Penn residents’ fight for a union could set a precedent for the future of labor organizing in medicine

“Breaks equal weakness.”

That’s how Christine Meyer, an Exton internal medicine specialist, explained the typical ethos of doctors, who are forced to work grueling schedules and 80-hour workweeks while training.

But that mentality may be evolving.

More than 1,400 residents and fellows at Penn Medicine became the first of their kind in Pennsylvania to pursue unionizing in February. They are among a growing number of medical residents exploring labor organizing nationwide, and the movement has spurred conversation among more veteran doctors about whether other groups of physicians could unionize.

Both residents and nurses’ unions described the punishing experience of the COVID-19 pandemic as a catalyst for a reenergized labor movement. The same could happen among more experienced doctors.

“It’s getting closer to happening,” said Michael DellaVecchia, an Ardmore ophthalmologist who as a former president of the Philadelphia County and Pennsylvania Medical Societies discussed labor issues with doctors. “We are not there yet but once again, you push people against the wall and they’ll come out swinging.”

Residents and fellows are a natural fit for labor organizing because they are hospital employees, and are locked into working at one place for the duration of their residency.

The National Resident Matching Program, known as The Match, handles hospital placement for residents. The Match is a mathematical algorithm designed to place residents at their top-choice program. But because positions are limited and some programs are more competitive than others, the algorithm also considers how institutions ranked candidates to assign them a hospital. Not everyone gets their first choice, and there’s no negotiating reassignment after The Match.

“What other job is one that a computer has an algorithm that assigns where you’re going to work?” said Chantal Tapé, a third-year resident in family medicine at Penn and member of the residents’ organizing committee. “It shifts the dynamic a lot in favor of residents having very little power or control over their work lives.”

Penn’s residents and fellows cited low pay, long hours, and cost cutting as issues a union could address.

Several veteran doctors empathized. They remembered residencies as grueling. The pressure from attending physicians and program directors filters down to residents, and creates a tense environment, even among peers.

“If I’m tired and I can’t function well I can’t take care of myself, let alone my patients,” DellaVecchia said.

Doctors also emphasized, though, that residencies need to be rigorous.

“You have to get to that point where you’ve seen things so many times you just instinctively know that something is wrong,” said Lawrence Ward, a specialist in internal medicine and vice president for physician services at Bayhealth Medical Group in Dover, Del. “That’s only gotten by hours and hours of training and seeing so many patients.”

He acknowledged, though, residencies can tilt from hard work into “a sense of being exploited and not having control over their situation.”

» READ MORE: Penn Medicine residents and fellows want a union, citing grueling workloads and 80-hour workweeks

Matthew Phillips, a cardiologist in Austin, Texas, for 40 years until retiring six years ago, has been following the Penn residents’ unionizing effort.

“I don’t think it’s reasonable to pay residents very little money anymore,” Phillips said, noting the cost of a medical education. “You need to be paying them enough that they’re not looking for a second job.”

Examples of unionized veteran doctors are rare.

The American Medical Association, which supports doctors’ rights to collective bargaining, reported just over 7% of practicing physicians were in a union in 2019, and among them are government employees, residents, and staff at nonprofit health-care clinics. About a third of podiatrists are unionized through Office and Professional Employees International.

Some doctors worry the process of creating a union or negotiating a new union contract could conflict with oaths to put patients first. For instance, unions in other fields may call for a strike to advance a stalled contract negotiation.

A 2020 article in the American Medical Association’s Journal of Ethics identified labor actions short of striking unions can take, such as refusing to perform elective surgeries. Doctors would have to guarantee patients still had access to emergency care and hospitalized people continued to receive treatment, the article said, and strikes should ideally be motivated by concerns that working conditions hurt patient care.

Some physicians believe that doctors’ lucrative salaries, their power to negotiate their contracts independently, and the ease with which doctors can find another job would also undermine a labor organizing effort.

“If you made me angry, you treated me badly, I can leave,” Ward said.

Traditionally, most doctors worked in private practice or contracted with hospitals, said Rebecca Kolins Givan, an associate professor of labor studies at Rutgers University. Doctors who essentially act as independent contractors can’t coordinate to set prices, she said, as it could be interpreted as a violation of antitrust law that bars competitors in a market from colluding. That’s been a major obstacle to unionizing.

Now, though, more doctors are direct employees of hospitals, health systems, and corporations than even a few years ago.

“Practicing medicine now doesn’t look like practicing medicine in the past,” Givan said.

The grueling conditions of the pandemic coincided with tens of thousands of private practices acquired by hospitals and corporate entities, according to a 2021 study from the Physicians Advocacy Institute. Consolidation, already in progress for decades, accelerated as private practices faced financial pressure due to COVID, an article in the Harvard Business Review said. In January 2019 about 62% of doctors worked directly for a hospital or corporation. By 2021, that jumped to almost 70%, according to the PAI study.

In the meantime, state legislation may address doctors’ most urgent concerns. Arvind Venkat, an Allegheny County Democrat and emergency physician, plans to introduce two bills that would create staffing requirements in health care and eliminate noncompete contract clauses that prevent health-care workers from finding other employment.

» READ MORE: Penn Medicine residents seeking union may have a fight ahead. Here’s what comes next.

Noncompete clauses bar physicians from practicing within a certain radius of their employer for a period of time after they leave a job. The radius can be so large doctors, especially those in big cities, may have to move to continue working.

“You’re not going to be able to practice,” Venkat said. “It’s unfair to family members, it’s unfair to practitioners.”

The Federal Trade Commission has also proposed a national ban on noncompete clauses, Venkat said.

Whether labor organizing spreads more widely among doctors may depend on how the residents organizing now are received when they seek out their next jobs. Even doctors who empathize with the residents said they would have felt pampered by an 80-hour-a-week schedule during their residency, which is now the maximum. It’s a reaction these more experienced doctors say they try to push aside.

“I don’t want them to think I’m saying ‘I did it so you have to do it’ — that’s a false argument,” Phillips, the retired Austin physician, said.

Meyer, the Exton physician, still runs her own practice and said she wouldn’t hesitate to hire a resident who had been involved in labor organizing if they were competent and compassionate, though she acknowledged some in the profession will likely be less understanding.

“I think they’re going to get laughed at as long as there’s old-school doctors practicing and they’re the ones doing the hiring,” she said.

Today’s unionizing residents, she said, may end up bringing that labor organizing spirit with them as they enter the larger medical workforce.

Jessie Ge, a resident at Stanford Health Care in California, led the unionizing effort there, and expects to continue labor organizing throughout her career.

“I think it’s a necessity for health-care providers to realize they do hold power and have a voice in the system,” she said.

Editor’s note: A previous version of this story mistakenly asserted that The National Resident Matching Program, known as The Match, determines pay for resident physicians. The error has been corrected.