On September 25, the resident physicians and fellows at the University of Washington (UW) participated in a “strike.” It lasted only 15 minutes, because above all else, they are physicians putting patient care first.
So, why are they striking?
For the bare minimum UW can give. The residents and fellows are merely asking UW to be comparable to the U.S. standard. These doctors are paid less than their peers across the country, not provided minimum safety precautions after absurdly long shifts, and cannot afford childcare or reasonable housing.
It’s no surprise after years of pleading (to which UW had deaf ears), the residents and fellows formed a union which has been bargaining with the employing corporate entity. What is a surprise is that even after formally meeting, UW is continuing to act in bad faith. In response to their residents’ reasonable requests, what did UW offer? A pay cut. To the doctors giving up their youth and wellness, to those who care for patients when they could be home with their own families, UW offered a punishment. Because in the eyes of the corporation that is University of Washington, resident physicians and fellows are disposable.
So the residents went on strike for a mere 15 minutes, and then went back to caring for patients. It remains to be seen if UW will listen. And if they do not, it may be time to strike in a more dramatic fashion, while maintaining the oath they swore in medical school to “do no harm.”
How can doctors strike against a monolithic entity while still providing the care their patients need and deserve? It’s all in the notes. Corporations care about money, not people. Doctors care about people, not billing, but are required to write notes to generate income.
So, still write your notes, doctors. But in your Review of Systems, type “ROS not performed” — it’s not actually medically necessary, but it means billing cannot be done. I’d love to take credit for this clever idea, but it’s lore from a former pediatrics chief. When I was an intern, he told our inpatient team about residents at a program in the Midwest who weren’t being listened to by their employer. So they, and their attendings, began the ROS-free note — and the administration started listening.
Because a corporation that cannot bill for your work has to do something.
The Epidemic We Don’t Talk About
Some may pop in to comment that because doctors get paid “so much” it is not ethical for them to strike. Yes, physicians even in the lowest paid specialties will make an impressive salary — after residency. They have bargaining power and the ability to change jobs — after residency. They have control over the number of hours they work, have time to start a family, and can start paying down their debt — after residency.
But residents are trapped in a contract with their training hospital for a minimum of three years, based on a lottery system. There is no negotiation of pay, vacation time, maternity leave, or call schedule. They cannot quit and go work at a different residency — they are essentially indentured to the hospital to which they matched. Despite this, it can be a bond of mutual benefit — residents receive required training and hospitals get skilled labor for minimal compensation, typically less than the salary of a registered nurse or physician assistant.
But as hospitals cut corners, and hire less support staff, residents are often forced to put patient care before teaching, get called in more frequently, and are dealing with a higher patient census of much sicker patients. This is not the way it was meant to be. The system is broken, and all of us know it — attendings, residents and medical students. The answer is not more mandatory “wellness” modules, check-box meditation classes, or human resources drones giving “talks” to lecture halls full of doctors about how their lack of “resilience” is the cause of their burnout.
According to data from ACGME and UWHA, 28% of residents are suffering from depression, 75% of UW’s residents are already burned out, and as many as one in four interns struggle with suicidal thoughts. Presumably this is due to a combination of excess “workload, work inefficiency, lack of autonomy and meaning in work, and work-home conflict.” And this is surely compounded by the epidemic of depersonalization and hopelessness in residency.
Residents feel trapped, knowing they can’t quit because of the crushing burden of their debt. This burden was initially taken on in the name of becoming a healer, yet so many of our doctors finally finish residency emotionally and spiritually broken. And far too many don’t complete it, but sink into despair, hopelessness — and take their own life. The actual rates of physician suicide are unknown, but Dr. Pamela Wible’s tally is now at 1300, with nearly 30 from Washington. It’s time to do more.
What to Do About This Mess
The following list is not about fixing the entirety of the broken U.S. health care system. It’s not even about doing the bare minimum for residents. It’s not Laws from on High, just suggestions. It’s not only for University of Washington, but for ALL residencies. It’s not an exhaustive list, as I’m sure residents in other specialties have more to add.
GME Offices and Program Directors: Let your residents guide your plans, listen to what they want, and implement those changes. Support them in becoming healers for our communities, to be the best physicians they can be, while letting them remain human. Investing in our future physicians is an investment in ourselves, our communities, and our patients.
- Food is love. Give residents food cards for your cafeteria or open access to a lounge with food 24/7. And if you’re an attending, bring in coffee or some treats once in a while — they will love you for it.
- Safety. My program reimburses for a cab ride home, regardless of time of day, if a resident feels unsafe driving home. We have a resident call room, yet they do this. Why? Because sleeping in your own bed provides better rest, and they care about their physicians. Residents have crashed their cars, so UW’s refusal to reimburse their residents for this is dangerous.
- Salary. While there are standards for salaries across the country, programs in high-housing-cost cities can add monthly stipends to help cover the actual cost of living in their city. Programs that don’t aren’t competitive for the best residents, and self-select away from diverse physicians who don’t come from wealthy families. Several programs I interviewed at as a resident offered this, including public institutions in California, and it made a difference in who I ranked.
- Self-care, sans mandatory modules. We all talk about exercise, but often can’t afford the cost of gym membership on our salaries. My program put a gym next to the doctor’s lounge last year. Other programs pay for membership to a local gym. Let your residents have flexibility in choosing a gym or yoga studio — just don’t make attendance mandatory.
- Protect time off. Create a logical and livable plan for how to cover when a resident gets called in for a delivery from clinic, or when they get sick and needs to stay home, or when a resident has a baby and coverage for their service has to be planned.
- Improve resident quality of life. A residency program or hospital can negotiate for significant discounts on laundry and house cleaning services, for the benefit of all staff. At first you may scoff, but many residents live alone and are so exhausted they don’t even eat, falling asleep the moment they sit down at home. Laundry and house cleaning just do not happen.
- Child care. Many residents are parents, and plenty of them do not have a stay-at-home spouse. Unsurprisingly, they cannot afford au pairs or in-home nannies, and it is impossible to find a last minute baby-sitter when you’re called in for a delivery at 3 a.m. Even in a supportive program, residents may have to send their kids to a family member’s or baby sitter’s house for six to 14 days at a time when they’re on call.
- Fight against mandatory mental health disclosure by state licensing boards. See Pamela Wible’s website, where she ranks state board practices, for information on this idiocy.
- Join Twitter. Look for the #MedEd, #MedTwitter, #USMLEpassfail, #WomenInMedicine, #GirlMedTwitter, and #SoME tags. You’ll discover more as you follow people who are fighting to change the system.
- Support each other. We are all in this together, and we can’t put the burden of physician suicide prevention on those whose brains are lying to them about their value or worth as a human. People deep in the pit of despair cannot reach up and ask for help, so keep asking and be annoying. Invite people out. Check on how they’re doing. Offer to listen, then do so without offering solutions, answers, or words. And cry on each other’s shoulders PRN.