Editor’s Note
For this article, New Labor Forum’s “Working-Class Voices” columnist Kressent Pottenger interviewed Dr. Phillip Sossenheimer, a member of Stanford Housestaff Union which is affiliated with the national Committee of Interns and Residents/Service Employees International Union (CIR/SEIU), Local 1957. In May 2022, the Housestaff union won its election for union representation and is in bargaining for a first contract.

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I am a third-year resident in internal medicine at Stanford Healthcare. I am categorized as Housestaff, a term that refers to physicians who are in the first part of their career after they finish medical school. Once you finish medical school you have an MD, but are not able to independently practice medicine in any state in the United States until you go through some sort of postgraduate training. Your first year after medical school is your internship, which is a subset of a residency. People do residencies in a variety of specialties, depending on what type of physician they want to be: family medicine, internal medicine, surgery, dermatology, ophthalmology, or other specialties. A residency tends to run three years for specialties like internal medicine and pediatrics, or seven years for some of the surgical specialties like neurosurgery. After residency, there is further training that you can do, which is known as a fellowship.

You do not necessarily have to do a fellowship to practice as a physician, but with some types of medicines you can’t practice unless you are board certified to do a fellowship. For example, if you want to be a cardiologist or gastroenterologist, you typically have to complete an additional one to three years of a fellowship. There is a lot about being a physician that does not have to do with the knowledge of medicine: how a hospital runs; how you put in orders; or where you see patients.

The less desirable jobs—like 24-hour call, weekend coverage, or night float (where you work nights in the hospital)—often fall disproportionately on residents and fellows.

Not all hospitals have residency programs. The ones that do, particularly teaching hospitals, heavily rely on residents and fellows in much of the day-to-day work of seeing and caring for patients. The less desirable jobs—like twenty-four-hour call, weekend coverage, or night float (where you work nights in the hospital)—often fall disproportionately on residents and fellows. The person who is the licensed physician, who oversees the residents and fellows, is what we call the attending physician.

Residents and fellows will often do a lot of the day-to-day managing of delivering medical care while the attending physician is then able to do other non-clinical work or oversee more patients. Frequently, when patients come into a teaching hospital, most of the doctors that they are interacting with, especially when they first come in, are going to be residents and fellows. I did my residency in Internal Medicine and spent time in different clinical environments. When I am in the ICU (intensive care unit), my hours are 6 am-6 pm, six days a week, that’s between seventy and eighty hours. We are supposed to be capped at an eighty-hour work week. Many of the more intense specialties—a lot of the surgical subspecialties—are stretched more thin. They also sometimes take home calls, mostly in cases of palliative care and geriatrics. A lot of people end up working more than the eighty-hour work weeks and under-reporting. Currently, I am doing a fellowship in Hospice and Palliative Medicine, which is much better about recognizing that doctors delivering end-of-life care are not able to rationally connect with people if they are working that much. Hospice and Palliative Medicine is a standard rotation for an internal medicine resident. My work in this rotation has much more of a boundary. I feel very lucky to be in that position now, but it is not the case for the majority of residents and fellows.

Sometimes, There’s No Place to Rest
At Stanford, there are designated spaces—call rooms for residents and fellows to rest. Often, they are not conveniently accessible to where people need to work. If I am in the ICU, there is an expectation that I would be proximal to the unit. People are on ventilators and medications that are keeping them alive. We need to be present quickly. If the call room is not proximate to the unit, then it is not really possible to use it. Often there are simply none available. That is an issue that our union is bargaining over. Stanford is a very rich hospital. If they cannot provide  sufficient call rooms for their resident physicians, I cannot imagine it is better at the financially struggling community hospitals. Workspaces are often a contentious issue, too. During Covid-19, administrators were around to ensure people were compliant with the environmental policies that regulated the number of people in a given space. They would say there are way too many people in a room, but that is the room that we had. I came to Stanford in the middle of the pandemic, that first year before the vaccines existed. We had heard all these horror stories from the East Coast. We were new interns just starting our journeys as physicians. Now you are practicing in a pandemic, where the mentors you are learning from have also never done that before. Emotions were running high. We were working a lot, covering the Covid-19 surge that first winter. I got off of elective rotations to help staff during the surge. There is no jeopardy pay, meaning no extra pay for work that exposes you to something like Covid-19. Generally, you have elective rotations, which are supposed to provide a bit of a decompression. You are doing weekends off. Not working fourteen- to sixteen-hour days. If you get pulled off of that rotation onto an inpatient rotation, the stakes are higher. You do not have weekends off. I was pulled into this rotation, doing the Covid-19 surge shifts and not getting paid anything extra for my work. On the other hand, Physician assistants who were moved from outpatient rotations into inpatient rotations were paid substantial overtime to be there because they have a contractual relationship with the employer—through another union—and a lot more bargaining power. Residents and fellows are in a unique position as we cannot just quit our jobs. In order to get a residency, we have to go through the match process, a process wherein applicants and residency programs rank each other and an algorithm determines where you are placed. The barrier to quitting is high, as you will not be able to practice without completing a residency program and will also have to wait a year to go through the match process again. Matching also does not guarantee entry into another residency program. So, it was disheartening for us to see this relationship where we felt like the default option when there were staffing shortages or other problems, without any regard for our preferences  and no extra payment. We were happy to help in the middle of the pandemic, but you are going to feel a bit of a sour taste in your mouth when there is this stark example of how your employer values your labor.

