Healthcare Insights: Today's Young Doctors Have Formed Their Own Union
In the past two years, there has been a flood of union organizing and near strikes among young doctors. Medical residents, fellows, and interns are graduates of medical school who continue their education and training for three to seven years after medical school. In this period of training, they work endless shifts (80-120 hours per week) in hospitals and clinics that are physically and emotionally exhausting.
Over the past two years, at many of the nation’s leading health systems, such as Stanford Health, University of California San Francisco, University of Massachusetts, University of Vermont, and the University of Southern California, residents and interns have successfully organized unions. Earlier this year a strike by residents and interns was barely avoided at three hospitals in the Los Angeles County Health System.
Here at Cornell-ILR, we have had a spate of press inquiries about this heightened labor activity. While many observers attribute the increased union activity as a response to the stress on the health system and its staff by the COVID-19 global pandemic, in our responses to the press inquiries, we tell a more holistic story.
In this month’s article, I would like to share some of the underlying causes of not just unionization, but also the perspective of young doctors who enter the medical profession at a time of tremendous stress, especially as it relates to the disparities due to race and ethnicity in health, health outcomes, and healthcare.
These combined dynamics of union organizing and the broader conditions in healthcare also shed light on the enhanced and changing purpose of collective bargaining.
I recently had the opportunity to learn about the experience of thousands of young doctors entering the profession from the leaders of the nation’s leading union for medical residents, fellows, and interns: The Committee of Interns and Residents (CIR), affiliated with Service Employees International Union (SEIU). CIR represents 1 out of 7 residents, fellows, and interns in the nation, with 22,000 members in California, Florida, Massachusetts, New Jersey, New Mexico, New York, and Washington, DC.
The current leadership of CIR were both very generous with their time, and I will share their reflections here.
First, some context…
Let us remind ourselves that though the USA is the richest country in the world, when it comes to health and healthcare, we do not get what we pay for:
The above chart tells a big part of the story: that while the USA spends by far the most of its GDP on healthcare, it ranks last, by a wide margin when it comes to health system performance and population health, compared to other wealthy nations.
Yet the story is even worse when we factor in disparities in health related to race and ethnicity:
“A broad array of factors within and beyond the health care system drive disparities in health and healthcare” (Figure 1). Though healthcare is essential to health, research shows that health outcomes are driven by multiple factors, including underlying genetics, health behaviors, social and environmental factors, and access to health care. While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors and social and economic factors, often referred to as social determinants of health, are the primary drivers of health outcomes and that social and economic factors shape individuals’ health behaviors. Moreover, racism negatively affects mental and physical health both directly and by creating inequities across the social determinants of health.
These issues of the social determinants of health and the disparities in health and health outcomes based on race and ethnicity have been with us for many decades and well known in the medical profession and in social theory and practice.
Dr. Lester Breslow, one of the nation’s early leaders in public health highlighted these facts going back to the middle of the last century:
“In 1952, President Harry S. Truman appointed Dr. Breslow director of a commission to assess the nation’s healthcare. The panel’s report emphasized that people make their own health choices but “exercise them mainly under social influences.”
In 1969, as president of the American Public Health Association, he said the public health profession must go beyond issuing scientific reports and suggest social actions to improve people’s lives. “In the long run, housing may be more important than hospitals to health,” he said
Healthcare in the nation is in crisis. It is too expensive, it is not equitable in relation to access and quality, and it is mired in racial and ethnic inequality.
For healthcare professionals who dedicate their careers and their lives to caring for those in need, they confront these realities on the frontline of care. They swear an oath to “do no harm.” They know that many of the conditions they see are preventable, yet due to the broad inequities inherent in the social determinants of health as illustrated above along with pressure to reduce cost, our dedicated caregivers find themselves in a state of “moral distress”.
Most recently they experienced the added “moral distress” of the pandemic when confronted with a novel coronavirus for which there was no known cure or treatment. They were virtually helpless as they confronted death and serious illness on an unprecedented scale.
What is “moral distress”? Moral distress occurs when one knows the ethically correct action to take, but feels powerless to take action. (Epstein and Delgado, “Understanding and Addressing Moral Distress”, Online Journal of Issues in Nursing, Vol 15., No. 3, September 30, 2010).
My interviews with Drs Gonzalez and Rodriguez Ortiz reflected “moral distress” in nearly every sentence they uttered in response to my questions about why residents, fellows, and interns were unionizing— and in some cases, even ready to strike. Their reflections as young leaders in the medical profession bring great inspiration and hope for all of us as we understand their experience as doctors and as union leaders.
Dr. Gonzalez explained that he is a second-generation Mexican immigrant who grew up in Anaheim, CA. His father was never able to attain full time work. He watched as his father struggled his entire life on part time work.
Then in 1994, he lived through the passage of Proposition 187 which denied undocumented people access to public services. Though Proposition 187 passed by a wide margin, it was never implemented due to protest by more than a million people shortly after its passage. Proposition 187 was a turning point for many Californians to take action against this type of discrimination.
Based on these experiences, he decided to go to medical school because he saw “science as activism”.
He studied Urban Planning at USC, and then after finishing medical school, he chose family medicine as his specialty. Harbor Medical Center provided the environment he wanted to practice and learn family medicine among low income people of color.
He enjoys the practice of what he calls “street medicine” and “border health” where he cares for the most disenfranchised. He works with mentors in community health settings who make change by practicing change each day, or as he says, “leadership comes from within each of us; individuals are the experts.”
