House Staff Unionization Has Come in Waves

Lately, resident physicians and fellows have been unionizing in droves. However, it’s far from a new phenomenon.

Amid a resurgent landscape, “it is important to consider how this wave of organizing can be different from past ones,” physicians contended in a new piece on the history of house staff unionization published in the New England Journal of Medicine.

Indeed, the unionization of house staff dates back to the 1930s, with a series of impactful strikes in the 1970s, followed by legal turmoil, noted Ahmed Ahmed, MD, MPP, of Brigham and Women’s Hospital, and Scott Podolsky, MD, of Harvard Medical School, both in Boston.

But the last 4 years “have seen the most substantial surge in house staff unionization since the mid-1970s,” Ahmed and Podolsky wrote.

“With this renewed push, U.S. medicine finds itself at a crucial juncture,” they added. “The problems inspiring house staff to organize have endured for the past 90 years: concerns about working conditions, patient care, and compensation remain top of mind.”

In the 1930s, at the height of the Great Depression, it was a “critical era for the development of the American medical residency,” Ahmed and Podolsky wrote.

During this time, medical residents in New York City raised concerns that included lack of any salary or limits on the amount of time they spent on duty, poor living conditions, low quality of teaching in some centers, and rising clinical volume without proper support staff, they noted.

In 1934, a group of 66 representatives from 26 hospitals convened to form the Interne Council of Greater New York, with goals to attain “elementary needs” for themselves and to improve patient care, they noted. Following early wins, however, the group evolved into a political organization and dissolved by 1952 after efforts were hindered by political attacks and insufficient funds.

In 1957, an enduring house staff union emerged in New York City hospitals, and that Committee of Interns and Residents has grown to become the largest labor organization of its kind in the U.S., they continued.

Momentum continued in the following decades, during a period of “broader social unrest and reform,” Ahmed and Podolsky wrote. At the time, pay was still a concern; however, working conditions and patient care took center stage.

“Though most house staff readily supported such causes, the methods some organizers deployed to achieve their aims soon became morally divisive,” they wrote. “By the mid-1970s, the resulting tension had become palpable.”

In 1974, Congress approved the Health Care Amendments to the National Labor Relations Act, and the legal right to unionize and strike was extended to employees of nonprofit hospitals, they noted.

Regarding strikes that ensued, even in the case of an observed “win,” residents “were forced to consider whether the ends justified the means,” they continued. However, “[d]espite these moral qualms, strikes continued to occur.”

Some hospitals responded to tactics taken by house staff with legal action, Ahmed and Podolsky noted.

In 1976, the National Labor Relations Board (NLRB) decided that house staff, “although they possess certain employee characteristics, are primarily students” and could not unionize. A rift ensued.

After other courts ruled against the NLRB in subsequent state cases, house staff at public hospitals (under the jurisdiction of state boards) could unionize, while their counterparts at private hospitals (under the jurisdiction of the NLRB) could not, Ahmed and Podolsky noted.

Ultimately, the rift lasted until 1999, when the NLRB reversed its decision and concluded that house staff were also employees.

“Despite the landmark decision,” Ahmed and Podolsky wrote, there was “little new movement” until the pandemic.

Once again, familiar concerns emerged: a lack of supplies, long working hours, and inadequate staffing and pay.

“Effecting needed change in U.S. medicine won’t be easy,” Ahmed and Podolsky concluded, “but it wasn’t expected to be.”

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