Overall, union membership in the United States has been steadily declining over the past 60 years. However, one of the consequences of the COVID-19 pandemic has been a resurgence of interest in doctor’s unions, especially among residents and fellows. In the past two months, residents at the Keck School of Medicine of USC, Stanford Health Care, and University of Vermont voted to unionize. Is a union in your hospital’s future?
- Overall, American physicians are less likely to belong to unions than other workers
- Residents are far more likely to be unionized than attending physicians
- Physician unions have limited ability to strike
- Interest in unionization may increase in the future as more physicians become hospital-employed
The Bureau of Labor Statistics recently reported that in 2021, there were 14 million wage and salary workers in the United States who were members of a union. This equates to an overall union membership rate of 10.3%. Overall, union membership has dropped considerably over the past 70 years.
There are tremendous differences in the union membership rates for public sector workers (33.9%) versus private sector workers (6.1%). There are also profound geographic differences in union membership rates ranging from high rates in Hawaii (22.4%) and New York (22.2%) to low rates in South Carolina (1.7%) and North Carolina (2.6%). Physicians are less likely to be unionized than most other professions with approximately 5% of U.S. doctors belonging to a union. Residents and fellows comprise the largest group of physicians who are unionized and their numbers are growing.
The largest union of residents and fellows is the Committee of Interns and Residents (CIR), a part of the Service Employees International Union. In normal years, the CIR reports 1-2 hospitals have union organizing campaigns per year. However, with the COVID pandemic, that number has tripled. Currently, residents at about 60 hospitals nationwide are unionized with an estimated 15% of all U.S. residents belonging to unions.
Fewer attending physicians are unionized. The largest union is the Union of American Physicians and Dentists, an AFL-CIO affiliate. It is estimated that about 10,000 of the 700,000 U.S. attending physicians are unionized, slightly less than 1.5%. Historically, most attending physicians were in private practices, either as solo providers or as part of medical group practices. There was very little reason for these physicians to unionize because they were self-employed. This may change in the future as physicians become increasingly hospital-employed.
The pros and cons of resident unions
The effect of resident unionization has not been well-studied. A 2021 study published in JAMA Network Open of 5,701 U.S. surgery residents found that unionized residents were more likely to have hospital-subsidized housing and more likely to have 4 weeks of vacation per year (as opposed to 2-3 weeks) than non-unionized residents. However, there was no difference in burnout, suicidality, job satisfaction, duty hour violations, mistreatment, salary, or educational environment between residents at unionized and non-unionized programs.
Residents and fellows hold a unique employment status – they are simultaneously trainees and employees of the hospital. They also have time-limited employment, unlike most American union members who can spend their entire employment career as union workers. Because of their unique status, there are advantages and disadvantages to residents unionizing.
The pros of resident unionization
- Ability to negotiate salary. Residents earn an average of about $64,000 per year. Typically, salaries increase by about $2,000 for each year of residency. Although the precise salary for residents varies from hospital to hospital, most of the variation is related to geographic cost of living differences. Most of the financial support for resident salaries comes from fixed Medicare payments to hospitals for graduate medical education. Overall, the ability of resident unions to impact base salaries is limited. However, supplemental pay for working during disasters and for in-house moonlighting may be more negotiable.
- Ability to negotiate vacation. Unlike salary, hospitals do have more flexibility in the amount of vacation time offered. The JAMA Network Open article found that unionized residents had more vacation time per year than non-unionized residents.
- Ability to negotiate fringe benefits. Hospital night call rooms, meals while on-duty, hospital-subsidized housing, and maternity/paternity leave are all on the table when residents are unionized.
- Ability to negotiate work conditions. Issues such as availability of personal protective equipment and prioritization of hospital employe vaccination became very important to residents during the COVID pandemic. Most healthcare workers experienced stressful working conditions during the pandemic and residents were no exception. Many residents turned toward unions in hope that unionization would reduce these stressful conditions.
The cons of resident unionization
- Union dues. Currently, annual dues for residents who belong to the CIR are 1.6% of their total salary. This can be an important deterrent to joining a union given that residents do not have high salaries to begin with and that residents are often feeling financial pressures due to student loans and young children at home.
- Short duration of employment. Internal medicine, pediatrics, and family medicine residencies are 3 years long. Psychiatry residency is 4 years long. Surgery is 5 years long. Many current residents do not want to go through the time and hassle of forming a union since they will personally only experience any benefits of unionization for a short period of time before they become attending physicians.
- Barriers to going on strike. The most powerful tool of any union is the strike. Some ethicists have opined that it is unethical for physicians to go on strike as a strike could lead to patient abandonment and resultant patient harm. It has been argued that since residents must be supervised by attending physicians, the attending physicians could cover patient care responsibilities if the residents go on strike. However, residents are integral components of health care teams and if they are not present, then there is a risk of team malfunction. There is also a very different public perception of physicians going on strike as opposed to other workers – if your Starbucks barista goes on strike, it is a minor inconvenience but if your doctor goes on strike, your health is threatened. Striking physicians may find little sympathy from the general public and may garner very negative opinions. That being said, last month, Los Angeles residents threatened to go on strike and the strike was averted at the last minute.
- Soured relation with attending physicians. When residents complete their residencies, they either get a job as an attending physician or continue their training as subspecialty fellows. In either case, they rely on the attending physicians that they trained under during their residency for letters of recommendation. If union activities result in an adversarial relation between the residents and those attending physicians, those letters of recommendations may take on a negative tone. Labor laws prohibit retribution against union members for union activities; however, when it comes to these letters, an average recommendation implies that the resident is actually significantly below average. Therefore, a resident whose union activities antagonized his/her attending physician could receive a lukewarm recommendation letter from that attending. Such a letter could not be proven to be retribution from a legal standpoint but would put that resident at a considerable disadvantage when applying to fellowship positions compared to other resident applicants with glowing letters. Moreover, residents who develop reputations for organizing collective actions against their hospitals on the part of their union may be perceived as troublemakers by fellowship programs at other hospitals, placing those residents at a competitive disadvantage when applying for fellowship positions after completion of their residencies.
