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Though resident unionization provided some benefits, it may have also yielded unintentional consequences, a qualitative study showed.

Interviews with general surgery residents, as well as program faculty and staff, at two unionized programs suggested that a lack of voice and agency drove unionization. Increased salary stipends and/or housing stipends were the most concretely identified benefits of unionization, reported Julie Johnson, PhD, MSPH, of the University of North Carolina at Chapel Hill, and colleagues.

However, unintended consequences of unionization were the irrelevance of certain negotiated benefits, paradoxical losses of surgery department-provided benefits, and framing of resident-faculty relationships as adversarial, they noted .

"Resident unionization continues to be hotly debated," Johnson and colleagues wrote. "Recent survey data demonstrate that unionized programs are more likely to offer a housing stipend and more weeks of vacation time, but resident burnout, job satisfaction, and impressions of the educational environment are similar between surgical residents in unionized and non-unionized programs."

"The reasons for this similarity in wellness between unionized and non-unionized programs represent a gap in the literature," they added.

Their study comes amid an ongoing wave of unionization by healthcare professionals -- including resident physicians and fellows -- at a variety of institutions nationwide.

"As the trend toward trainee unionization progresses rapidly, best practices on leveraging a union to enhance the work environment without inhibiting the learning environment are promptly needed," wrote Adam Mikolajczyk, MD, and Colin Goodman, MD, both of the University of Illinois in Chicago, in an .

In general, "every action has unintended consequences," Johnson told MedPage Today. And "being up front and talking about that is important."

All union-related interviews pulled for the present analysis occurred from 2019 to 2020 at two general surgery residency programs: one that had recently unionized and another that had been unionized for decades.

The interviews had been conducted as part of the exploratory phase of the Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) trial intended to study the impact of the learning environment on resident well-being at 15 general surgery residency programs.

Ultimately, the group collected 22 transcripts with content relevant to unionization, Johnson and colleagues noted. Nineteen of these were from individual interviews with residents (n=10), faculty (n=4), a member of administrative staff (n=1), a program director (n=1), a department chair (n=1), and designated institutional officials (n=2). Another three came from resident focus groups. Residents from all postgraduate years were represented, as were residents in their professional development years.

Among the findings by Johnson and colleagues was that unionization allowed residents to "reframe complaints and move into a proactive space of improving their working conditions," they noted. For instance, one PGY-1 resident interviewee said that, "It's a very surgical mentality to just plod through things and not complain," pointing to an operating room workroom where half of the computers were always broken.

Additionally, residents as well as faculty "enumerated financial gains negotiated by the union," Johnson and colleagues reported. One PGY-5 resident said the following: "We're paid probably $10,000-$15,000 more than our closest neighbor. ... We have great benefits in terms of our health insurance." Other financial gains after unionization included meal, housing, and educational stipends; subsidized parking; medical equipment; licensing or board examination registration fees; and fertility coverage.

Meanwhile, though financial benefits were "universally appreciated," residents found some benefits "irrelevant or inaccessible to them," Johnson and colleagues noted. Residents reported they could not take full parental leave without extending their training due to American Board of Surgery requirements, nor could they take guaranteed holidays due to inadequate clinical coverage. They also reported they did not use preventive care time due to a surgical culture of self-sacrifice.

Furthermore, union rules and regulations to enforce uniformity across programs had the potential to yield two kinds of loss: of "previously established benefits" -- because other "less well-funded departments could not match the resources of surgical departments" -- and of "flexibility for the program to meet residents' individual needs."

Educational leaders also "perceived that union executives encouraged residents to engage in conflict rather than bring issues directly to their leaders to be solved collaboratively," Johnson and colleagues noted. "Conflicts around clinical educational assessments were particularly contentious."

At the same time, "[a]side from its effect on resident-faculty relationships, unionization was described as having positively affected the clinical and educational environment by advocating for increased support staffing," they noted.

Chief among the major limitations of the study was that union-related interviews came from just two of 15 programs. Additionally, interviews had been structured around a general wellness framework instead of participants' union experience, Johnson and colleagues noted.

Moreover, opinions of members of non-unionized programs were not included, and interviews were conducted before the pandemic, "after which resident unionization has risen," they cautioned. Also, no programs were in the process of unionizing, and the stated resident benefits were not independently verified.

The study's authors "have taken a crucial step forward by attempting to characterize the effects of unionization on a smaller scale," Mikolajczyk and Goodman wrote. "However, the themes generated from this study also clearly highlight the need for a much broader dataset to ensure the generalizability of themes across all graduate medical education in order to create initiatives to preserve the educational alliance."

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