Mass General Brigham residents to unionize, hoping for 'a seat at the table'

Key takeaways:

• After their hospital declined to voluntarily recognize their union, MGB Housestaff United announced their election for representation.
• A member of the union’s organizing committee spoke with Healio about its goals.

Recent efforts from major residency and fellowship programs in the United States have sparked discussion about health care workers unionizing.

Mass General Brigham (MGB) Housestaff United, specifically, has drawn national attention in the last month, including recognition from Sen. Bernie Sanders, I-Vt. and Sen. Elizabeth Warren, D-Mass. MGB Housestaff United represents thousands of residents and fellows from diverse specialties at Harvard Medical School and MGB, a nonprofit integrated health care system in Boston, founded by Brigham and Women’s Hospital and Massachusetts General Hospital, two of the nation’s top hospitals.

Kayty Himmelstein, MD, MSEd, an infectious disease fellow at MGB and a member of the MGB Housestaff United organizing committee, told Healio that the interest in forming a union came from “a desire to be able to take care of ourselves so that we can take good care of our patients” and “advocate for the resources they need to stay healthy,” but the COVID-19 pandemic “spurred us to think a bit more about it.”

“We were on the front lines ... caring for our community,” Himmelstein said. “I think in that context, we really felt the urgency of having our employer look out for us as well, through fair wages and benefits, adequate protective equipment, time to take care of ourselves when we or family members were ill, and those things became increasingly urgent for us.”

The physicians filed for a union election on April 4.

On April 19, they held a press conference hosted by the Committee of Interns and Residents (CIR) to formally announce their election for union representation because MGB declined to voluntarily recognize it.

“MGB is the biggest health care system in Massachusetts with some of the top hospitals in the nation, and it’s the largest employer in our state,” Sascha Murillo, MD, a third-year internal medicine resident at Massachusetts General Hospital, said during the press conference. “My colleagues and I believe that just as MGB is at the cutting edge of patient care, through our union, we can revolutionize residency and patient care.”

MBG has had “the opportunity to shepherd this movement,” she added, “but unfortunately, their actions thus far have only sewn mistrust and bad faith.”

“Much like big corporations like Amazon and Starbucks, we have seen them use the same union-busting playbook,” she said. “They've been holding captive audience meetings with residents, creating fear mongering websites that pit us against one another. But we're strong and we're strong together, and we will not lose our voice.”

Paul Anderson, MD, interim Chief Academic Officer of MGB, said in a statement to Healio that, “though health care is facing unprecedented challenges, MGB remains committed to the lifelong advancement of our medical trainees and working directly together to continuously improve our educational programs.”

“MGB is home to some of the top-ranked and highest-paid residency programs in the country,” he said. “We promise an outstanding educational environment that balances clinical service and learning, and provides well-rounded support to ensure a meaningful experience, professionally and personally, to these highly valued members of our community.”

Working conditions

Residency has always been a job in which people are expected to make “extreme sacrifices in terms of their own well-being,” Himmelstein said.

The house staff at MGB, Himmelstein added, live in one of the most expensive cities in the United States, “with incredibly high costs for renters.”

“House staff are often making really profound sacrifices,” she said. “We're not able to meet our own needs. Given that high cost of living, folks are turning down their heat at the end of the month. People are eating hospital snacks at the end of the month because they don't have money left for groceries.”

House staff’s ability to access health care for themselves is a major concern, she said. If they are out sick, colleagues must cover their work for no additional pay.

“I went 3 years, for example, without a dental cleaning because that wasn't an emergency. I wasn't going to make a colleague cover me so that I could go get my teeth cleaned. But that's not a standard of care I would recommend to my patients,” she said.

Additionally, those with children often heavily rely on unpaid labor from family members, Himmelstein said, because the cost of child care is out of reach, particularly for house staff who often work upwards of 80 hours per week.

“A part of residency is this expectation that folks will work really hard, will sacrifice their own well-being, will really struggle to make ends meet,” she said. “For a long time, house staff have thought about ‘what can we do to address that?’ And unionization is an answer.”

Part of a national trend

At the end of 2019, CIR, the nation’s largest and oldest house staff labor union, represented more than 17,000 residents and fellows. Today, it represents more than 25,000 house staff across the country.

CIR provided a statement to Healio that said, in the past year alone, house staff from seven organizations have unionized with them: California Pacific Medical Center, Keck Medicine of USC, Lifelong Medical Care, Montefiore Medical Center, Stanford Health Care, the University of Vermont Medical Center and the University of Washington. That translates to about 4,800 people.

The organization also expects elections for Penn, George Washington and MGB, which would mean at least 4,350 more members, according to CIR.

Lewis Nelson, MD, a professor and chair of the emergency medicine department and chief of the division of medical toxicology at Rutgers New Jersey Medical School, said he has been involved with training residents for 30 years. The residents he has worked with “have always been in a union” and he was part of the CIR as a resident.

