CORR® Curriculum—Orthopaedic Education: Resident Unionization

The increase of union representation for residents is a recent shift in the relationships between residents, their programs, and individual academic medical centers [2, 4]. Currently, about 10.5% of all residents belong to unions, which act as representatives for resident collective bargaining across all specialties at an academic medical center, with the most recent additions being programs in Miami and California [1, 2]. Unions now are involved in a variety of aspects relating to resident work conditions, including pay, benefits, and time away.

Authors of a recent opinion piece by resident union representatives suggested that resident burnout, which increased during the COVID-19 pandemic, has been a major driver of this action [2]. The authors also shared the perception that residents, in general, feel they do not have a voice in expressing their concerns. This is potentially a much larger problem. Graduate medical education requires an openness and candor not normally seen in other employment circumstances. An increase in resident union representation may be a result of ongoing erosion of an appropriate close relationship or sense of community previously seen in residency programs [3].

Why has this occurred and how can we reverse this trend?

Why the Shift?

The COVID pandemic stressed healthcare systems in numerous ways, but the stress was most evident during the pandemic’s several waves, when large volumes of patients testing positive for the virus needed attention. To adequately care for the surges in hospital admissions during each spike, exigent measures were taken, and exemptions to Accreditation Council for Graduate Medical Education (ACGME) requirements occurred. In-person meetings were discontinued to prevent the spread of infection among faculty and house staff. Virtual meetings became the norm for educational events.

Moving from in-person to virtual meetings had several negative effects. With the change to online didactics, I and other resident educators believe there was decreased absorption of what was being taught, and faculty assessment of residents became more difficult. The lack of face-to-face interactions with faculty also had other unintended effects, whereby faculty were less able to assess a resident’s progress, their learning environment, and resident wellness. Mentoring also became more difficult in the virtual world. Although in-person meetings are returning, it is unclear what long-term damage has occurred as a result of the last 2 years of the COVID pandemic.

No Voice?

Some residents feel that they have few avenues for communicating their opinions about the issues that affect the wellbeing of physicians in training, such as burnout, pay, and working conditions. Although this may have been previously the case, the ACGME instituted several changes in 2007 mandating resident representation on institutional and hospital committees, competitive salary, and safe, clean working conditions. Additionally, within programs there is mandatory resident representation within the Program Education Committee. Most departments have resident representation on key committees and representation through administrative chief residents. Today, other than adjusting salaries in high-cost-of-living areas such as California and Miami, union promoters seem to want a larger voice to address more widespread issues associated with the practice of medicine and burnout [2].

Despite the ACGME-mandated changes, some residents still perceive that they have no voice for themselves, and that is related to a number of different reasons. One of the strongest themes I hear is residents feeling disconnected from faculty, and that faculty seem disinterested in their careers. The recent trend of fewer face-to-face interactions seems to have accelerated this perception.

Program Size a Factor?

Residency program size may be another factor. Ludmerer [3], among others, has noted that larger academic medical centers, with multiple departments containing above-average size residency programs, may feel large and impersonal, making it difficult for residents to develop a sense of community. Such settings may make it harder to develop appropriate “learner-teacher” and mentoring relationships.

Perhaps not surprisingly, larger academic medical centers are also in the forefront of resident unionization [2]. An American Academy of Orthopaedic Surgeons survey of residents and their families reported that higher levels of stress and burnout symptoms occurred in larger programs (more than 6 residents per year group) compared with smaller programs [5]. Although COVID has accelerated these circumstances, the milieu has been eroding for a long time [3]. The development of larger departments with multiple subspecialties, which has been seen as necessary for organizations to attend to the patient populations they’re charged with caring for, has also contributed to a lack of communication and mentoring, as well as a sense of “belonging.”

A Way Forward?

Resident unionization facilitates representation and negotiation with academic medical center leadership as a single voice for all residents. It’s important that we treat what I think is the key driver behind resident unions as a symptom deserving of our attention and our care: the perceived erosion of trust and communication between residents and the institutions in which they work.

Rather than trying to eliminate resident unions—which we can’t do, and we shouldn’t try—instead, we ought to try to create an environment in which all parties feel comfortable sharing their concerns candidly. I believe that unions ultimately will stifle this, but if we don’t want unions to gain further ground (and I do not), the onus is on faculty and program leadership to engage the residents further in a more meaningful way to promote a sense of community.

Residents already have a number of avenues to voice concerns at the program, institution, and ACGME levels. But this does not seem to be helping with the perception of “not having a voice.”

In my opinion, improved wellness is seen when programs involve a sense of community. The residents feel like they contribute in a meaningful way and have a voice. Orthopaedic surgery residency programs often get this correct. They are often smaller (relative to internal medicine residency programs, for example), which provides the time for faculty and residents to get to know each other. The educational benefits are that faculty tend to understand each resident’s strengths and weaknesses better, with the ability to make individual educational plans to meet a resident’s needs.

Larger programs may be problematic because in general, they have big teams but rotations of shorter duration. It is easier for residents to feel lost or to feel like they don’t have a voice in these programs. Program directors should look for ways to structure rotations with smaller teams and of longer rotation duration. Ludmerer [3] cites the Johns Hopkins “Aliki rotation” experience at Bayview Hospital as an example of an enhanced education rotation for internal medicine residents, combining limited resident workload panel with dedicated educators with small teams to care for patients. In a similar vein, Ludmerer [3] cites internal medicines’ Integrated Teaching Unit at Brigham and Women’s Hospital as a small-team, high-quality educational experience, with a limited patient load and with dedicated educators. Both of these examples allow time for an in-depth educational experience and close faculty contact, which has led to these rotations becoming the most valued experience among internal medicine residents [3].

I believe program directors and faculty should encourage smaller teams or direct one-on-one rotations for residents with high-quality faculty. This structure will not apply to all rotations (orthopaedic trauma comes to mind, which is often a team), but most programs have the opportunity to have some alignment with this model. Having rotations in which residents work closely with faculty is a structure that allows for developing relationships more conducive to learning and wellness.

The quality of teaching by the faculty member is important to making this model work. Faculty who provide quality supervision, teaching, and resident assessment should be promoted. Programs and departments should emphasize quality teaching and promote faculty development in this area.

There is a price for creating this educational environment. It may conflict with faculty who have high productivity and little time to teach or conduct research. So, programs should now be looking to provide a higher quality educational experience that is meaningful for residents and allows them to feel as though they are an essential part of the team. Although restructuring an entire department is not necessary, experimentation with smaller, more cohesive teams could be made a part of any educational experience within the next year. For example, one option already available to many programs might be an enhanced Veterans Administration (VA) experience. VA hospitals are structured toward having small teams, often with a general orthopaedic practice. Staffing at VAs is often a problem, so program directors would need to ensure there are engaged, dedicated teaching faculty as a part of this program.

Although unions may or may not become more prevalent, as educators we should be concerned about promoting an environment which allows residents to have a sense of belonging and community within their residency program to promote wellness and help prevent burnout.