In Chicago’s South Loop, the nightly salutation to health care workers begins at 8 p.m., first with a few flashing lights from old holiday decorations, followed by a cacophony of car horns, boomboxes blaring ’90s rock, and metal railings being transformed into percussion sets. There’s even a laser light show — a blinding, neon green heart and lovingly yet poorly drawn electrocardiogram projected onto the façade of a high-rise apartment building.
The nightly celebration has become a source of comfort for us, two oncology fellows, as we nervously watch Chicago’s daily Covid-19 numbers. As thoughtful as the ritual is, though, it feels inadequate. Nurses, physicians, and other hospital workers are dying, including resident physicians working on the frontlines. All are suffering new emotional traumas, creating fresh wounds in places where scar tissue hasn’t yet formed.
As fellows, we join resident physicians, or residents as they are more commonly known, in the community of graduate medical education trainees. We are doctors who have finished medical school and are completing supervised training to become board certified, independently practicing physicians. Residents and fellows do much of the work in teaching hospitals, yet have little or no say about their working conditions and lack the bargaining power to improve them. The power imbalance between trainees and their hospitals has become even more lopsided in the Covid-19 pandemic.
Across the United States, health care workers, including residents and fellows, have experienced lack of access to adequate personal protective equipment, inadequate supervision in taking care of critically ill patients with Covid-19, and punitive measures when speaking out about their struggles caring for patients.
The nearly 35,000 resident physicians in the United States frequently work more than 80 hours a week for an average of $61,200 a year while carrying an average debt burden of more than $190,000. While pay and hours have improved somewhat over the past 40 years, residents endure three to seven years of this experiential learning to eventually gain their employment. Throughout that time, they meaningfully contribute to patient care and their hospitals’ bottom lines at every step.
A defining moment in every resident’s life is the National Resident Matching Program, usually known as The Match. Often compared to Hogwarts’ Sorting Hat, The Match’s algorithm pairs medical students with residency programs based on both parties’ preferences. Upon applying for The Match — but before matches occur — medical students and residency programs enter into binding commitments so all matches are final.
In this way, The Match has created a monopoly on the resident physician market, as medical students who seek to train at an accredited residency — a must if they want to eventually obtain a license to practice independently — need to apply for that residency job through The Match.
Physicians have recognized that The Match inculcates a culture of disenfranchisement, and the resulting lack of bargaining power sets the stage for abuse. Before and after The Match, residents are contractually committed to their assigned residency and are unable to negotiate pay, benefits, or, as Covid-19 has brought to light, their own safety.
Without the leverage to negotiate these fundamental conditions of their employment, the overwhelming majority of residents rely upon the beneficence of their hospitals, some of which have served as hotbeds of physical and emotional abuse, lost accreditation due to reports of sexual assault, or shuttered without warning as Hahnemann University Hospital did in 2019, leaving residents to scramble for new jobs in an intentionally distorted labor market.
In May 2002, a group of physicians brought a class-action lawsuit in federal court against several national organizations that oversee graduate medical education, including The Match and 29 teaching hospitals that sponsored residency programs. The case, known as Jung v. Association of American Medical Colleges, asserted that The Match is an inherently anticompetitive, collusive, and coercive agreement that violates antitrust law.
Fourteen months later, following lobbying efforts by the Association of American Medical Colleges (AAMC) and the American Hospital Association (AHA), which were bolstered by articles in academic journals stressing that “a legislative solution seems highly desirable,” a rider (appended to a totally unrelated bill) received bipartisan support and was signed into law by President George W. Bush. It stated that The Match simply was not unlawful under the Sherman Antitrust Act and that any evidence to the contrary was inadmissible in court. Not surprisingly, Jung v. Association of American Medical Colleges was quickly dismissed.
Since then, the capacity of medical trainees to organize and advocate for self-preservation, let alone advancement, has been difficult. During the Covid-19 pandemic, this absence of self-representation has revealed academic medicine’s ugly side.
When residents in New York City raised the prospect of hazard pay to frontline doctors, hospital responses were swift, severe, and tone-deaf. One resident physician based in New York City described with dismay her hospital’s response to residents’ collective request for hazard pay.
One physician administrator sent an email to residents saying, “I am not indifferent to your anxieties but personally feel demanding hazard pay now is not becoming of a compassionate and caring physician.”
There were also thinly veiled threats of retribution against those who had signed a petition, with one program director directly asking if any of the program’s fellows had signed it. This response featured one of American medicine’s familiar tropes, the weaponization of professionalism, made all the more frustrating by belittlement of the residents’ collective voice.
As stories abound of nurses and physicians being fired for speaking up about the lack of personal protective equipment, hospitals have threatened the only remaining recourse for medical trainees: sharing our observations and stories. Social media has become a communal platform for health care workers to openly express their daily trials on the front lines. One resident in Seattle posted on Instagram, “We so appreciate the love and kindness the city of Seattle has shown to us … But it’s hard to hear that appreciation when the institution we work for shows us every day how little they value us.” #GetMePPE and #WeNeedPPE are examples of health care workers’ advocacy efforts to not only protect themselves, but also to prevent Covid-19’s nosocomial spread.
Organizations that purportedly represent and protect medical trainees, like the Association of American Medical Colleges and American Hospital Association, have lobbied against trainees’ past efforts to be treated like other workers. Yet in the post-Covid-19 world, there will be a path forward to address violations of trainees’ rights.
With a goal toward revisiting Jung v. Association of American Medical Colleges, we believe that residents and fellows should continue their unionization efforts, following in the footsteps of strong nursing unions and existing physician unions such as the Committee of Interns and Residents.
Nascent grassroots efforts should be supported as important and reasonable countervailing forces in medicine. The University of Washington Housestaff Association staged a walk-out in September 2019 to secure a living wage. The Collective for Resident Rights at Yale New Haven Hospital penned the first “Resident and Fellow Bill of Rights” in November 2019. And the University of Michigan House Officers’ Association is now in its 45th year of operating on behalf of residents and fellows.
Not right now — we have a long fight on our hands, after all — but at some point after the worst of the Covid-19 crisis is behind us, medical trainees and their colleagues need legislative action to secure safe working conditions, wages adjusted to the cost of living, and a mechanism to air grievances against employers. In the meantime, all of us — health care workers and the general public alike — should continue to apply collective pressure against institutions that impede safe and equitable working conditions, including some hospitals and national associations.
Each day health care workers put themselves at risk to treat people with Covid-19. To our neighbors making noise in the South Loop, and to those doing the same elsewhere across the country, health care workers hear you and appreciate you. Know that our pursuit of self-determination is one part of our mission to make health care better for all of us.
Ajay Major is a fellow in hematology and oncology at the University of Chicago and a former resident physician in internal medicine at the University of Colorado. Garth Strohbehn is a fellow in hematology and oncology at the University of Chicago and a former resident physician in internal medicine and chief medical resident at the University of Michigan. The views and opinions expressed here are those of the authors and do not necessarily reflect those of their employers, past or present.