However, he said that he does think places that have not had unions seem to be unionizing more and more today.

“Health care is changing. There are some places where faculty are unionizing as well. In fact, the faculty at my institution are unionized,” Nelson said. “This is the same struggle that all industries have where the administration and the institutions get stronger. There's a feeling of disempowerment among the workers, and they feel that there's a benefit to creating an alliance and joining a union.”

Every union, he said, “comes with some good and some bad.”

Differing perspectives

Himmelstein said that the overarching upside for union members is that they will “have a seat at the table.”

House staff, she said, are in a vulnerable position because they match into residencies and fellowships, “meaning we don't get to shop around or compare contracts” and “have no ability to negotiate.”

“Without a seat at the table, it’s really limited what we're able to do to advocate for ourselves and our patients,” Himmelstein said. “So, I think the real upside is for us to say, ‘we need a legally recognized body, we need a democratic process for us to express our needs and the needs of our patients, to our employer, to the health system.’ I think that's really the main upside.”

In terms of downsides, Himmelstein said, “I really, to be very frank, don't think there are very many of them.”

When employers try to fight unions, they often say things like “you will lose your flexibility or ability to negotiate separately,” but “we don't have that power now,” she added.

“Every year, MGB writes a contract and sends me an email and says, ‘here's your contract, sign it,’” she said. “Individually, we're very vulnerable and we can't accomplish much. The purpose of the union is for us to say, ‘we have a shared interest in terms of our own lives, in terms of our own survival.’”

Nelson pointed to concerns about patient care as a potential downside to unions.

“Sometimes a sense of advocacy can come a little hyperbolic on the side of the union and they tend to set unrealistic expectations for the union members,” he explained. “Health care is a tough world and there’s a lot to do, a lot of responsibility. Education is many long, hard hours and to think that you're going to be educated without doing that, because the union says you should, doesn’t seem like a reasonable selling point.”

The days of working 100- and 110-hour weeks are over, he said, and the industry is trying to fine-tune the amount of work that residents do, “but there is an educational component.”

“We want to make sure that patient care is delivered and education and training are done, and that can't really be done on a shoestring,” he said. “So, I think you just have to be careful that we don't overdo the work hours regulations and approaches to the point in which that affects the quality of education that people are receiving.”

Physician strikes are another issue that could impact patient care, Nelson pointed out.

Worst-case scenario

The first major physician strike in the U.S. took place in 1975 after months of negotiations and involved 21 New York hospitals. At the time, one of the physicians involved wrote in an editorial for The New England Journal of Medicine that the strike was “a revolutionary event in medical history.”

The most recent potential strike came from the LA County CIR bargaining team in June 2022, but it was ultimately averted. It would have been the first since 1990, according to the CIR.

Nelson said he does not foresee physician strikes becoming an issue in the U.S., largely because of the ethical considerations.

“Without having an adequate system to care for patients when we go on strike — it does seem a bit on the ethically questionable side,” Nelson said. “There are human beings, lives involved. It's one thing when a construction site doesn't get worked or maybe airlines don't fly, but here you're talking about people's lives.”

Himmelstein also noted that physician strikes are “incredibly rare.”

“The last house staff strike was decades ago, even though there have been tens of thousands of unionized residents and fellows for years,” Himmelstein said. “There have been unions that have been able to fight really effectively for benefits for patients, and for house staff without strikes because there are lots of other mechanisms for us to use to advocate for ourselves.”

Himmelstein additionally addressed the perception that, if house staff were to strike, they would abandon their patients.

“That's certainly not the case. First of all, we all are doing this work because we care about patients and would never want to do and never would do anything to jeopardize their safety,” she said. “When other essential workers like our nursing colleagues go on strike, there's a very clear process to prevent harm to patients. They give 2 weeks’ notice, the hospital has time to find temporary staff to fill in those roles and ensure patient safety.”

When unionized workers strike, she added, it is “a last resort because their employer has been unwilling to negotiate and meet their needs.”

“I think that house staff strikes can certainly be avoided by employers negotiating in good faith with house staff to make sure that they're doing their best to meet our needs and arrive at fair contracts,” she said.

References:

• Committed to improving working conditions and care at Mass General Brigham hospitals, MGB doctors unionize. https://www.cirseiu.org/press-advisory-mgb-press-conference-4-19/. Published April 12, 2023. Accessed April 12, 2023.
• LA county resident physicians reach tentative deal with county. https://www.cirseiu.org/la-county-resident-physicians-reach-tentative-deal-with-county/. Published June 6, 2022. Accessed April 19, 2023.
• Pact ends doctor strike; staffs return to hospitals. https://www.nytimes.com/1975/03/21/archives/pact-ends-doctor-strike-staffs-return-to-hospitals.html. Published March 21, 1975. Accessed April 18, 2023.
• Shear K, et al. N Engl J Med. 1975;doi:10.1056/NEJM197506052922322.