As a third-year neurology resident at Mass General Brigham, I started my career at the height of the Covid-19 pandemic. Now Covid numbers may be down, but hospitals continue to overflow.
On a 28-hour shift, I cared for more than 40 patients, 11 of whom were newly admitted to the hospital overnight. Stretched too thin, I skimmed through the patients’ medical charts and did a quick physical exam to make sure each person was stable. I simply could not spend enough time at bedside to clarify my patients’ complex medical histories or learn what’s important to them.
Unfortunately, this particular shift wasn’t an anomaly. Sleep deprivation and the overwhelming cognitive load have led me to make mistakes like updating the wrong family member or forgetting to order a particular imaging test.
During my training, a discerning reality sunk in: The care I was providing for patients was not always what I would want for my own family members. I was suffering from moral injury as health care systems forced me to provide inadequate and at times inequitable medical care. And I’m not alone.
Recently, resident physicians and fellows at Mass General Brigham gathered enough votes to file for a union election. I voted yes because I’ve struggled to provide patients the medical attention they’ve needed and haven’t received fair compensation for the work I put in. With a union, I believe residents will have agency to enable change within a troubled health care system.
First, there’s the financial strains that come with the job. The average annual salary in 2022 for a first-year resident was $60,942, according to a survey from the Association of American Medical Colleges. For a first-year resident who works on average 60 hours a week (a gross underestimation) and receives four weeks of vacation, this means at best their hourly wage is $21.16.
Institutions across the country vary in how much they account for inflation and cost of living. Housing, child care, and retirement benefits aren’t common. Trainees also have to pay for medical licensing fees and board certification tests, costs that often add up to thousands of dollars. And then of course there’s the compilation of student debt, with the average medical student owing more than $200,000.
Financial stress was one of many reasons why resident physicians at the University of Illinois formed a union in 2021, and it worked. Hospital administration had initially only offered a 0.9% salary increase, but the union was able to negotiate an 18.5% raise with an additional $2,500 to $3,000 stipend. Anis Adnani, a second-year emergency medicine resident at the University of Illinois, told me that after the news broke, “residents were pretty emotional that this money had changed our lives.”
But unionization isn’t just about money. The physical and emotional demands of a being a new doctor take a toll.
During her first year of residency at Stanford Health Care, Meaghan Roy-O’Reilly was diagnosed with Charcot-Marie-Tooth, a disease that causes nerve damage and trouble walking. Now a third-year neurology resident and advocate for trainees with disabilities, she has been part of the union organizing and bargaining committees to negotiate, among many things, safer working conditions and better health benefits. “Once I became disabled,” she told me, she realized that “I need to stop pretending that I need to stay up 28 hours and not have consequences.”
Long hours and low hourly wages aren’t new — the expectation has long been that once a resident finishes training, they’ll earn more flexibility and income as an attending. But the promise that life gets better after residency falls short: Some of my attendings, compassionate and brilliant educators, are burned out or work extra jobs to make ends meet in a high cost-of-living city.
At times, all of this has made me question if becoming a physician was the right career choice. But as I’ve cared for patients, I’ve also wondered: Shouldn’t I just be grateful to practice medicine? Am I asking too much by choosing a union?
Other residents share that feeling. “Doctors tend to be driven, self-sacrificing, giving individuals, and it’s easy to have those qualities weaponized against you,” Roy-O’Reilly told me. But to have better working conditions, we have to be firm. “If I’m asking for my needs to be taken care of, it does not make me a bad person or greedy,” she said.
Now that the majority of residents and fellows have taken a stand and signed union cards, Mass General Brigham is on track to join more than 70 residency programs that are part of the Committee of Interns and Residents, the largest resident physician union in the country. Its membership has increased dramatically in the past two years.
Since union efforts went public in late February, Mass General Brigham Interim Chief Academic Officer Paul Anderson and Vice President of Education J. Kevin Tucker have sent multiple emails to trainees like me discouraging unionization. On March 2, they announced a 10% salary increase, a $10,000 stipend, and increase in retirement and disability benefits. When I asked whether this was in response to unionization efforts, I was told “no” and that “these changes began in 2022.”
But this was inconsistent with prior announcements. On Jan. 27 of this year, an email was sent to trainees stating that there was going to be a 2.5% salary increase for the upcoming academic year, an increase much lower than the national inflation rate of more than 6%. It was only after unionization efforts went public that the additional benefits and salary increase were disclosed.
Chief Medical Officer of Massachusetts General Hospital William Curry wrote in an op-ed for the Boston Globe that unionization could hurt mentorship with faculty, an argument that goes against the premise of academic medicine, which is to educate the next generation of physicians. In response, more than 80 Mass General Brigham faculty and medical staff signed a letter in support of unionization.
I tried to keep an open mind and reached out to hospital administrations from four institutions with resident unions in process or in place to see if there were better alternatives.
Mass General Brigham was the only one to respond. To illustrate the lack of need for a union, representatives pointed to established educational committees as well as the newly developed Education Operations Coordinating Committee, which led initiatives like 24/7 food options and more medical service teams. But this new committee is missing something key: So far, it has included program and fellowship directors, department chairs and hospital administration, but no residents and fellows yet (although there are plans for trainees to join in the future).
Even with proper representation, these alternatives pale in comparison with the legal strength of a union contract that prevents employers from retribution and allows for sustainable advocacy. I worry that without a union, concerns of residents and fellows may not be promptly acted upon or even dismissed by the time the next cycle of doctors-in-training come in.
The very limited research out there currently doesn’t prove one way or the other if residents unionizing actually works. Ahmed Ahmed, a fourth-year medical student at Harvard Medical School, was lead researcher for a recent JAMA study looking at unionization trends among health care workers.
His study found that between 2009 and 2021, health care workers who joined a union earned more weekly earnings and benefits. It’s true, though, that this data didn’t look at resident unions specifically; the only study that has (which union naysayers like to point out) showed resident unions did not make a difference with burnout, salary, or mistreatment. But it surveyed only surgery residents, who, ironically, were asked to answer questions about burnout after taking a grueling, five-hour exam. So forgive me if I don’t find these results particularly convincing.
But as I look at the residency programs that have unionized, I can’t ignore what they’ve been able to accomplish. At the University of Michigan, residents get paid extra for holidays, whereas most hospitals expect residents to work holidays without overtime pay. In the University of California health care system, residents have fought for and won a $30,000 fertility benefit package.
The next step for Mass General Brigham residents and fellows is to go through a formal election process overseen by the National Labor Relations Board, as soon as the end of the month. My vote to move forward with a union comes from the hope that with a collective voice, residents and fellows can care better for ourselves and for our patients.
Minali Nigam, M.D., M.A. in journalism, is a third-year neurology resident at Massachusetts General Hospital and Brigham and Women’s Hospital, teaching hospitals of Harvard Medical School.
Read a counterpoint by another third-year resident at Mass General Brigham who wants to delay the unionization vote.
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