Not surprisingly, resident unions surged during the COVID-19 pandemic as labor shortages and grueling working conditions also exposed significant patient care inequities. But a new article co-authored by a Michigan State University physician argues that giving residents a real seat at the leadership table is a better alternative to unions for residents and health care institutions alike.
Britani Javed, D.O., is assistant dean of clerkship education at the Michigan State University College of Osteopathic Medicine (MSUCOM). The article, “Resident Unions: Why Now and Will They Change Medical Education and Health Care?” was published in the February 2025 edition of Academic Medicine.
“Unionization is a natural consequence of residents feeling like their voices aren't being heard,” said Dr. Javed. “Residents just felt like they didn't have a voice within the system. And unionization was their mechanism to protect themselves.”
Dr. Javed recalls working in a hospital as a new physician during the height of the COVID pandemic, which no doubt contributed to her passion for health policy and advocacy.
“I was eight months pregnant and told to go see patients in the ER. They’d say, ‘You're going to be fine, don't worry about it.’ But I was terrified of something happening to myself or my baby, and I felt like my voice wasn't being heard,” Dr. Javed said. “When you're putting individual safety at risk potentially, that's when you have to say, ‘Okay, I know I'm tired. I know I'm just trying to get through the week. But this is not right.’”
Living in a gray area
According to the Committee of Interns and Residents, about 20% of all physician residents are now unionized. By comparison, just 7% of attending physicians were unionized as of 2019.
Obviously, unionization is a means to achieve higher pay and greater benefits, as well as helping to advocate for improved staffing needs and working conditions.
“Do they have a good place to sleep at night that's not an actual closet?” Dr. Javed mused. “Do they have access to some food at night, instead of stealing Graham crackers from the nurses’ station?”
Other examples include childcare and/or lactation rooms. Dr. Javed adds that unionization is also a way that residents can advocate for improved patient care.
“It can be pointing out something like, ‘Hey, our floor doesn't have enough respiratory therapists. Our patients aren't getting the care that they need.’ Without unionization, residents can send an email to someone. But they don't really have an institutional or collective voice to illuminate potential patient care inequities,” she added.
What’s more, there is no evidence that resident unions have adversely affected accreditation, education or clinical care.
The problem, however, stems from the gray area that residents find themselves in as both student learners and professional employees. Most institutions resist unionization, which can lead to greater animosity between hospital leadership and residents.
“The major concern is that the process of unionization can create an adversarial relationship between residents and the attending physicians who are supposed to teach and supervise the residents,” Dr. Javed explained. “Is there going to be tension and pushback at the negotiating table? And toxic environments within the healthcare system is something that we're trying to get away from.”
Even more worrisome is the possibility that professionalism and advocacy for the needs of patients might take a back seat when relationships become strained during union organization efforts or future contract negotiations. Nor is there any evidence that unions lessen burnout.
“At the end of the day, increasing your pay or providing wellness modules isn't going to get you any more sleep or lessen the number of notes you need to write,” Dr. Javed points out. “It's not going to reduce how many patients you have to see, and this is true for both residents and attending physicians.”
Supporting residents as true partners
Resident physicians aren’t the only ones who suffer from a lack of control. Fully trained doctors also experience less autonomy thanks to the growing corporatization of health care. More than half of all doctors in the U.S. now work for a health system or a large medical group, instead of having an independent practice.
“Physicians are feeling so powerless when you're working in these big organizations,” Dr. Javed said. “Instead of seeing a patient every 15 minutes, they’re expected to see one every 10 minutes. There is this increased pressure of volume, volume, volume, and it comes with that moral injury, too, because you want to do the best for your patients.
“And when our calling is in jeopardy, that's just going to lead to overall burnout and physicians leaving medicine.”
Dr. Javed argues that hospital systems should provide regular pay increases and conduct due diligence to ascertain other ways to meet the needs of residents well before union organizing takes place, which can have long-lasting repercussions for everyone involved.
The key, she insists, is to support residents as true partners. Giving them the time and space to understand and help problem-solve institutional complexities should be part of their medical education. She proposes a model where residents chosen by their peers would participate in institutional decision-making meetings on a rotating basis.
“As a profession, we need to do a better job at advocating for ourselves in light of this increased corporatization,” she said. “That’s why we should really encourage residents to get that seat at the table now, before they become attending physicians moving forward. The earlier that they get this experience and start to understand the impact that their voices can have, the better off our profession will be.”
By Lynn Waldsmith