3 Advantages (and 3 Disadvantages) of Joining a Union in Residency

By Francis Bayes, WCI Columnist

I'm a dues-paying member of my residency program's union, founded in 2014 and affiliated with one of the largest national unions representing residents and fellows in the country (CIR-SEIU). I joined as soon as I started residency, not only to show support but also because a new collective bargaining agreement (CBA) negotiation was on the horizon. Even during the COVID-19 pandemic, our union had secured significant concessions from the health system without compromising patient care.

But even at my institution, not everyone shares my enthusiasm, as the membership rate by specialty ranges from near 100% to sub-50%. Today, I will weigh the pros and cons of training at an institution that has a union for residents and fellows.

Disadvantage #1 – Membership Dues

A trainee does not have to pay membership dues to have the same salary as union members. Since my PGY-1 year, the dues have increased from 0.5% of my salary to 1.6% as we transitioned from a grassroots organization to a chapter of CIR-SEIU. But for reference, my disability insurance premium was 1.7% of my PGY-1 salary, and its cost is probably the No. 1 reason why residents do not buy disability insurance. Convincing residents and fellows to “opt in” to become a dues-paying member requires either a concrete financial incentive or a track record of successful negotiations.

At least at my institution, member benefits offer negligible value for the majority of residents and fellows. The members have access to the childcare fund ($75,000 divided among dues-paying members who apply), a research grant ($1,400), and a $200 discount for post-training contract review. But even my wife and I, who are sending our daughter to daycare, were not eligible for the childcare fund because our household income was too high.

Advantage #1 – Higher Salary

For dues to be worth paying, the pay raise with our new CBA had to exceed them, and it did.

Before our CBA expired, our health system proposed total compensation that was $3,200 higher than the previous salary for my postgraduate-year (PGY) level. Their Last, Best, and Final Offer (LBFO) two months after the CBA expired was $4,400 higher. My salary under our new CBA will be $5,800 higher.

The protracted negotiation suppressed our salary until we signed the new CBA. But even after taking it into account, my salary will be approximately $3,900 higher than my current salary and $1,000 higher than the LBFO. For the remainder of my training, my total compensation will be $4,400 higher.

Interns will reap the greatest benefit. Their starting salary will be $9,000 higher, and their total compensation will be 20% higher over 3.5 years of the contract. Although my “return on investment” on my dues will be smaller than an intern’s, I am happy to pay it forward since I can moonlight and will become an attending psychiatrist in July 2027.

Disadvantage #2 – More Like the House Than the Senate

Frontloading the pay raise meant that residents and fellows who are further down the training (e.g., PGY 5-9) would see smaller pay raises. This reflects the reality that 1) everyone is an intern at one point and 2) the biggest residency programs—internal medicine, emergency medicine, pediatrics, and psychiatry—are either three or four years long. Residents in smaller programs with longer training might lack the representation to advocate for an even distribution of pay raises.

Advantage #2 – Better Fringe Benefits

The union provides meaningful fringe benefits for both members and non-members. The biggest fringe benefit is access to Guaranteed Standard Issue (GSI) disability insurance. Residents learn about the portable GSI policy earlier in their career rather than settling for the non-portable disability insurance that our health system offers. I wrote about my experience deciding between the GSI policy and other underwritten policies. Long story short, even though I do not have any medical issues or dangerous hobbies, the GSI policy was cheaper than identical underwritten policies, thereby saving me roughly 10% on premiums annually.

Other fringe benefits include increased meal reimbursements (from $12 per day to $14 per day), free public transportation ($1,296 per year), free parking during nights and weekends (varies), and increased bereavement leave.

Disadvantage #3 – Distracting Applicants from More Important Factors

The most important factor when choosing residency programs is “fit.” It's the quality of training, people, and location. Family considerations can also play a significant role; a partner may prefer to live close to their parents or have a job that does not allow relocation. Financial factors, such as benefits during residency, should serve as a secondary or tertiary tiebreaker at best. Even an applicant with a strong personal conviction to train at a unionized program should not choose one that is a poor fit.

Advantage #3 – National Know-How and Institutional Knowledge

The higher salary and better fringe benefits would have been harder to gain without the help of our national union. Support staff from the national union have experience negotiating with other institutions and mobilizing residents and fellows for protests or walkouts without putting patient safety at risk. Otherwise, “housestaff associations” represent residents and fellows without the organizing ability and leverage tactics of a union.

Moreover, the national union provides the continuity that is necessary for building upon each CBA negotiation. A typical CBA runs four years, meaning the residents and fellows who led the last negotiation are often no longer in training by the time the next one begins. The incoming leadership team may be talented and motivated, but they will be walking into the next negotiation unaware of which concessions were made, which proposals the health system stonewalled, and which tactics worked.

Health system administrators face no such turnover problem. Their labor relations team will be sitting across the same (virtual) table, negotiating against a group of trainees who likely have limited experience. Without a national union and its professional staff, such asymmetry would repeat every cycle, and residents would underperform their potential at the bargaining table. The national union breaks that cycle by retaining the staff who carry the institutional memory that the residents and fellows do not have. In that sense, dues are not just buying us a seat at the table but buying the expertise to know what to do once we are there.

Residents Unionizing and Attendings Unionizing Are Different

The case for resident and fellow unions rests on a structural reality: we entered our programs through the Match, a process that binds us to a single employer with no ability to negotiate individually or to walk away. Attendings can leave. We cannot. Such asymmetry, combined with the inconsistencies across different programs on everything from meal reimbursements to disciplinary procedures, is why residents and fellows benefit from collective bargaining. Whether similar logic extends to attendings is a question The White Coat Investor has already explored.

Unionizing has its pros and cons. They should be weighed carefully when implementing a union and when choosing whether to join one as an individual, whether as a trainee or an attending physician.

Would you join a union as a resident? What other advantages would there be? What about disadvantages? 

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