American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

2020 RAS-ACS Symposium Teaser

Resident Unionization: Future of Resident Advocacy or Deterioration of a Profession?

Julia R. Coleman, MD, MPH; Navin Vigneshwar, MD; K. Benjamin Lee, MD; Brett M. Tracy, MD; Brett Starr, MD; Kate Stadeli, MD; and Randi Ryan MD

Medical school debt, work-life balance, wellness, and salaries discordant with cost of living—these issues are only a few of the complex stressors faced by surgical residents. While the Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to maintain a Housestaff Association to advocate for residents, many trainees feel that these groups are not adequately positioned to effect change. For several institutions across the country, these circumstances have eventuated in resident unionization, giving trainees the authority to tackle sensitive and contemporary nodi.1 However, the concept of resident unionization is not without controversy. While proponents of resident unionization report an increase in the recognition of their voice, enhanced communication with hospital administration, and more effective advocacy efforts, those opposed to resident unionization cite concerns that unions usurp energy and resources from housestaff associations or other existing leadership structures, distract residents from clinical and educational duties, and creates a confrontational, adversarial culture.

Now, more than ever before and in light of the ongoing COVID-19 pandemic, thousands of residents across the country considering advocacy issues, ranging from hazard pay and loan forgiveness to workplace safety, have re-ignited the debate about the role of resident unionization. To address these questions and discuss important, pressing issues in resident training, the Resident and Associate Society of the American College of Surgeons (RAS-ACS) Advocacy and Issues Committee hosts the annual RAS Symposium at the ACS Clinical Congress. Each year, the Symposium organizes a panel to discuss a current issue that affects surgeons and surgical trainees. This year, the 2020 RAS Symposium will explore the widespread opinions on resident unionization.

History of Resident Unionization in the United States

The National Labor Relations Act (NLRA), established in 1935, guaranteed all workers the right to unionize and enter collective bargaining.2 The original law included healthcare workers or physicians; however, in 1947, employees of not-for-profit hospitals were excluded from NLRA by the Taft-Hartley amendment due to the belief that disruption of health services would cause harm to public welfare.3 It was not until 1974 that Congress allowed physicians who were not “supervisors” nor employees of the hospital to enter collective bargaining.4 

The history of resident physician unionization follows a slightly different timeline. As far back as the 1930s, reports exist of residents in New York City who organized in an attempt to petition for improved salaries and working conditions.5 Later, in 1958, the Committee of Interns and Residents (CIR) was created and became the first organization of residents to successfully use collective bargaining to reach an agreement on a salary increase. The CIR Bill of Rights outlined resident physicians’ rights to many of the most important and clamant issues that trainees faced then and still do now (Figure 1). Built around these guiding principles, the CIR is currently the largest national housestaff union in the United States.6 Throughout the country, other training programs, from Michigan to Massachusetts, witnessed the successes of the CIR and followed suit to engage in successful collective bargaining at their respective institutions.7,8

Resident unions garnered national attention, controversy, and federal response. In 1976, the National Labor Relations Board (NLRB) ruled that residents working in private, non-profit hospitals were primarily students and therefore not eligible for collective bargaining.9 The 1976 ruling was in response to a petition filed by the housestaff of Cedars-Sinai Medical Center in Los Angeles, California for the right to organize in attempts to negotiate their salaries and working conditions.10 The primary argument made by the NLRB was that residency is considered a part of graduate medical education, in which salary is fixed and considered a stipend rather than compensation for services rendered.9 More than 20 years later, the previous NLRB ruling was revisited in 1999 after the consolidation of Boston City Hospital (BCH) and Boston University Medical Center into Boston Medical Center (BMC). As part of this consolidation agreement, the Boston City Council required that BMC recognize the House Officers’ Association (CIR) as the collective-bargaining representative of the 280 former BCH housestaff it had represented prior to the merge.7 Ultimately, the CIR filed a petition with the NLRB in order for Boston Medical Center Housestaff committee to be officially recognized as a union.11 As a result of this petition, the NLRB overruled the previous 1976 decision, thereby recognizing trainees as employees and granting them the right to unionize.7 This decision set a precedent and rekindled the debate around resident unionization.