- Lack of credibility. It can be difficult to negotiate for salary and benefits when everyone knows that you are going to have an annual income of hundreds of thousands of dollars in a couple of years.
- The ACGME already dictates many work conditions. The Accreditation Council for Graduate Medical Education has fairly strict limits on weekly duty hours, call schedules, educational curriculum, resident responsibility for non-clinical activities (such as patient transportation, blood drawing, etc.), and work environment. As such, the ACGME has functioned in a resident advocacy role similar to the advocacy roles played by unions in other occupations. Failure of hospitals to comply with ACGME requirements can result in loss of hospital accreditation which can be a death sentence to the hospital’s residency program.
- The loudest voices do not always represent the majority of the doctors. Often, the residents who are most opinionated and passionate are the ones who become most vocal in union affairs. This can result in issues that are of no importance to the silent majority of residents becoming the forefront of union demands.
- Most residents cannot chose to unionize. Senior medical students are assigned the hospital where they will do their residency by the National Residency Match Program. The students create a preference list of the residency programs that they are most interested in and a computer then matches the students with the residency programs based on their degree of mutual interest. Most students will list about 10 programs on their match list but for competitive specialties, such as otolaryngology and ophthalmology, students will typically list 20 or more programs. Unless a residency program is located in a right-to-work state (see below), the students have no say in whether or not they will be in a union. After 3-5 years, all of the residents turn over and those who had originally voted to unionize are replaced by others who may or may not have any interest in belonging to a union.
- Loss of autonomy. As a breed, doctors tend to be independent. The surgeon in the operating room, the emergency medicine physician in the ED on trauma call, the cardiologist doing an emergent heart catheterization – all of these physicians have to be self-reliant and generally do not want to be told how to do their job. A hospital with a thousand doctors is a hospital with a thousand people who think of themselves as the CEO. Many physicians are inherently distrustful of any organization that tells them what to do and that includes unions.
American unions became empowered by the 1935 National Labor Relations Act (Wagner Act). This allowed workers to organize into closed shops (where union membership was a prerequisite requirement to employment), union shops (where non-union workers could be hired with the requirement that they join the union within a specified amount of time), agency shops (where workers were not required to join a union but could still be charged union dues), and open shops (where workers were neither required to join a union nor pay dues). In 1947, the Taft-Hartley Act repealed some elements of the Wagner Act – closed shops became illegal and states were individually allowed to decide whether union shops and agency shops would be allowed.
The result of the Taft-Hartley Act was that some states passed legislation or state constitutional amendments to become “right-to-work” states. In these states, union shops and agency shops were not allowed and unions could only exist act open shops. The phrase “right-to-work” in essence means that workers had the right to work without having to join a union. 27 states have have right-to-work laws (red in the map below) and in addition, Delaware allows individual localities to make their own decisions about right-to-work.
The vast majority of unionized residency programs are in non-right to work states, meaning that once the residency is unionized, future residents do not have a choice about whether or not they want to participate in the union or pay union dues.
A new era of physician unionization?
In the 1950’s, about 75% of U.S. physicians belonged to the American Medical Association. Today, that number is only about 17%. The AMA is not a union but it does play an important role in physician advocacy and lobbying. Today’s physicians have not felt that the AMA provides sufficient benefits to warrant membership and attendant annual dues of $450 per year. As a consequence, the AMA has less political and public health influence today than it had in the past. Some medical leaders have called for a new form of unionization for attending physicians to more strongly advocate for issues of importance to physicians such as gun control and vaccinations against communicable disease. Although a laudable idea, it is probably unrealistic.
However, the recent change in physician employment models resulting in most physicians now being hospital-employed rather than in private practice may change the appetite of some physicians to become unionized. As many specialties have had compensation become untethered to professional practice income, physicians in these specialties depend more on the wording of their hospital employment contracts for their salary and work hours. Anesthesiologists, hospitalists, critical care physicians, and emergency medicine physicians are perhaps most notable. For example, tying hospitalist RVU production too tightly to compensation can work counterproductively to hospital goals of patient length of stay, readmission rates, and patient satisfaction scores. For shift work-based physicians, unionization may become appealing if the physicians perceive that their hospital is not responsive to appeals to improve working conditions or pay competitive salaries and benefits.
Physicians whose incomes are more closely tied to their RVU production (such as surgeons, gastroenterologists, and ophthalmologists) are likely to feel less benefit to unionization as they would want to preserve their ability to tie high incomes to work effort. Also, when there are relatively few physicians in a specialty at a hospital, they already command a great deal of power and may not perceive a benefit to unionization. For example, if there are only 2 orthopedic surgeons at a hospital, just one of them threatening to leave to go to another hospital on the other side of town can be enough for the hospital to acquiesce to their demand to contract with a different joint implant vendor.
For the foreseeable future, there is projected to be physician shortages in most specialties. This results in a state of perpetual imbalance between supply and demand for physicians. A hospitalist who is not happy with their salary or required number of shifts per year at one hospital can easily get a job at another hospital within commuting distance. This imbalance gives attending physicians a great deal of power in negotiating salary, benefits, and working conditions with the hospital. In the future, if the supply of physicians catches up with the demand for physicians, then the benefits of unionization may become more appealing to physicians in some specialties.
For now, unionization is likely to be primarily relegated to residents and fellows. The current increased interest in resident unions will likely be transitory as life in the hospital returns to normal with receding COVID-19 cases.
June 16, 2022