Collective Action Can Get Results
Once the Covid-19 vaccine came out, there was a vaccine algorithm used at the hospital to determine which hospital staff got the vaccine. The algorithm was based on which unit you worked in. But residents—who do rotations—are not formally assigned to any one unit. There are around 1500 residents and fellows employed by Stanford. Less than ten of them were included in the first wave of vaccinations. These are folks who are doing intubation on Covid-19-positive patients, which is a very high-risk procedure. Anesthesiologists, emergency room doctors, people in the ICU. It definitely hurt to not be included in that first wave. It made us feel undervalued, especially when we were being overworked and relied on by staff. The administration knew the algorithm was flawed, but still chose to roll it out. We organized a protest. A couple hundred of us walked out during a lunch break. It was not a work stoppage, but those who could take a break walked out. That same day, Stanford reversed course, allowing residents and fellows to get vaccinations in the first wave. That was a big awakening, that people are not necessarily going to watch out for our interests. Second, we saw that collective action can get serious results. People listen when we speak out as a group. That is where the union movement at Stanford was birthed, and a group of
organizers reached out to CIR/SEIU.

We want contractual language that will prevent problems like what happened during the pandemic . . . as well as mechanisms for protecting our rights at work, like a grievance procedure or the ability to file an unfair labor practice claim.

We want contractual language that will prevent problems like what happened during the pandemic from happening in the future as well as mechanisms for protecting our rights at work, like a grievance procedure or the ability to file an unfair labor practice claim. One big issue our residents and fellows face is fatigue.

Folks are working over eighty hours a week or working longer than twenty-four- or twenty-eight-hour shifts. Some colleagues have to work thirty-plus hours with no sleep even when they are home, because they are on call. We want to make sure that residents have access to fatigue mitigation strategies. If they are not safe to drive home after a shift, they should get a transport home or at least have a call room to sleep in. We are also advocating for better-paid paternity and maternity leave and gaining access to lactation spaces for new mothers as well as more consistent vacation and scheduling across departments. We are not only limited by our relationship with Stanford, but by the specialty boards that grant us licensure. While these boards may not have  specific work-hour requirements, they do require a level of exposure to certain procedures—say X number of gall bladder operations. So, there is only so much vacation that we can advocate for before it is too much time off, for example, to become a surgeon.

What It Costs to Become a Doctor
Another issue is the cost of education to become a physician—in excess of $200-$500,000. If people do not get scholarships and try to be frugal—whether they go to a private or public university—tuition is still easily in the $200,000 range. When you come to a place like Stanford, which—like a lot of prestigious academic medical centers—is in an expensive area, not only do you have all this tuition debt, but you also have to live in an expensive area. We end up having physicians that are either already wealthy or people who take on a lot of student debt. Those are the only two options. It is a big problem if the only people who become physicians are not representative of the general public. The lever we have is trying to get those struggling with student debt a living wage that can sustain them and their families. One of my colleagues spoke out about her struggles. She is a resident at Stanford who has been living in a van because it was too expensive to afford rent. Her partner stays with her two-year-old child in their van, which is in a neighbor’s lot.

I think for most of our members, the most pressing issue is the cost of living. It baffles me that this is the world we are building—that these are the physicians we want taking care of us when we are either at the end of life or very sick. I think it’s shocking to doctors, too. Historically, doctors were business owners: they were in private or group practice. They generally owned their groups. That changed a lot in the 1990s-2000s, but especially during the pandemic. Now the majority of physicians are employees of hospitals. Physicians historically have been a highly paid professional class. That is starting to change. It is not to say that they are not better paid than people working at McDonald’s. They definitely are. We should be organizing for the people at McDonald’s, too. But physicians need to realize that whether you are a relatively well-paid or a less well-paid employee, your position within the corporate hierarchy is the same. You are still an employee. You still do not have ownership. The group that you are a part of is still going to be subject to changes in staff, without your input. Even in nonprofit institutions, you and your patients potentially are on the line, subject to the profit motive. This pressure is starting to build up within medicine as hospitals start to feel pressure to cut costs.

It is a big problem if the only people who become physicians are not representative of the general public.

