Strike it While It's Hot

Resident Physicians in Heated Labor Fights

As residents and fellows at Mass General Brigham, we voted in favor of unionizing 1215-412 last week. Since then, and even before, the idea of residents authorizing strikes has been the subject of much dismay from leaders. For example, Brigham and Woman’s Hospital’s surgeon-in-chief Dr. Doherty thinks that a strike “would hurt everyone. patients, hospitals, residents” and that “residents voting to strike is a disaster.” Meanwhile, cardiac surgery chief Dr. Tolis thinks that if residents strike, hospitals would run more efficiently. He admits he didn’t think of himself as an employee during residency, so residents unionizing and striking is understandably puzzling to him. Residency is a unique opportunity to learn as much medicine as possible before independent practice. Because we have a duty to our patients, the idea of striking can only be seen as a disaster by many, perhaps especially so if they were trained under worse conditions. At first glance, it may sound like a convincing argument. Except, tolerating less-than-ideal working conditions is a tacit embrace of petering quality of care. There is mounting evidence, including work published by faculty at my hospital, that improving residents’ working conditions leads to a better quality of care. "First, do no harm” requires us to see the harm done in the status quo and to address it with all our might. I will discuss this at length later, but for now, let’s review the best evidence out there on the impact of healthcare strikes.

The most comprehensive study I could find on healthcare strikes is a meta-analysis published in 2022 in Health Services Research, titled “The impact of healthcare strikes on patient mortality: A systematic review and meta-analysis of observational studies.” The authors pooled and analyzed data from seventeen studies that examined in-hospital (14 studies) and population mortality (3 studies). In-hospital studies represented 768,918 admissions and 7191 deaths during strike action (0.9% mortality rate) and 1,034,437 admissions and 12,676 deaths during control periods (1.2% mortality rate). The pooled relative risk of in-hospital mortality did not significantly differ during strike action versus non-strike periods. Mortality was not impacted by country, profession on strike, the duration of the strike, or whether multiple facilities were on strike. None of the three studies of on population mortality reported a significant increase in mortality attributable to strike action.

But wait, there is also a study focused on physicians’ strikes. I’ll admit that this is a less well-studied area because physicians rarely strike. After all, we often don’t think of ourselves as part of the working class, even though physicians increasingly do not own their practices and are more and more employed by hospitals or large systems. But in the prestigious Social Science and Medicine, one 2008 study managed to pool data on physicians’ strikes from various countries. I was shocked to learn what they found: not only is mortality not worse, but there is a paradoxical decline in mortality shortly after physicians’ strikes, mostly attributed to a significant decline in elective surgery. Yes, that’s right. Surgery is a lucrative but dangerous endeavor. During a strike, hitting the hospitals where it hurts most, i.e., holding up money-making elective procedures, ends up saving some lives. Crazy right?

To be sure, some people likely experience hardship when a strike occurs. If their surgery gets delayed, they may incur additional costs or have difficulties rearranging support for the postoperative period. These costs are hard to quantify. But in the status quo, some may experience preventable adverse events directly or indirectly related to workers’ conditions.

Mission-driven work, such as caring for others, is often a setup for exploitation. And it’s been shown empirically: employers find worker mistreatment and exploitation acceptable if the workers are thought of as passionate. Hospital administrators may guilt you into believing that authorizing strikes or striking itself inherently harms patients or violates our oath and commitment to patient care. Don’t let them. Even when the administrators are trained as doctors and nurses, worrying about balance sheets is part of their job, and at times, that clashes with commitments to high-quality care. When this clash happens, they can squeeze workers drier (see changes in nursing staffing ratios, a common cause of agita among nurses). Do not fall for it. Push back. Push back again. And If you’ve got a union, leverage all its power. And remember: the “threat of a union” is not more powerful than a union that can threaten to and authorize a strike.

And on a lighter note, enjoy this video of #MedTwitter comedian and ophthalmologist Dr. Glaucomflecken on hospital leaders’ adverse reaction to residents unionizing.

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