Resident Unionization: The Future of Resident Advocacy?

Over the last 30 years, relatively stagnant inflation-adjusted wages, skyrocketing medical education debt, and decreased compensation packages have led resident physicians to begin exploring a unified presence to influence change where they work.12,13 While achieving clinical competence and excellence is an integral component of training during residency, developing a sense of professional identity is equally important.14 Many residents feel that creating a unified presence for advocacy and mobilization is an integral part of the pursuit towards professional identity. Additionally, the American College of Surgeons (ACS) strongly encourages trainee involvement in their leadership and advocacy efforts at the chapter, regional, and national level, augmenting trainees’ desire to pursue collaborative efforts for their respective institutions.

The CIR and other institutions’ resident unions have played a significant role in policy changes beneficial to their constituents, addressing issues from low salaries and increased premiums for resident health insurance to defining more reasonable work hours.1 With these historical models, the momentum supporting unionization has intensified. The increasing interest in resident unionization is multifactorial, but thought to stem from concerns over loss of physician autonomy, increasing regulations, decrease in physician-owned practices, and importantly, increasing desire to advocate for patient safety and quality of care in a bureaucratic system.15 More recent events with the COVID-19 pandemic further added fuel to the fire, generating an outcry to organize within the medical community to increase influence in both public and private sector16,17, whether in the form of unionization or short walk-outs to capture attention and empower discourse.18,19

In addition, within the last year there have been multiple incidents illuminating workplace harassment, abuse, and resulting suicidal thoughts among residents.20 Hu et al, in a cross-sectional national survey of 7,409 general surgery residents, found that 31.9% of trainees reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment; 38.5% of residents reported weekly burnout and 4.5% had suicidal thoughts in the past year.20 In the setting of these aforementioned pressing issues, from trainee wellness to insurmountable medical school debt, many residents feel existing leadership structures are insufficient to achieve meaningful negotiations and advocacy measures. The influence of historic mainstays, such as internal housestaff associations, may be complicated by bureaucratic barriers and the pathology of “placeholder leadership” which stall progress. For many, organizing a collective voice of residents via resident unionization is an attractive method of “taking the matter into their own hands” to improve work conditions.20,21 Contextualized within COVID-19 pandemic, collective bargaining has empowered residents who are working on the front lines of the pandemic to bring issues to hospital administrations, when individual resident concerns otherwise could have been easily overlooked or overpowered.22

Some argue that resident union advocacy only focuses on professional issues, which affect resident physicians and detracts from public support for physicians as “public servants.” While resident unionization certainly benefits its members, it also has great potential to effect positive change for patients, medical students, faculty physicians, and other healthcare workers.1 In fact, advocacy via resident unionization may allow residents to have an augmented role in decisions around financial and resource allocation for their patients. For example, residents in a New Mexico union advocated for part of their union funds to be allocated to a “patient care fund”, which distributes money for unmet patient care needs such as medical equipment, discharge medications, and transportation assistance.1 Additionally, empowerment of residents and improved working conditions could potentially lead to lower rates of burnout, harassment, and abuse. Furthermore, some bargaining efforts have resulted directly in more educational resources. For example, at Hurley Medical Center in Michigan, a resident union has existed since 1978 and effectively advocated for increased educational resources, including increased access to medical literature and computer labs for the medical campus.8 As resident unionization continues to empower trainees (and therefore physicians) to have a voice in pecuniary discussions, future generations of residents and possibly faculty physicians may have more power to advocate for both their patients and constituents.

Resident Unionization: Deterioration of the Profession?

