used as a last resort, “when you’ve tried to solve a problem in a collegial way and failed.”

A commonly held perception of unions is that striking is their most powerful tool; to many, the idea of a physician strike seems antithetical to the profession. Sriram Rangarajan, MD, MAS, a general surgery resident at Arrowhead Regional Medical Center and Kaiser Permanente in Colton, Calif., observed, “The morality and ethicality of a resident physician strike is unclear.”

“Consider the power of the press. If you call a reporter or post on social media and explain that the objectives of the union are good for the hospital, for patients and for the community; if you argue that the hospital’s resistance is harming the community or patient care, that’s powerful leverage.”

But unions can use less disruptive tactics to get their point across, Dr. Adelman said.

Brooke Bredbeck, MD, a surgical resident at the University of Michigan in Ann Arbor, acknowledged that opinions on unionization are highly charged: heroic defense of workers’ rights versus bureaucratic obstructionism. In medicine, where the stakes are high and labor practices are restricted, unions should be used only under one of two conditions, she said: “first, if employees are exposed to unsafe working conditions, and second, if employees cannot engage in a competitive market and are therefore at high risk for exploitation.”

The implementation of duty-hour restrictions aside, medical residency has changed little over the past decades, and a substantial factor limiting reform is financial, Dr. Bredbeck said.

“While medicine is a calling for physicians, it’s a business for the hospital. Hospitals readily take advantage of resident salary price fixing, and residents are often scheduled to cover the longest and most undesirable shifts, not for educational purposes but because it serves the bottom line of the hospital.”

A union can serve as a powerful advocate when dynamics are unbalanced, she said—for example, to collectively bargain for fair wages and working conditions. At her institution, the union also advocates for benefits, such as paid parental leave for non-birthing parents.

“If a dispute occurs and cannot be resolved within the program, which is, of course, the preferred method of resolution, the union has administrative and legal authority to pursue resolution.”

Con: Unions foster an adversarial culture and can jeopardize resident training.

As John Potts III, MD, a senior vice president of Surgical Accreditation at the ACGME, sees it, considering that only a slim minority of physicians in the United States belong to a union, perhaps only a few thousand out of nearly a million similar organizations are unwanted.

“Potential members are staying away in droves,” Dr. Potts said. “It’s also difficult for me to believe that patients want their physicians to be union members.”

Physician unions are also unnecessary, he said, observing that the ACGME protects many of the same standards as a union would.

“If one goes through the due process of one’s own institution and is not satisfied with the outcome, one can always file a complaint directly with the ACGME,” Dr. Potts said.

Unions are also not necessary as tools for advocacy at the state and national level, Dr. Potts said. “The ACS, the AMA and many other membership organizations actively advocate not only on behalf of practicing physicians but also on behalf of residents.”

The most important argument against resident unions, he said, is that they are unprofessional. “The ‘hammer’ of any union is a work stoppage. Any work stoppage in the care of patients betrays not only those patients but also the profession.”

Although he agrees with Dr. Adelman that there are several issues for which residents may wish to advocate, “patient safety, the burdens of EHR, fallout from the seemingly never-ending hospital mergers,” they should not strike.

“They should advocate through their local resident forums, through the RAS and ACS, and even through social media.”

At a fundamental level, Dr. Rangarajan argued that resident unions are inappropriate because unions were designed to protect laborers, and residents are not laborers. Despite the National Labor Relations Board’s 1999 decision to consider residents primarily as employees, their duties and responsibilities align more closely with those of students, he said.

“Residents are apprentices who are expected to combine on-the-job acquisition with daily study and repetition.”

The amount of time residents have to accomplish these goals is finite and regulated by the ACGME, and residents already struggle to balance academic endeavors with family responsibilities and other life matters, Dr. Rangarajan said. He observed that some potential union demands, like shorter work shifts, more days off and limited call could further chip away at their time in training.

“Residency is a fleeting, precious time; the closer it comes to an end, the more apparent this becomes,” Dr. Rangarajan said.

Furthermore, “unionizing as surgical residents has the potential to complicate the relationship with faculty and undermine the public’s trust in resident surgeons.”

Wrapping up the debate, Dr. Coleman reiterated physician unionization’s tumultuous history. Those who support unionization see it as a way that residents can advocate for issues ranging from medical debt to patient care without eroding professional relationships, while those who oppose unionization argue that it undermines professionalism and detracts from clinical and educational duties.

“Ultimately, while the solution to this debate could be specific to each institution or region, there must inevitably be an effective mechanism for residents to voice their concerns, be heard and understood, and most importantly be respected,” Dr. Coleman said.

This article is from the December 2020 print issue.