Working conditions

Pros and cons of joining a labor union in residency: Is it really worth it?

The rate of residents organizing union campaigns has nearly tripled since the beginning of the pandemic.


It’s no secret that residency training is challenging and taxing on each physician in training. Residents have commiserated over gruesome schedules, 80-hour work weeks and 24-hour shifts, all the while receiving inadequate salaries in return. While harsh working conditions have been the norm for residents for decades, it seems that this toxic work culture is currently seeing the consequences of the standard it has set.

Roughly 300-400 physicians die by suicide each year in the United States. Suicide deaths are 250% to 400% higher among female physicians compared to females in other professions. Medical students have rates of depression 15% to 30% higher than the general population, and suicide rates are also higher in medical students compared to the general public.

Burnout and mental illness have been on the rise as the COVID-19 pandemic has greatly impacted health care workers and hospital systems.

Unions: Vehicles for improvement

In other occupations, workers have gained control over their circumstances through creating a labor union. Although every workplace is different and the needs of workers vary, there are some basic steps involved in gaining a union voice on the job. Getting started usually involves residents indicating interest by signing union cards. If enough of them do so, the employer must bargain with the union.

The rate of residents organizing union campaigns has nearly tripled since the beginning of the pandemic. It is important to note that while this rise in the organizing campaigns has been more noticeable since 2020, many concerns had been voiced even before the pandemic.

Others in medical education have argued that while residents play a significant role in patient care, they are also apprentices who are receiving valuable training that is an expense for institutions to provide. However, this rebuttal can be perceived as dismissive and disregards the reality that the current training environment has fostered burnout.

“I can understand both sides,” says Andrea Attenasio, DO, regional vice president for the Committee for Interns and Residents (CIR), the country’s largest resident union. “Hospitals do have to account for residents and ensure a proper education, which is taxing for medical education. However, hospitals are compensated for the residents that they choose to take on.”

Dr. Attenasio, who is also a PGY-4 at Jersey City Medical Center, is referring to the budget provided to training hospitals from the Centers for Medicare & Medicaid Services (CMS). This branch of the federal government is largely responsible for the residency slots available, and the budget allocated for many training programs to provide resources for programs, financial support for hospitals and salaries for residents.

Relatively, resident salaries are a small percentage of the money allocated to programs, with the rest being used as deemed necessary. On average, first-year residents earned just under $60,000 in 2021.

Many residents in training hesitate to be involved in unionizing due to fears of retribution from employers. Some residents also worry that unionizing could undermine patients’ and communities’ trust in them.

“We care deeply about our patients, and we don’t want to risk possibly compromising patient care,” said Toni-Kaye McDoughall, MD, a PGY-1 at Ascension Providence Hospital in Michigan.

The time investment required

Another reason for hesitation involves the time required to organize a campaign.

“I work 12- to 14-hour shifts six days a week. I become nervous thinking about sacrificing time from my education and patient care for a cause I am unsure will even be successful,” said Dr. McDoughall.

While the time commitment is a valid reason as to why residents might stray away from unions, this highlights the need for pre-established unions for health care workers even more.

There are many unions aimed at addressing these issues, the largest of them being the Committee for Interns and Residents (CIR). The CIR is a part of the Service Employees International Union (SEIU) and is composed of over 22,000 resident physicians and fellows nationwide. The CIR works to advocate for resident well-being and negotiate better contract terms for physicians in training. Today, roughly 15% of U.S. house staff in more than 60 hospitals are represented by CIR.

Union wins

The CIR has a long history of advocacy that stretches back to the 1970s. In 1975, the CIR won contractual limits for on-call schedules in New York City. In the late 1980s and early 1990s, the CIR successfully negotiated innovative maternity leave clauses, won pay for house staff covering for absent colleagues, and in 1989 helped shape New York State’s regulations that set maximum work hour limits for house staff.

In the 1999 Boston Medical Center case, CIR won a National Labor Relations Board decision guaranteeing residents in private teaching hospitals the right to join a union. Before this, medical interns, residents and fellows were classified as students and not allowed to protest for higher wages or go on strike due to their working conditions.

CIR members have played an active role in advocating for access to care for the uninsured and for important services like interpreters. In 2010, the CIR lobbied for passage of the Affordable Care Act. The organization has also worked with teaching hospital employers to secure vital funding for safety net hospitals.

In recent news, CIR union members at the Institute of Family Health in Harlem, New York, successfully negotiated a three-year contract that reduced the 80-hour-per-week cap to 70 hours and increased salary over the course of the contract.