Although the collective voice provides a platform to effect change for current and future resident physicians and their patients, for many, there are ethical, practical, and public perception considerations that are yet difficult to reconcile. In response to the NLRB decision to classify physician residents as employees and permitting unionization, the former president of the Association of American Medical Colleges, Dr. Jordan Cohen wrote of his concerns in an infamous article in the New England Journal of Medicine entitled “White coats should not have union labels”.23 In this 2000 article he writes, “The adversarial dynamics that frequently characterize labor–management relations in the American workplace are fundamentally antithetical to the atmosphere necessary for education. Educational objectives cannot be achieved without a firm foundation of trust between teacher and learner. The foundation for collective bargaining is, by contrast, naturally adversarial.”23 This quotation echoed through institutions where opponents of resident unionization voiced concerns about potential unanticipated adverse consequences of collective bargaining, especially among resident trainees. The primary ethical consideration against resident unionization is the loss of focus on patient-centeredness. Unions exist to promote the welfare of their members, and arguably a union’s most powerful tool, the strike or walk out, is an act that may be viewed as fundamentally contradictory a physician’s duty to care for patients.

Beyond potentially damaging the doctor-patient relationship, unions can foster an adversarial culture that corrodes the training and educational environment. Rooted in the threat of labor strikes when negotiations fail or unpopular policies are passed, unions run the risk of diminishing the trust between residents and their faculty mentors and hospital leadership. A commonly used example is the concern that a resident union may interfere with decisions related to resident promotion, remediation, or dismissal.24 These decisions fall within the realm of clinical performance and resident education and require cooperation between faculty and trainee to be resolved successfully. The involvement of an outside arbitrator related to a union in this process is seen as inappropriate and potentially detrimental.26

Another concern around resident unionization is that participation may detract residents’ time and focus away from their primary clinical duties. Organizing a union demands time away from the learning environment and patient care. For example, at the University of New Mexico, where a resident union has been in place since 2008, negotiations between the administration and the union require up to 3 hours a week for 6 to 12 weeks of the year.1 In addition to stealing residents from clinical duties, union dues are also paid from resident salaries for potential questionable benefit in the context of other existing leadership structures which have the same goals as resident unions. For example, the ACGME is already recognized as fulfilling the role of governing both working conditions and educational environment for residents, ensuring that residents receive adequate training.25 In addition to the ACGME as a whole, the Resident Review Committees (RRC) and institutional Graduate Medical Education Committees (GMEC) are venues that give residents the ability to negotiate for better working conditions. As such, one may argue that the only additional benefits granted by the payment of union dues are the right to organize walk outs and create legally binding negotiations.26

Finally, resident unionization may detract attention from one of the primary purposes of residency: training competent surgeons. Residents, by the very nature of the training paradigm, are temporary workers at an institution. This temporary state of employment at an institution is fundamentally different from other unionized workforces such as truck drivers, factory workers, teachers and police officers who face long-term employment at a steady salary level and need the power of collective bargaining to demand changes to their wages and benefits.1 Residency is a small portion of time in the lifespan of a surgeon. A surgeon’s ultimate success and total career earnings is predicated upon graduating with appropriate clinical decision making and demonstrable surgical competence, which requires full attention, time, and focus. Optimization of clinical training, rather than short term salary increases and benefits, should be the focus of efforts to improve residency programs.27 Ultimately, despite the potential benefits of resident unionization, these concerns about misdirected attention and energy of residents creates doubts over the benefit of unionization.


In 1864, in response to the New York Workingmen’s Democratic-Republican Association, Abraham Lincoln said, “The strongest bond of human sympathy outside the family relation should be one uniting working people of all nations and tongues and kindreds”.28 Indeed, regardless of the trainee, type of program, or region of the United States, surgical residency has a unifying power. Similar to most unions, resident physician unionization has a tumultuous history involving the NLRA, the Taft-Hartley amendment, the NLRB, and the CIR. The product of such legislation has offered surgical residents the opportunity to advocate for issues surrounding prodigious medical school debt, monetary compensation and educational funds, working conditions, quality of life, and even patient care. However, individuals who believe in a less-than-henotic representation of trainees purport that unions undermine professionalism, challenge the doctor-patient relationship, and detract from existing clinical and educational duties. Others believe collective bargaining is the best path forward and the results of negotiations can enhance residents’ ability to learn and care for patients without eroding professional relationships. This polarizing debate previously ensued at a limacine pace, but current events involving the COVID-19 pandemic have reignited the fight on the trainee side even as hospital administrations grapple with increased financial stress. While the solution to the dispute 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.


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