What If the Doctor Is Out?

— Strikes can lead to important changes for interns and residents

by
Michael Rosenbaum, MD, and Sorcha A. Brophy, PhD

September 23, 2023

Chief Complaint: Los Angeles House Staff Threaten to Strike

In June 2022, Los Angeles interns and residents, collectively known as “house staff,” made a strike threat for what would have been the first house staff strike in about 30 years. The reasons were financial (low salary, long hours, and an expensive city), allegations of non-meaningful responses from Los Angeles County, and the stress of the COVID pandemic.

At the time, Monique Hedmann, MD, MPH, was a second-year resident in family medicine at Harbor-UCLA medical center, and one of the negotiators between the Committee of Interns and Residents (the largest U.S. house staff union) and Los Angeles County. She told us, “We were not feeling valued by our employers and so we had to threaten to strike. The shortages of personal protective equipment, hours, loss of life, and being pulled from other rotations was too much.”

At the last minute, the proposed strike settled, but the momentum grew. Across the country, house staff were re-energized and began reexamining their relationship with hospitals at every level. If nothing else, this movement toward better treatment of interns and residents may actually be a positive consequence of the pandemic.

History of Present Illness: Long Hours, Burnout, and the Pandemic

House staff have always worked hard. By the mid-20th century, work expectations had evolved from “residing” at hospitals to working about 120 hours per week (often continuously for 36 hours or more in some programs). In 1974, work-related medical and physical exhaustion was officially titled “burnout,” now a recognized medical diagnosis. In 1987, the Bell Commission recommended limiting resident work weeks to 80 hours or less and shifts to 24 hours or less to protect patients from overtired and under-supervised physicians.

During the COVID pandemic, house staff worked extra hours, usually unpaid, and covered many other duties for the over 230,000 healthcare workers who exited the workplace. Symptoms of “burnout,” especially depression and anxiety, increased significantly.

These numbers do not surprise Adina Rusakov, MD, a pediatrician in New York City who was a house staff member at Montefiore from 2018 to 2021. Her 3 years of internship and residency were about evenly divided between a pre-pandemic and a pandemic phase. “We became bodies allocated to other departments,” she said. “We had to learn at the bedside to care for adults who were often drug-seeking and aggressive, as well as geriatric patients who asked us each day if they were going to die. We were scheduled for 90 hours of shift work per week, but often had to stay later to finish our notes.”

House staff responded to these challenges with substantial reorganization. According to Sunyata Altenor, communications director of the Committee of Interns and Residents, union membership among the approximately 145,000 U.S. interns and residents has increased by over 50% since 2019.

Review of Systems: A Re-Examination of Strike Consequences

Recently, there have been stringent analyses of claims that reduced work hours compromised training or harmed patients, thereby violating the Hippocratic Oath. Analyses of all scientific reports of doctor strikes from 1946 to 2021, as well as multiple smaller studies, reported variable results, but overall found no consistent increases in patient morbidity or mortality regardless of strike location or duration. Another study compared reported preventable adverse events before and after a 16-hour per shift work limit for first-year residents was implemented by the Accreditation Council for Graduate Medical Education (ACGME). It found that resident-physician-reported medical errors and adverse events fell by approximately a third, and medical errors resulting in patient death declined by almost two-thirds. Another study found work hour reforms to have no detrimental effect on the quality of the care provided post-residency. Limits also have positive effects on house staff well-being.

Now, the tightness of the self-imposed restrictions that had kept strikes historically rare have been appropriately “slackened” and house staff are speaking out more and more.

Despite the debate over whether house staff are trainees or employees, it is clear that they are the “golden geese” of hospitals. Their average annual salary to reimburse them for their hospital work is about $64k (most of which is paid by the government along with additional indirect medical education payments), and a typical medical school debt of over $200,000 (significantly higher for Black and Latinx house staff) plus any college debt. As opposed to impacting patient outcomes, house staff slowdowns or strikes have major consequences for hospital finances. When the University of New Mexico’s neurosurgery program lost its ACGME accreditation in 2019, it had to “replace” its eight residents by hiring 23 new advanced practice providers, such as physicians’ assistants or nurse practitioners at an individual cost of about $115,000/year: a five-fold increase in operating costs. Imagine a strike in which these expenses accrued across all hospital departments, not just neurosurgery! The bottom line is that action by house staff is likely to have a more favorable outcome for providers and patients than it is for hospitals’ financial health.

Treatment and Results: Room for Improving Structural Flaws

To be sure, the experiences of internship and residency cannot be summarized by discussions of working conditions and house staff or hospital finances, and what might be best for these physicians in the 2020’s might not be applicable to their predecessors. Some doctors may feel that the long hours were character building, created a unique camaraderie, or improved their skill set, while others may focus on the lectures they missed because they dozed off or had too much paperwork to attend to as “new” doctors. Many will object to the idea of major program changes for the newer house staff who are now more empowered to negotiate with hospitals to better address programmatic structural flaws and thereby avoid strikes. Rusakov is not sure if she would support a strike, but she feels strongly that the work hours and stresses of internship and residency need to be addressed by some organized means because they are not producing healthier patients or better doctors by denying that these problems exist.

The consequences of that Los Angeles strike threat were predictable. We spoke with Altenor shortly after the settlement and she was “100% sure” that there would be a strike, even if it wasn’t in Los Angeles. She was right. House staff at Penn Medicine, Mt. Sinai, Montefiore Medical Center, and others quickly entered the fray, culminating in an actual strike at Elmhurst Hospital in Queens, New York, in May 2023.

Prognosis

Fortunately, the prognosis for interns and residents is excellent. It seems that better-resourced, better rested, and better-paid house staff would provide better care. Optimal scheduling will vary by specialty, but overall, moving away from the 130-year-old tradition of treating house staff as inexpensive labor with working hours equivalent to at least two “normal” jobs might be a beneficial outcome from the pandemic.

Michael Rosenbaum, MD, is a professor emeritus and special lecturer in pediatrics and medicine at Columbia University Irving Medical Center in New York City. Sorcha A. Brophy, PhD, is an assistant professor in the Department of Health Policy & Management at the Columbia Mailman School of Public Health.