“One of the best things about CIR is the strength it possesses in numbers,” says Dr. Attenasio. “We’re a large organization, and we have access to pull support from a vast amount of members.”

Keeping balance in mind

Residents who are skeptical of getting involved with labor unions have reasonable concerns. As a profession, we prioritize refining our craft rather than our own personal needs to ensure the best patient care and outcomes possible. This is especially important for new medical graduates, who aim to be the ideal image of professionalism and competence.

While this is understandable, self-sacrifice is not a sustainable approach to medical training and contributes to high rates of burnout and depression. Ultimately, joining any organization requires one to determine whether it is a good fit for their individual interests and goals. Doing what is best for ourselves will ultimately lead us to what is best for our patients as well.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

Related reading:

Residency interviews: Successful residents share their 9 top tips

The top 3 things you can do to prepare for residency applications in the first 2 years of medical school


  1. Christopher Blair

    As an attending surgeon, I find even the concept of unionization for residents to be shameful. Residents should remain focused on continued improvement and appreciate that no matter the investment in time and effort, they will still struggle to learn all they need to successfully practice. Unionization is not only a waste.of resources in time and effort put to much, much better use, but at the end of the day adds yet another layer of cost to an already overburdened educational system. Nurses want to unionize and hold employers hostage for more agreeable employment terms? Let them. Doctors are above that.

    1. AL

      Hard disagree. Physician lifestyle has degraded so much in the last 20 years. Tuition and student loan interest rates exploded. Average med school debt without parents paying for it is now 300k not including undergrad loans. Cost of living has gone up, while both resident and attending salaries can barely keep pace. Hospital systems and organization and private equity have snapped up so much clinics that Private practice makes like what, 25-35% of doctors now, and is diminishing with each year. Unionizing is the only way we have to even begin to fight back.

      I find it shameful that residents are continually abused and younger doctors placed in worse and worse situations.

    2. Sam Gibbs

      If they will struggle to learn all they need to successfully practice regardless, shouldn’t there be an obligation to care for the mental health of residents and prevent burnout/depression? Ignoring those problems is why people in health care suffer or leave the profession altogether. What’s more, more people would JOIN the profession and help the overburdened system if there were better conditions for all healthcare workers

    3. Sean

      Hi Dr Blair,
      I find your perspective very admirable, as I do believe physicians, to a great extent, do embody one of the highest ideals in the provision of medical care. In training, whether directly or indirectly, we learn that patients come first, but that means that something must come second, third and fourth. Does that mean our personal health, sleep, spending time with our families and having “downtime” should never come in first? If so, when can we treat ourselves first? I think this movement really speaks more to the fact that new trainees and attendings want to be taken seriously, versus discounted by the large hospital systems we almost certainly work for. Sometimes that power comes in groups. Is this the right path to be able to come to the boardroom table with hospital executives? Only time will tell, but I can tell you many, many hospital systems and insurance company executives (United Healthcare…) that have made plenty of $ during the pandemic, one of the greatest challenges to our profession in this generation. Maybe physicians and residents are tired of being the sacrificial lamb? This will be interesting to follow.

  2. LB

    Dr. Blair’s comments are exactly why union representation in residency is so important. No one is holding hospital systems “hostage” by demanding sane, humane work conditions. Resident unions help ensure residents *can* learn all they need to successfully practice because policies such as duty hour limits can be in place. The current resident system is broken and the onus falls on residents. Hospitals are supposed to be able to run completely without resident support, ensuring that the TRAINING we are actually in is just that, not cheap labor to be exploited. How many hospitals can honestly say they can run without residents if we were to disappear tomorrow?

    Health corporations won’t simply change because we want them to. We need to force change and unions are one method to do so.

  3. Sam Garloff

    Unionization of residency programs will not result in stopping physician suicide, reducing student debt or improving the mental health of medical students. Unionization in some cases may result in increased pay and/or an improved work environment. This may also (in some cases) be obtained by interns and residents appointing one of their peers to address the issues with training chiefs and administrators. Unfortunately neither approach may be successful. The difference is that one approach represents trainees as labor and the other as emerging professionals. Whether you approach negotiations as a labor force or a professional force you will begin dialogue which may in time result in positive change. My hope is that you as physicians in training will view yourselves as a professional group instead of presenting as craftspeople, tradespeople or laborers. I loved practicing my profession, hopefully you will also.

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