To move between hospital buildings and see her patients, Dr. Carmen Kilpatrick had to be pushed around in a wheelchair by her colleagues. Kilpatrick, a second-year psychiatry resident at UC San Francisco and a first-time mom-to-be, was expecting twins. The twins’ position put Kilpatrick at risk of premature labor, and her obstetrician advised against standing for more than a few minutes. The risk eventually became so high that she started her four weeks of paid maternity leave early.
“I thought to myself, ‘This is absolutely not enough time.’ I was very, very worried,” Kilpatrick recalled. So she reached out to her union at UCSF for help.
Working many hours with few benefits and little pay has long been the standard for doctors in training. These include interns, residents, and fellows, who are called “house staff” in the hospital. These are the doctors who, at many hospitals, are the first to meet you and spend the most time at your bedside. They regularly stay up for 28-hour shifts taking care of patients, only to find respite for a few hours in a small apartment that costs most of their earnings. The average starting salary for house staff is $60,942 nationally, and they can spend up to a decade after medical school under these conditions. Over 60 percent of house staff experience burnout related to working conditions, and several have committed suicide.
Tired and dismayed, especially since the Covid-19 pandemic, house staff across the United States are now unionizing in order to collectively bargain for greater benefits. In the past two years, at least nine hospitals have unionized, with California and New York leading the way. The largest house staff union in the country, the Committee of Interns and Residents (CIR), has grown in membership by over 40 percent since the start of the pandemic in 2019, and represents over 24,000 house staff members.
Simply forming a union is no easy undertaking. Laws on unionizing vary by US state and by whether a hospital is public or private. In some states, it is illegal for house staff to even form a union. Where it is legal, most hospitals do not recognize unions when they first form. House staff unions then must appeal to the National Labor Relations Board for a formal election. This was the case at Montefiore Medical Center, which held its election in late February this year, overwhelmingly voting in favor of unionizing. House staff at the University of Pennsylvania have recently requested an election.
Even after a union forms, change is by no means guaranteed. The union still needs to productively negotiate with the hospital to gain any wins codified in a contract. Hospitals can evade negotiations, sharing sentiments described by Dr. Jordan J. Cohen in The New England Journal of Medicine. President of the Association of American Medical Colleges at the time of writing, Cohen argued against house staff unions, feeling they were unnecessary because house staff can communicate feedback to hospitals in other ways. In fact, he wrote, unions are harmful because they can create contention between house staff and the hospital that might erode public trust.
So many do question: Can the current growth in house staff unions bring about meaningful changes in health care?
The answer is yes. At a time when business incentives of large hospital systems increasingly dictate how medical care is practiced, unions can give a voice to the house staff who actually deliver that care. An examination of the tangible changes achieved by one of the more active house staff unions at UCSF, where I am a fellow, shows exactly how.
Historically, the success of house staff unions in the US has aligned closely with the country’s fluctuating politics and economy. The first house staff union formed in the early 1930s, when US President Franklin D. Roosevelt enacted the New Deal to stimulate the economy out of the Great Depression. After the passing of the National Labor Relations Act, private sector employees earned the right to unionize. A group of medical interns in their first year of clinical training lobbied for many of the same requests made by house staff today: reasonable working hours, more educational conferences, and the elimination of discriminatory practices in medical education.
But by the early 1950s, in the more conservative political climate marked by McCarthyism, the organization disbanded amid claims of subversive communist ties. CIR formed in 1957 and negotiated the country’s first collective bargaining agreement for house staff in New York City. Since then, the union has expanded to represent approximately 15 percent of house staff across the country. Now is a fervent time for unionization across labor sectors, from Amazon warehouse employees to Starbucks baristas, with 71 percent of Americans supporting labor unions. House staff unions are no exception to this national trend.
At UCSF, house staff first unionized under CIR in 2017. Shortly after, they negotiated their first contract with the hospital. Among the initial wins were housing stipends to offset the high cost of living in San Francisco and 3 percent salary increases to adjust for inflation. According to CIR, the hospital contributes 1,500 house staff to the national union, the most of any hospital.
Kilpatrick’s 2021 case addressed the parental leave benefits in the initial contract that had been negotiated between CIR and UCSF. Kilpatrick had read through the contract very carefully and interpreted the terms as entitling her to eight weeks of maternity leave, rather than the four weeks she had been offered. The union agreed.
Immediately, CIR began advocating on Kilpatrick’s behalf. They disseminated her story on social media, collected over 400 signatures of support, coaxed house staff to call the hospital’s chancellor and CEO, and arranged for them to testify at a University of California Board of Regents meeting. The union eventually hired a lawyer to engage in discussions with the hospital. Two weeks after her twins were born, the arbiter decided that, based on the language of the negotiated contract, Kilpatrick was entitled to eight weeks of total paid maternity leave.
“I felt vindicated and relieved, and also so happy—all these emotions altogether. There was so much going on in the first weeks after delivery that there was no way I could have gone back to work, or have any responsibility, or should have any responsibility, for patient care. It probably wouldn’t have been safe,” Kilpatrick said.
The case set a precedent. As of earlier this year, all but one of the academic health centers in the UC system have contracts stipulating eight weeks of paid parental leave for house staff.
Unions boost life quality for house staff, which is critical in sustaining the health of young physicians and, in turn, the patients under their care. Persistently high rates of burnout signal that the system is inadequate in responding to house staff feedback for change. Instead, Kilpatrick’s case shows how unions not only help house staff voice their ideas, but also provide the resources to actually implement them. House staff are a unique type of laborer in that they are still learners who are generally altruistic in their pursuit of providing the best possible care to patients. They are apt to do whatever it takes to finish their training and are at risk of becoming elastic labor, stretched out thin to cover gaps in the hospital. This is a vulnerability that can lead to serious mental and physical health issues that unions protect against.
Unions can also be the catalyst for strengthening a culture of advocacy that supports better patient care. A more pervasive culture of advocacy looks like a fierce championing of health equity by physicians, the development of new health technologies and drugs, and broader health insurance coverage for patients. Challenging the status quo is the basis for innovative change everywhere, and medicine, which for so long has prided itself on tradition, should not exclude itself.
Unions directly result in patient advocacy, too. Several contracts negotiated by CIR incorporate patient care funds, which promise money from hospitals to house staff, who decide how to allocate the money in ways that best advance patient care. These funds expand ways for optimizing patient care, especially when hospital departments are strapped for money. They also open a route for introducing newer health technologies into the hospital through physicians who are forward-minded and adept at using them. Last year, house staff working in the public health hospitals of New York City received $650,000 through patient care funds, and house staff in Los Angeles County received over $2 million. These grants went toward purchasing routine exam room supplies, novel portable ultrasounds, simulation equipment for training house staff to respond to cardiac arrest, and a custom-built supercomputer to analyze complex health data in the emergency room and identify risk factors for Covid-19 infection.
House staff unions are not at odds with the health system, according to Dr. Lorenzo González, the current CIR president and a family medicine physician. Rather, González says house staff unions work together with the health system toward a shared goal of improving the quality of health care. “What we’re trying to do is utilize labor to make sure that we all win—that the community wins, that our residents win, and that our health systems win.”
And if the past can offer any testimony, that is exactly what unions do.