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California's Early-Career Doctors Unionize, Demand Fair Pay and Conditions

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Kaiser Permanente employees on strike on Oct. 4, 2023. The workers held a demonstration in front of the Kaiser Permanente South Sacramento location demanding higher wages and more staffing. (Miguel Gutierrez Jr./CalMatters)

In some California hospitals, early-career doctors make as little as $16 per hour working 80-hour weeks. It’s training, known as residency, that every board-certified doctor must complete.

The grueling schedules for little pay have been contentious in medicine for decades, and they’re increasingly driving medical residents to form unions. The national accrediting agency for residency programs limits the average workweek to 80 hours.

Last week, hundreds of resident physicians and fellows at Kaiser Permanente’s Northern California facilities became the latest to join the wave of medical trainees demanding better pay and working conditions. Their petition filed with the National Labor Relations Board comes after Kaiser Permanente refused to voluntarily recognize the union.

Union membership at medical training programs in California has more than doubled since 2020, according to data from the Committee of Interns and Residents, the union that represents most unionized trainee doctors nationally. Residents at Stanford Health Care, Keck Medicine of USC and all six of the University of California academic medical centers have organized labor unions in recent years.

Northern California Kaiser staff now must hold a formal vote to finalize unionization. If the vote succeeds, residents could join most other Kaiser workers — including pharmacists, nurses and housekeepers — in gaining union representation at the largest health provider and private employer in the state. More than 9 million Californians get health care through Kaiser.

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Dr. Brandon Anderson, a second-year internal medicine resident at Kaiser San Francisco Medical Center, said the move to organize was spurred in part by other hospital residents unionizing across the state and country. In an informal vote more than 70% of trainee doctors across Northern California Kaiser facilities supported unionizing, Anderson said.

“There is a huge national movement to recognize residents as decent workers,” Anderson said. “We’ve become pawns in this giant game of making money for a hospital at the expense of your frontline workers.”

Nationally, union membership among medical residents has expanded from 17,000 to more than 32,000 in a little over three years. There are more than 144,000 doctors in residency programs nationally, according to the Association of American Medical Colleges. In California, the number of unionized medical residents has grown by 62% since 2020, said Annie Della Fera, a spokesperson for the Committee of Interns and Residents.

In a statement, a spokesperson for Kaiser Permanente said the organization is committed to providing a good learning and working environment.

“We respect our long-standing relationships with labor unions and the rights of our employees to make decisions about whether they want to be represented by a union,” the statement said.

Increased pay, overtime compensation, housing stipends and more manageable schedules are at stake. Unions representing residents have bargained for fertility benefits to support delayed family planning. Dr. Berneen Bal, a third-year psychiatry resident at Kaiser’s Oakland Medical Center, said some colleagues have even traveled out of state where it’s cheaper to freeze eggs.

“As more residencies have unionized, it’s put greater criticism on this training structure that we’ve all just accepted for so long,” Bal said.

Pay for medical residents in California

At Kaiser’s eight Northern California hospitals, residents make around $80,000 per year and typically work between 60 to 80 hours a week, getting one day off per week, Anderson said. The pay range for residents at other non-unionized health systems in California is similar or lower. In contrast, starting salaries for full-fledged physicians are nearly $300,000 depending on specialty.

Unions represent few certified doctors in California because many employment structures make them business partners and prohibit them from joining a labor organization. Many doctors participate in the politically powerful California Medical Association, which represents their interests in the Capitol.

Doctors-in-training have long bemoaned grueling workweeks and little pay, but the pandemic fueled unionization, said Ken Jacobs, co-chair of the UC Berkeley Labor Center.

In health care specifically, COVID and the aftermath of COVID have pushed a lot of people into seeing the need for a union and going out and doing the work necessary to win a union election,” Jacobs said.

Hospitals relied on residents for surge staff during COVID-19 peaks but didn’t pay them overtime or offer other worker protections, several doctors interviewed for this story said.

Stanford Health Care initially excluded residents from eligibility for the first round of COVID-19 vaccines in 2020, a breaking point for trainee doctors who unionized there in 2022.

“It showed us that they view us as an expendable workforce,” said Dr. Philip Sossenheimer, a hospice and palliative medicine fellow at Stanford Medicine. “It was so stark the differences of how we’re treated compared to our colleagues who are doing similar work.”

Sossenheimer said doctors-in-training are especially vulnerable to exploitative employer practices because it is nearly impossible to leave a residency and find another position. They are contractually obligated to complete their residency training if they want to practice medicine. Residencies last between three and seven years (PDF) with additional time for specialty training known as fellowships.

Last year, residents at Stanford Health Care won additional benefits and a 21% across-the-board pay increase in their first contract.

Kaiser union could set precedent

Hospitals began adhering to an 80-hour workweek for medical residents 20 years ago. A 2009 Rand Corp. study found that reducing residents’ workloads to meet that standard and to prevent fatigue would cost major teaching hospitals more than $4 million a year, expenses driven by hiring substitute providers and additional residents.

Hospital executives across the country have been outspoken about increasing labor costs leading to higher prices for consumers, something which puts pressure on California’s attempts to tamp down medical costs. Research shows that wages contribute to higher health care costs in the U.S. compared to other countries, but spending on administration and prescription drugs are bigger drivers.

Despite the growing appetite for collective action among resident physicians, not every institution has accepted unionization efforts. Residents and fellows at Loma Linda University Health are locked in a legal battle over bargaining. The 80-member unit won union representation last June under the Union of American Physicians and Dentists, but the hospital is refusing to bargain citing religious exemptions, according to case documents filed with the National Labor Relations Board.

Loma Linda University Health is affiliated with the Seventh-day Adventist Church.

Dr. Jessica Muñoz, an emergency medicine resident who led unionization efforts at Loma Linda, said seeing other residents win contracts and move to organize offers hope to her and her colleagues.

“No matter what happens here, I’m excited for all of these residents and fellows that are unionizing around California and the country,” Muñoz said.

Jacobs with the Berkeley Labor Center said establishing a union among Kaiser residents could have far-reaching impacts given the size of the health care behemoth, often looked at as a leader for worker pay and benefits.

“It’s a big deal to take on something the size of Kaiser,” Jacobs said. “What happens here will have an impact and is likely to ripple out.”

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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