“After many years of residents being overlooked by health care systems, I offer this prediction: residents have had enough. Residents, together with their nursing colleagues, serve as the backbone of the health care delivered in academic medical centers. Their power and importance cannot be overstated.”
I wrote this in December 2023 for Forbes’ “Healthcare Insiders Predict the Future,” which invited me and other “health care insiders” to forecast important trends for the coming year. While I might have prognosticated publicly about any number of trends in health professions education, I settled on the continued growth of resident unions because, as a former dean of medical education and, before that, a residency program director, I have long noted with deep concern that, all too often, residents in graduate medical education programs are “underpaid and underappreciated labor” who fill gaps in the American health care system.
The reemergence of resident unions in the last few years is telling us something vitally important about the current and future state of health care in America: Our system of on-the-job training and education is not working for the newly minted MDs we rely on to care for patients. But it is not just residents who feel that things have gone horribly wrong—our faculty, nurses, and health professionals are all showing distress. And this distress is often directly related to factors that prevent faculty, residents, and staff from being able to do their work at the level they expect of themselves and they know our patients deserve.
Take the example offered by a third-year neurology resident who wrote in STAT News last year that she wanted to unionize because she felt ethically compromised by the care she was “forced” to provide to her patients, care that she would not always deem acceptable for her own family members: “I voted yes [on the question of whether or not to hold a formal election to form a union] because I’ve struggled to provide patients the medical attention they’ve needed and [I] haven’t received fair compensation for the work I’ve put it in. With a union, I believe residents will have agency to enable change within a troubled health care system.” This opinion is in line with the origins of the resident unionization movement which began in the early 20th century and was seen as a pathway for improving patient care and safety.
Residents provide the first line of care to the sickest patients with compensation that is not in keeping with the many years of education they have already attained, few additional benefits, and often with little input regarding working and training conditions or patient safety and quality of care. Those of us responsible for training the next generation of physicians have an obligation not to be so in thrall to the past that we are unable to make appropriate changes to the clinical learning environment and the experience of students and learners.
Residents once had the opportunity to develop meaningful relationships not only with their patients, but also with their faculty. Now there is time for neither. Faculty, like the residents, are themselves under enormous pressure. They are simultaneously pressed to generate clinical revenue, manage ever increasing documentation requirements and generate grant funding such that the time for teaching and relationship building is squeezed right out of their daily work. These relationships and finding meaning in work are essential to well-being, not just for residents, but for their faculty as well.
What residents deserve
If residents have been ruled to be learners, then let us embrace that as a guide for their identity, first and foremost. I will go further and propose that we commit to a new social contract for medicine, for the betterment of medical education and the profession, and for the benefit of all who are present in our health system: patients and their families, faculty, residents, nurses, and other health professionals.
This new social contract for medicine was inspired by the work of Dr. Minouche Shafik, president of Columbia University. In her 2021 book, What We Owe Each Other: A New Social Contract for a Better Society, she explores the concept of the social contract, which defines the terms of our mutual cooperation within families, and across communities and countries. She posits that most of the disaffection being expressed today “stems from the failure of existing social contracts to deliver on people’s expectations for both security and opportunity.” These contracts are failing because the world in which they were founded has fundamentally changed, including the expanded role of technology in our lives and the continued advancement of women into the labor market—two factors that have certainly shaped medicine as a profession over the last fifty years. Thus, she proposes a new social contract based on security, shared risk, and opportunity.
Shafik’s call for an updated social contract rests on changes that have taken place at the broader societal level, but these same changes are impacting academic medicine, whose systems, traditions, and employment policies have not kept up with changing demographics, norms, and values. One very simple example: In 2022, women—once rarely seen in residency programs—comprised nearly half (48.3%) of active residents and fellows, and most residents, both male and female, are in their prime family-building years, yet there is tremendous variability across residency programs when it comes to family leave policies and access to childcare for residents who regularly work 80-hour work weeks.
It was not until 2021, that all American Board of Medical Societies’ member boards with training programs of two or more years duration mandated leave for trainees: a minimum of six weeks away once during training for purposes of parental leave without exhausting time allowed for vacation or sick leave and without requiring an extension in training. How slow are we as a profession to adapt if it was only three years ago that we chose to provide the bare minimum of time away from work for those who become new parents during their training?
Since medicine—like society—has undergone fundamental shifts, I am suggesting that everyone who works and learns in clinical environments should ideally rely on an updated social contract for medical education that ensures:
- The right to be and feel safe in all clinical environments, whether in the clinic, the hospital, or the laboratory;
- The opportunity to flourish and thrive, including equitable access to resources specifically for salary and other benefits consistent with their years of education and training; and
- The experience of support, including feeling like they are welcome and that they not only belong on our care teams, in every field of medicine, and in the profession itself but that we are fully invested in the development of their clinical acumen and skill and in their overall career development.
Notably, this new social contract is not a guarantee against residents’ discomfort. I am not suggesting that, because residents are rightfully pushing back on valid complaints, including low pay, long hours, lack of benefits, and mistreatments and discrimination, that they should be handled with kid gloves and spared the rigorous mental and physical demands and uncomfortable ethical and moral challenges of residency training. I fully agree that, as a faculty member quoted in a recent essay: “discomfort is part of the human condition and a prerequisite for learning. Violence and oppression are to be avoided but not discomfort. The ability to discern the difference is a form of emotional maturity that we should encourage.”
A new social contract that ensures safety, support, and opportunities to flourish would bring everyone within the clinical learning environment to a place of greater mutual respect, trust, and collaboration. It also would allow our residents and faculty to experience work that is at minimum “decent,” which meets workers’ rights and needs in terms of safety, security, and dignity; and more aspirationally, is “meaningful,” which is work that is experienced as positive and significant.
Today we celebrate the inaugural annual, national Health Workforce Well-Being Day, launched by the National Academy of Medicine’s Clinical Well-Being Collaborative. In honor of this initiative, and in deep agreement with its goals and principles, I suggest that we commit to a new social contract in medical education—one that recognizes our responsibilities to care for and support each other and work together to improve the working conditions for the current and future generations of physicians. In doing so, it will become obvious that, for too long and in too many ways, we have undervalued residents and fellows. We must respond with alacrity to their genuine concerns for their patients and for their own well-being and that of their families. We also must work together to make meaningful change for the future of health and health care in America—not just for our workforce, but for their patients and the communities they serve.