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Just about thirteen percent of the 100,000 plus resident physicians in the United States are union members — and many more would choose to join if it weren’t for the fierce pressure exerted by some teaching hospitals, chairs and program directors. Although it is illegal to threaten resident physicians with retaliation for expressing their desire to form a union, the law is difficult to enforce. Ought medical educators examine the impact of an atmosphere of intimidation on the positive learning environment that the Accreditation Council on Graduate Medical Education (ACGME) is working so hard to foster? We strongly believe so.

Physicians-in-training are taught that our commitment to patients is sacrosanct and that the ability to provide safe, quality care depends upon trust, honesty and transparency — with our patients and families, colleagues, supervisors, and the public. They must feel safe and supported to report adverse events, even if that may result in deeply uncomfortable situations; to tell their attending if they are too tired to safely care for patients, even if that requires the attending to come in; and to report a disruptive supervisor, even if that action may result in a poor evaluation or put a fellowship recommendation out of reach. Many residents seek a collective voice to more safely ensure that their values and commitment to patient care are reflected in their work environment.

Physicians are taught that this type of ethical decision-making is required of us as medical professionals. We are granted the privilege of practicing with great autonomy in exchange for demonstrating that commitment to our patients always comes first. This is the fundamental core of what it means to be a professional. But unfortunately, the hidden curriculum in many hospitals teaches submission to hierarchy over ethical conduct and relies on subtle (and not so subtle) pressure not to rock the boat when it comes to lapses in superiors’ ethical conduct.

To help address this cultural dissonance and to emphasize the importance of patient safety, the ACGME introduced the Clinical Learning Environment Review (CLER) program in 2012 where teaching hospitals are visited every 18 months. The goal of the CLER site visits is “to gain knowledge about how clinical sites are supporting the training of residents and fellows in the areas of patient safety, health care quality, supervision, transitions in care, duty hours, fatigue management, and professionalism,” as stated in the Journal of Graduate Medical Education.

The ACGME understands the critical importance of residents being free to accurately and honestly describe their teaching hospital environment in order to ultimately improve it.

But what if a teaching hospital forcefully delivers another message; a message that residents should not exercise their legal right to form a resident organization and that if they do, there will be serious personal and professional repercussions for those who persist?

For example:

One orthopedic surgery program director told residents that if they sign a petition to unionize, the ACGME will think there are problems and will not grant extra residency slots to the program — meaning a higher workload for existing residents.

GME staff has sought to alter or re-interpret the bylaws of an ostensibly resident-run housetaff council after learning that pro-union residents were elected to lead the council.

Resident leaders at one hospital were even told that if they went through with the union election, their (beloved) program director would be fired.

Are these behaviors consistent with the lessons that medical educators want to impart on their residents? What are the impact of such coercive administrative measures on medical educators and residents?

This pressure creates ethical distress for residents who are forced to choose between their personal values — a desire for the collective representation of their concerns, which they know to be both legitimate and legal — and their continued security and advancement in the profession.

In 2009, ACGME CEO Thomas Nasca and co-authors explained in Academic Medicine that ACGME accreditation standards “recommend an institutional form or other mechanism to give residents the opportunity to raise questions about and discuss educational and working conditions … the standards acknowledge that a resident association (which could be a union) is one way to accomplish this.”

The authors went on to say that “The ACGME requirements seek to establish a balance between the idealism of “pure education” and a realistic acknowledgment that residents function within “real-life” institutions needing to attend to multiple, often competing objectives.” And they emphasized the importance of:

… the philosophy that one does not train humanistic practitioners by treating residents in anything other than a humanistic fashion. Unrealistic duty hours, inadequate financial support, harassment or intimidation, absence of the opportunity to eat or sleep during prolonged periods of work, and absence of balance between service and education go beyond employment grievances. The ACGME recognizes these as elements of an informal curriculum, one which produces toxic outcomes such as cynicism and the loss of altruism, empathy, and compassion. Regardless of one’s specialty choice, these are outcomes that are unacceptable.

Passions run deep on the subject of resident unions. Some, like Dr. Jordan Cohen, former president of the Association of American Medical Colleges, have long opposed residents unionizing. They see unionization as profoundly eroding professionalism, championing self-interest and destroying patients’ confidence and believe that the ACGME is in the best position to address resident concerns.

Others, like Drs. David Sklar, Betty Chang and Benjamin Hoffman, medical educators at the University of New Mexico, have observed that resident unions can provide a welcome and unified voice that encourages inter-specialty communication, resident engagement in patient safety and quality improvement and service to the community and strengthens altruistic professional attitudes.

These differing perspectives will undoubtedly persist, but everyone – on either side of the argument — should agree on one thing: both the law and the integrity of the clinical learning environment require that residents be able to make up their own minds – free of threats and intimidation — about whether or not to join a union.

Flávio Casoy is a psychiatry fellow and Joanne Suh is a family medicine resident. Together, they are board members of the Committee of Interns and Residents/SEIU Healthcare.