In late September, resident physicians at the University of Washington did something virtually unheard-of in their profession: After months of fruitless contract negotiations, they walked out of their hospitals in the middle of a shift to protest inhumane working conditions and salaries that they say fall far below par for the field.

The walkout was not a strike: In Washington state, public employees (which all UW employees are) have no legally protected right to strike. In fact, the current contract governing UW residents expressly prohibits them from striking. That’s why the University of Washington Housestaff Association (UWHA), the union for medical residents and fellows at UW, branded the 15-minute walkout a “moment of unity.”

“Morale is very low right now,” said Dr. Kellie Satterfield, a third-year ophthalmology resident and UWHA president. “We don’t feel it’s safe for us as providers, or for our patients.”

The Washington residents were following their peers at UCLA, who’d planned a similar walkout after 10 months of dead-end bargaining with UCLA Health on August 14 of this year (they reached a tentative agreement with the health system that same night). These actions make perfect sense when you consider the quality of life of a medical resident. Related Article How Medicare for All Would Stop Hospitals Like Hahnemann From Closing Adam Gaffney

Also known as “house staff” because they used to live in the hospital itself, residents are physicians who have finished medical school but still need three to eight years of apprentice-style training in their chosen specialties in order to achieve board certification. The process is fraught from day one. First, students spend thousands of dollars flying to hospitals around the country to interview for residency positions. Then, they rank their program choices, but their ultimate destination is decided by an algorithm known as the Match that analyzes student and program preferences. The results are binding: Once placed, students may not back out of their assigned programs without facing large penalties.

If you think the Match sounds like a monopoly because it’s essentially the only way to secure residency positions, you’re not alone. In 2002, residents in the District of Columbia charged that the Match violated the Sherman Antitrust Act. Their suit was dismissed because of a 2004 law, heavily lobbied for by hospital interest groups, that essentially retroactively preempted antitrust action against the Match. The Match process brings a certain reliability to the process of resident selection, and the bodies that benefit from cheap resident labor have no interest in granting residents powers of self-determination.

Once “in house,” residents can expect to work 80 to 90 hours a week, for a fraction of what attending physicians make. By the hour, that can add up to less than minimum wage. They operate at the bottom of the rigid medical hierarchy, subject professionally and personally to the whims of their superiors, all the while confronting extreme trauma and tragedy on a daily basis. There are no guaranteed breaks or meals, and little recourse for wrongs committed against them. One study found that over half of residents report crashing or nearly crashing their cars because they were profoundly fatigued. Current Issue View our current issue

According to the UWHA, UW residents are among the lowest paid in the country when you factor in the cost of housing (not to mention transport and child care) in Seattle: Salaries can be as low as $58,200 before taxes, and residents taking home call must be within 30 minutes’ travel time of UW hospitals and clinics, which forces them into Seattle’s most expensive neighborhoods.

“We’re required to live right next to Amazon headquarters,” says Dr. Satterfield. Satterfield said UW officials have not taken the bargaining sessions seriously, failing to present reasonable counter-offers after 40 hours of negotiation. They have only proposed reducing yearly salary increases to 1 percent, which, after inflation, amounts to a pay cut.

UWHA Vice President Dr. Zoe Sansted says that low pay impairs UW’s ability to recruit a diverse resident population. “We know that patients get better care when they’re cared for by a diverse set of doctors,” Sansted said. “No matter how much you talk about wanting to have a more diverse residency class, if they can’t afford to live in Seattle, it won’t matter. Right now, we are selecting for wealthy, white doctors.” Related Article This Massachusetts Nurses’ Union Is Reviving the Strike Jane McAlevey

Research has shown that a homogeneous workforce can have dire consequences for minority patients. In the United States, the mortality rate for black infants is 2.5 times greater than it is for white infants. Black women with breast cancer are 67 percent more likely to die from the disease than white women. Increasing representation of physicians from racial and ethnic minorities is a critical step in combating the institutional racism that pervades the world of medicine.

The history of resident labor organizing stretches back decades. In 1957, residents working in New York City’s public hospitals founded the first house staff union, the Committee of Interns and Residents or CIR, now a local of the Service Employees International Union (an intern is a first-year resident). Today CIR is the largest resident union in the country, with over 17,000 active members.

Nineteen seventy-five saw the first resident strike. Three thousand New York City residents struck successfully at 15 private hospitals, demanding fewer work hours than the then-standard 120 or more in a week. In 1981, strikers at seven municipal and two private NYC hospitals (Montefiore and Bronx-Lebanon), demanded not money or time off but adequate hospital staffing and equipment. Residents ended that strike out of fear of losing their medical licenses and accreditation for their training programs, and the State Supreme Court fined union leaders $100,000 for each day of missed work.

A quarter-century later came a turning point for house staff labor relations. In 1999, CIR petitioned the National Labor Relations Board to represent residents at Boston Medical Center. The NLRB overturned a 1976 ruling, reclassifying residents as employees rather than students, which gave them the right to unionize. The unions that grew out of that ruling have been instrumental in securing better pay, benefits, and health care access for their members.

Though they are building on the efforts of those who came before them, residents of this generation face distinct challenges. For one, they often carry student debt burdens in the hundreds of thousands of dollars. Though residents can defer paying down debt during residency, they are on the hook once graduated, which makes dropping out of residency a non-option—they need to finish in order to secure the well-paying jobs that will allow them to operate in the black again.

And working conditions have improved only marginally. Trainees today spend most of their time typing into the electronic medical record, a consequence of the digitization of billing. They are bullied by virtually everyone they work with, from nurses to attendings. Their onerous, irregular schedules isolate them from loved ones, leaving them to cope with the stressors of the job alone. Depression and suicide among physicians have risen to epidemic levels; in the United States, 300–400 doctors kill themselves each year, twice the rate of the general population. Suicide is the second leading cause of death among residents, after cancer.

Dr. Sansted recalled a moment “just the other day, when my intern and I were leaving the hospital. She got a text from her friend saying that one of their co-interns in another program killed himself. It’s October 1st, and it’s already started.”

But organizing, as a resident, doesn’t come naturally. Residents tend to respect the chain of command, and prefer not to make trouble.

What’s more, opposition to physician organizing runs even deeper, right up against the most sacred mantra of the trade: Always put your patients first. Health care providers feel guilt about prioritizing their own needs, and organizations prey on this guilt to exploit health care workers. In order to achieve sustainable working conditions, physicians will have to be repositioned in the popular imagination—and in their own—as laborers with their own rights.

For now, the will among house staff groups to demand fair treatment seems to be gathering momentum. “We don’t want to have to hold up picket signs and make a big deal like this,” said Dr. Lola Mudgistratova, a third-year resident in emergency medicine and UWHA officer. “We just want to work and become the best physicians we can be. But we’re treated like we’re totally disposable.”

Energized by the moment of unity, Mudgistratova still holds out hope for future bargaining with the university. “So many people came out and talked to the union reps. We had other SIEU members, and reps from the nurses’ unions there in solidarity. From the standpoint of communal support, it was awesome. It feels great that more people know our story.”