Dr. Gonzalez shared that science itself is a kind of dogma, and there is an inherent bias against speaking up for change. As a result, leadership among doctors advances slowly. But he has seen that in his specialty of family medicine, identifying closely with the patient is natural, and in this process the social determinants of health become dominant. As such the desire to become an activist has evolved within him, along with the evolution of care as a team as opposed to the individual doctor alone. For Dr. Gonzalez, collective experience is replacing individual experience, so for him there is a natural tendency for organization.
His experience with the growth of the union is related to the need to be heard, to break away from the mindset that doctors must be martyrs, that they have rights to raise issues of economics, raises, improvement, and most importantly to advocate for more funding to address the needs of the community and of their patients.
He sees that the labor movement is a natural evolution of advocacy among a group of individuals who really never had a job before becoming a medical resident. Suddenly these recent medical school graduates are working 80-120 hours a week and they see first hand the inadequacies of the healthcare systems as they try to balance their own health and needs.
As a result, as a union leader, he subscribes to the notion of “bargaining for the common good”: that what benefits the doctor through collective bargaining must also benefit the patients they serve.
Dr. Gonzalez says that the pandemic was the last straw in a growing environment of stress related to working conditions as well as the moral distress of seeing patients who were suffering from indignity and discrimination. As such the prime motivation for leadership of the union is to give members a voice.
Dr. Rodriguez Ortiz grew up in Ponce, Puerto Rico. She is the first doctor in her family who was inspired by her mother, a medical professional. She chose the nephrology fellowship at Houston Methodist because of her love of research, especially the opportunity to study the prevalence and causes of kidney disease among the Latino population in Houston. That research has also led her to a deep interest in public policy.
When the pandemic hit, she was working at a hospital in Brooklyn, NY, the epicenter of the epicenter of the earliest days of the trauma. She and her fellow residents were working “crazy hours” with no ability to treat the patients. “It really was a fight for the community”, she says.
From these experiences, their union leadership has focused on a true bottom-up approach in organizing and bargaining with their members. They are true to the principle of supporting the autonomous voice of the local chapter of members as opposed to a nationally-determined bargaining strategy. While issue of wages and hours and schedules are always part of bargaining, they feel that the real strength and resilience of the union is based on their commitment to advancing the voice of members from the frontlines.
On bargaining in Southern California, Dr. Gonzalez shared that important victories were achieved in very non-traditional demands: they achieved agreements to attain a diverse workforce that reflected the diverse ethnicities of the patients they served. They also won the establishment of a “security fund” which required that money be set aside to purchase medical equipment in typically underserved communities.
In Houston, Dr. Rodriguez Ortiz reported that the doctors were concerned that they were receiving no financial credit for what is called “Preliminary Years” training. With this focus, the doctors achieved an agreement whereby they would receive increased salaries no matter where they completed previous training. Finding ways to achieve increases in wages is always difficult, but this turned out to be very successful because the doctors themselves raised this inequity and made the case in bargaining.
Indeed, wages are an important issue in bargaining now more than ever. Inflation makes the issue of wages particularly acute. We also should never forget that the average cost of a medical education is $200,000-250,000 while salaries for residents, fellows, and interns range from $50,000-65,000/year. When we consider that these student-doctors work 80-120 hours a week, their hourly wage is very low (around $14-15/hour). (see AAMC News, June 7, 2022).
In a June 7, 2022 article from the American Association of Medical Colleges (AAMC), the editors write:
“CIR (Committee of Interns and Residents) has a lot of initiatives to support patient safety and quality care,” says Joan St. Onge, MD, MPH, senior associate dean for graduate medical education and faculty affairs at the Miller School of Medicine. “They also have an outreach effort that helps residents address concerns, such as racial justice, within our local community. We collaborate very well with them on that work.”
Brandon Pepliniski, MD, RFPU’s immediate past president, says unions can also promote patient care by helping support diverse individuals in the physician workforce.
“With a union, you can short-circuit traditional channels for change that can be quite slow moving or downright performative,” he said. That’s significant, he notes, because “people who have historically been systematically excluded from medicine are often those who need the better protections and benefits a union can offer,” such as increased stipends for housing. He adds that unions can provide such services as counseling about options for how to respond to discrimination.”
While the article in the AAMC News also points to the inherent challenges in collective bargaining, including the threat of work stoppages and possible frayed relationships that can result from intense bargaining, it appears that there is plenty of room for dialogue on issues that the medical establishment must confront.
At a time in American healthcare when more and more emphasis is being placed on the social determinants of health, disparities in health outcomes based on race and ethnicity, as well as the collective concern over cost, access, safety, and quality for all, it is significant that doctors who are entering the profession are turning to a leadership that has a focus on these social challenges.
Dr. Gonzalez told me that he has heard some refer to the Committee of Interns and Residents as the “steelworkers of the 21st century”. To some that may seem like an exaggerated stretch of comparison. To Drs. Gonzalez and Rodriguez Ortiz, it means something very specific.
In the early 20th century, America’s industrial workforce had no voice, and through their effort to organize, the industrial labor movement changed the nation. That collective voice led to most of the breakthroughs that created a social contract for much of the latter half of the 20th century for a substantial part of the American workforce. That social contract was far from whole as women and people of color benefitted less, or not at all.
In the 21st century, we know that the nation’s infrastructure both physical and social must be rebuilt, must be inclusive of all, and must eliminate the disparities that have made equality an ideal that has not been achieved. To accomplish this feat requires new leadership with the direct experience and knowledge about the root causes of our inadequate and discriminatory social fabric.
Doctors will always have a leadership role to play in health and healthcare. The upsurge in unionization among medical residents, fellows, and interns who bring “science as activism” as a central tenet of their leadership will continue to influence the direction of how health is thought about and delivered. These dynamics at play in the new generation of doctor leadership and their unions make collective bargaining central to social change, and on a potentially large scale.
John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.