Residency unions have grown in prominence, particularly in the wake of the COVID-19 pandemic. Unions can provide resident physicians collective bargaining power and the ability to advocate for improved working conditions. Although no study has demonstrated improvement in resident happiness, burnout, and job satisfaction after unionization, the number of institutions having unions representing their residents are growing. While these unions offer several benefits, there are also significant downsides to surgical specialties, as the ‘one size fits all’ model does not always allow for differences in training.
Unions aim to provide equal representation and support for all resident physicians; however, an inherent paradox exists as they achieve equality without ensuring equity. This paper discusses the distinction between equality and equity within the context of residency unions. Furthermore, concerns exist regarding resident unions being inequitable to residents in surgical training as the union vote proceeds with one vote per resident, and those in smaller residency programs, such as surgical specialties, can be outnumbered by larger residency programs where the requirements and needed skillsets are different.
Equality refers to providing the same resources or opportunities to all individuals. In the context of residency unions, this often means standardized policies, uniform salary scales, and equal access to union support services. Equity, on the other hand, involves recognizing and addressing the varied needs and challenges faced by individuals (e.g., different specialties), thereby providing tailored support as needed by the trainees.
Residency unions are typically structured to promote equality through standardized contracts that ensure all residents receive the same salary, benefits, and working conditions, which provide uniform policies on work hours, leave, and grievance procedures. While these measures are crucial for preventing exploitation and ensuring a consistent level of fairness in residency programs, it should be stated that unions are not the only mechanism in place for these benefits to be obtained. Resident house staff associations working together with their Graduate Medical Education have been able to effectively work towards these goals at many institutions.
A challenge exists, however, of ensuring equity for those involved in residency unions. Different residency specialties have varied demands and challenges; a universal approach may not be equitable for all residents. For example, some specialties may not want a 24-hour call period; but surgical specialties may prefer this type of arrangement to limit time away from the operating room or clinics. Some institutions with unions have done away with the 24-hour call, which has raised significant concerns from the surgical residents regarding exposure to cases, mentorship, and time in the operating room, all which directly impact their training.
Those who support unions and union representatives will often argue that concerns regarding the union effect on the training experience are not warranted and may give examples of other institutions where there is no change or only changes for the better have occurred. This does not consider that each GME office has different financial obligations. One institution may allow for certain benefits; however those benefits may not be possible at a different institution (i.e. comparing apples to oranges). In other words, just because something happens at one institution, it doesn’t mean it will be possible at another.
For example, many surgical specialties rotate at outside institutions (‘off-campus’) or travel to satellite clinics away from the main campus to supplement their education or for a different type of experience (urban vs. rural, different patient population etc.) When residents rotate offsite, the hospital is not able to be reimbursed by Medicare. The hospital, however, is still paying the residents’ salaries and benefits during the months the residents are at the other hospital. Average Medicare reimbursement is $154,000/per year per resident. If a resident spends 3 months off site, this totals $38,500 per resident/per year that the hospital is not reimbursed. As typically more than one resident is off site each year, this is a substantial amount of money that the hospital is losing. With the negotiation process, resident demands cost money (increases salaries/benefits/food stipends etc.) and the hospital may not be able to afford the new demands and the loss of revenue due to the off-site rotations. The GME may be forced to withdraw the approval for the surgical residents to go off site. It is important to understand that there is no guarantee that a GME will continue to fund the residents rotating at those institutions. Even though one institution allows residents to rotate offsite, that may not be feasible at another hospital.
The desire to have equality between specialties within an institution may not consider the specific educational needs of each unique specialty. Although needed by the surgical residents to obtain and well-rounded and thorough training experience, rotating off site may be unappealing for some in primary care specialties. Concerns arise if the medicine or pediatric residents (those with large residency programs) do not want to travel off site, and as part of the negotiation include that as part of the contract even though the surgical residents (typically smaller number of residents) need and want to rotate off site. These types of unknowns carry enormous risks for surgical training, and it is imperative for all involved to understand the potential impact.
Unions negotiate for all residents to have the same benefits. Residents are awarded the same amount of vacation/time away from work. Although in theory, this seems fair, many surgical specialties allow for time off for fellowship interviews, attending meetings, presenting at meetings, and funding presentations at meetings that may not occur in other specialties. The same benefits for residents across all subspecialties may limit the amount of time permitted for fellowship interviews or presenting at meetings or funding for activities. The days off for fellowship interviews (often as many as an extra 14 days) are not shared with other specialties and may result in those days needing to be taken as vacation days. Funding residents to attend meetings or having meals during in-hospital conferences may also raise issues as other residency programs may not have the same degree of funding, which would mean these benefits would no longer be possible. Furthermore, many surgical specialty boards mandate a certain number of days worked; therefore, certain policies/benefits that are negotiated and meant to benefit everyone (e.g., 16 weeks of family leave) may only benefit those without the requirements.
Residents in unions pay 3% of their salary to the union. Those in surgical specialties will continue to pay a greater amount of their salary into the union as surgical residencies can be 5-8 years vs. 3 years for primary care specialties. Geographic locations of residencies may dictate salaries, but on average a PGY3 resident makes $74,000/year compared to a PGY6 who makes $86,000/year. This is a difference of $360/year paid by the chief residents of surgical specialties than the chief residents in shorter residencies.
Lastly, meetings to discuss unions are often during the day/lunch hours when it is much more difficult for surgical specialties to be a part of the discussion. In some institutions, surgical residents have proposed a meeting time that is earlier, so all can attend; however, meeting times continue to be at the most convenient for the greatest number of residents (non-surgical residencies) to attend, which is often after the surgical day has started. There is no question that early meetings would allow a better representation of all residents, especially the surgical or procedural subspecialities, however the majority is who is dictating the time. Representation necessitates the presence of those that are being represented and hearing their voices.
Conclusion
Residency unions aim to protect residents by implementing uniform policies across all specialties. While these policies ensure a baseline level of fairness, the union’s equal treatment of all specialties can result in inequities for surgical residents, affecting their training. Unions may be equal, but there is a significant concern in the equity that they provide surgical residents.
It is important for surgical residents to be aware of the consequences unions have on surgical training as well as understand the importance of having their voices heard and not be complacent while others who are not familiar with the needs of surgical education make crucial decisions that will impact their livelihood and their profession.
References
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