Private equity is moving into the space, especially in emergency departments with private equity–owned physician groups of emergency department staffing. Shareholders are talking about strategies to shift staffing away from physicians and toward advanced practice providers like physician’s assistants and nurse practitioners—toward having higher ratios for patients to staff, and more patients per physician. We are not centering patient care. I am not saying that this is what is happening at Stanford. I still think we deliver good patient care. But nationally, the trend is worrisome if you have a profit-motivated system and there is not a countervailing force. I hope that physicians can recognize that they could be that countervailing force. Historically nurses have advocated fiercely for safe staffing ratios. I think physicians need to catch up and recognize that we have been disorganized. We have not reflected critically on our relationship to the corporate structure of medicine nor on what that might mean for our patients and how we need to organize to make sure that that the corporate trend does not continue.

A Culture unto Its Own in an Immoral System
Medicine is an interesting culture. It can be very militaristic in many ways. To become a doctor, you have to be the kind of person who can put your head down and follow rules for a long time. You have to put a lot of trust into outside institutions, and into authority. I think that contributes to an unwillingness to go against the grain.

Private equity is moving into the space, . . . nationally, the trend is worrisome . . . if there is [no] countervailing force . . . Physicians . . . could be that countervailing force.

In the beginning, you are an excited young medical student. Then you look out onto this landscape of the American healthcare system, and all you see are people who are being bankrupted by medical costs. I had one patient who came with visible metastatic breast cancer—these visible skin lesions, a terribly deformed breast. She was just so distraught. And everyone was like, how could you not have known? How could you not come in? But she knew that what that might mean was expensive treatments for someone who does not have insurance, was already poor, and coming to an institution where doctors do not look like you, where you are already feeling marginalized, and where your community’s been taken advantage of. We see people every day who are impacted by poverty by not having access to healthcare.

And every day, we have to kick them back out to the streets. I feel like I am the end agent for this incredibly immoral system, and there is nothing I can do. We have so many patients at Stanford who we try to get resources for, to find shelter beds, or get them signed up for medical [insurance]. But for many, there is just no net to catch them. You end up discharging them to the street. It is horrible. They are gonna get sick. They are gonna be right back. Stanford shut down its onsite outpatient pharmacy. Now we cannot even discharge these patients with meds. If I have a homeless patient who I have to discharge to the street, we can give them a taxi voucher to Walgreens to pick up their meds. Every day we see not only this crumbling safety net, but also we see it getting worse. That is really demoralizing, especially since the pandemic. I do not know anybody who does not feel that way.

Winning Our Union Election
I was at the protests for the vaccine rollout, and then got involved with the union organization effort when we were in the phase of still feeling things out. We won our union election in May 2022, and I am on the bargaining team and the contract action team which keeps members informed of upcoming organizing efforts. Once we have our contract, we will have an election and appoint delegates. Instead of a hierarchical leadership, we have a flat leadership structure that allows us to share the work of the union. We have not had much success through negotiations with the administration, so we are working on a petition that would go directly to the board of directors of Stanford. Anything that would involve a work stoppage is a last resort. Residents and fellows are people who have sacrificed a lot of their time, youth, energy, health, a lot of their bodies to this job, and also their financial stability due to student debt. They do not do that lightly, but because they love the actual patient care. So much of our system takes us away from that. People really just want to be taken seriously and be able to do that without having to strike. I wish that the NLRB (National Labor Relations Board), and our labor law had more bite to it outside of work stoppages. We are still in the phase of trying to pressure Stanford in every way possible.

In the beginning, you are an excited young medical student. Then you look out onto this landscape of the American healthcare system, and all you see are people who are being bankrupted by medical costs.

Culture change is never easy. But it is happening, and not just at Stanford. Medicine residents at the University of Pennsylvania and Fellows at Mass General Brigham Housestaff recently unionized. It is going to take time for people to adjust to the fact that being in a union is not a bad thing. Maybe this could be good for my professional development because I am going to learn skills about negotiation, public speaking, and what advocacy can look like. As a profession, maybe we could actually organize to change this harmful system instead of organizing to perpetuate it like we used to. I would tell young medical students worried about professional repercussions of unionization that people more senior to me are on board with unionizing. We are not the only  ones who are suffering under the thumb of corporate medicine nor the only ones who see how broken the healthcare system is. The people who are going to be your bosses in the future, the department chairs, are also physicians. I have been the most vocal pro-union guy at Stanford, but they hired me, and I have a fellowship. Union activity is a protected right under the U.S. law.

To the general public, I would say ask your doctor if they are unionized, and be vocally supportive of the union especially if they are in contract negotiations. We will be fighting for protections for you. Call the hospital and submit a comment on the patient review portals. Let them know that you are paying attention. That you are proud to have physicians who are unionized. This is not just a movement within medicine. Get involved in local politics and support candidates who are pro labor.

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Author Biography
Kressent Pottenger holds an MA in labor studies from The Joseph S. Murphy Institute for Worker Education and Labor Studies at CUNY, and was awarded the SEIU 925 Research Fellowship by Wayne State University in 2012. She is currently working on a research project about 925, and women organizing in the workplace.