As the topic of residency unionization has entered the spotlight in recent events, discussions surrounding the utility, risks, and benefits of resident unions have also increased in popularity.1–10 This study evaluated the perspectives of General Surgery trainees on residency unionization as an intervention for improving their financial wellness.
In May 2020, a survey approved by the institutional review board of the Veterans Affairs Boston Healthcare System was distributed nationwide by general surgery program directors in the Association of Program Directors in Surgery on a voluntary basis to their residents. The survey consisted of 30 questions (19 multiple-choice; 8 yes/no; 3 open-ended) focusing on the financial situation of the general surgery residents.11 Participants were informed in writing that by answering the questions and returning the survey, they were providing and documenting their consent.
A total of 419 general surgery residents completed the survey. The response rate could not be calculated because the method of distribution of our survey did not allow us to know how many general surgery residency program directors decided to distribute the survey to their residents.
Survey respondent demographics are described in Table 1.11 Respondents were mostly age 30-39 (55.1%), male (53.6%), single (53.9%), and white (63.1%). The majority of respondents trained in the Northeast (46.5%) and Midwest (29.3%), with a minority from the Southeast (12.2%), Southwest (6.7%) and West (5.3%). Respondents were distributed among PGY-levels (12.7-23.8%).
Nearly three-quarters of respondents (73%, n=305) believe that resident unionization would improve their financial compensation (Figure 1). There were no demographic-related differences in our participants’ responses.
The benefits of unions in the nursing profession have been well studied, with a reported 5.5% reduction in inpatient mortality in California hospitals with nursing unions.12 However, only 11.4% of other health care practitioners and technical workers report union membership.12 Despite the relative lack of participation among healthcare workers, numerous articles relate the implications of residency unionization.
Resident unionization is not a novel concept. The first union was organized in 1934 to advocate for compensation, as residents were initially not paid.13 Then in the 1990s, the topic of discussion was the debate about whether resident physicians were considered employees in relation to federal labor laws.13 Most recently, the University of Vermont Medical Center voted to launch a resident union. Public attention was drawn to this event as Senator Bernie Sanders sent a letter in support of the efforts to form a union. Sanders raised the issue of the 80-hour work week and low salaries. He emphasized the importance of advocacy in the face of the COVID-19 pandemic.14 The COVID-19 pandemic played a major role in raising awareness of the working conditions of resident physicians. The Committee of Interns and Residents (CIR), the country’s largest resident union, saw a near tripling of the number of new programs organizing a union.13
The role unionization plays for residents centers around advocacy for aspects like pay and working conditions. Some unions have voted to do away with 24-hour shifts, while others increased pay and benefits. Having a union can also play a beneficial role for hospitals, where patient safety and quality care are emphasized. Well-rested residents may have more capacity to address their patients’ needs more effectively.13
The organization of resident unions is not without its risks. Actions taken by unions could affect how physicians are viewed professionally.12 Resident unions may compromise professionalism, cause a rift in the relationship between trainee and educator, and introduce administrative third parties in making decisions regarding clinical duties.15 A potential disadvantage to patients when patient care is compromised during physician strikes or unionization. Medicine is a service profession, and how society views physicians is surrounded by the idea that physicians are altruistic. Formation of a union or physician strikes could alter that view of physicians by society and patients.13 Lastly, residency unionization has its own financial impact on hospitals, as training has costs associated with it, along with the benefits offered by individual hospitals.13
When it comes to surgical residents, the idea of residency unionization has a number of unique implications to the specialty. First, surgical residents are required to complete a certain number of cases to graduate from residency. Therefore, there can sometimes be more pressure on residents to stay longer in order to complete a case that is required for residency graduation. Extra time off may not be as beneficial, as it would mean less time to complete the requirements.13
In a cross-sectional survey investigating the effects of resident unions on the well-being and working conditions among surgical residents in 2021, 10.5% of respondents were unionized. There was no difference in burnout, suicidality, thoughts of attrition, dissatisfaction with the decision to become a surgeon, dissatisfaction with time for rest, duty hour violations, discrimination, or bullying between residents at unionized versus non-unionized programs. There were no significant differences in reports of dissatisfaction with educational quality, inadequate time for patient care, lack of support staff, and the perception that their program did not take wellness seriously. There were no differences in reported protected educational time, operating room time, operative or clinical autonomy, or program responsiveness to resident concerns. Although salary did not differ between unionized and non-unionized programs, unionized programs more frequently offered 4 weeks of vacation and housing stipends. Rates of subsidized childcare, relocation, and technology stipends did not differ.15
The current literature on resident unionization has not made a clear argument for or against the concept. There are benefits as well as drawbacks in the organization of residency unions. However, the potential for improving the overall culture of residency is worth continuing the discussion.
This study has several limitations. Given the voluntary distribution method by program directors, a response rate was not able to be calculated and the opinions of non-responders is unknown. Additionally, our sample was largely from residents training in the Northeast and Midwest, and as such, our results may not be generalizable to all surgical residents nationwide. However, the results were similar across geographic regions, suggesting that the results are likely reflective of the perspectives of surgical residents as a group. Furthermore, although we surveyed residents from multiple different institutions, we were not able to compare each program’s individual responses.
Despite these limitations, this study suggests that general surgery residents believe that unionization could improve their financial support.
General Surgery residents support unionization as an approach to improving their financial wellness. While more evidence is necessary to determine whether unionization can lead to increased resident compensation, the Accreditation Council for Graduate Medical Education and residency programs should work with surgical residents to create solutions for improving their financial well-being.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.