Kayty Himmelstein works 80 hours a week and has at times worked 12 consecutive days. In the past, she has lacked time to schedule routine health care appointments. She and her partner moved from Philadelphia to Cambridge for Himmelstein’s job, and Himmelstein is rarely home to help with housework, cat care, or navigating a new city. Her work is stressful.
It’s not a healthy lifestyle. Yet it is one that, ironically, health care workers are forced to live. Himmelstein is a second-year infectious disease fellow working at Massachusetts General Hospital and Brigham and Women’s Hospital after three years as an MGH internal medicine resident.
“I was not getting the primary care I’d recommend for my own patients while I was in residency because I just didn’t have time during the day to go see a doctor,” Himmelstein said.
Himmelstein is among the residents and fellows seeking to unionize at Mass General Brigham, over management’s opposition. The decision whether to unionize is one for residents, fellows, and hospital managers to make. But the underlying issue of grueling working conditions faced by medical trainees must be addressed. In an industry struggling with burnout, it is worth questioning whether an 80-hour workweek remains appropriate. Hospitals should also consider other changes that can improve residents’ quality of life — whether raising salaries, offering easier access to health care, or providing benefits tailored to residents’ schedules, like free Ubers after a long shift or on-site, off-hours child care.
“There are a lot of movements to combat physician burnout overall, and I think a lot of it is focused on resiliency and yoga and physician heal thyself, which really isn’t solving the issue,” said Caitlin Farrell, an emergency room physician at Boston Medical Center and immediate past president of the Massachusetts Medical Society’s resident and fellow section. “What residents and fellows have known for a long time is we really need a systems-based approach to a change in the institution of medical education.”
The 80-hour workweek was actually imposed to help medical trainees. In the 1980s, medical residents could work 90- or 100-hour weeks — a practice flagged as problematic after an 18-year-old New Yorker died from a medication error under the care of residents working 36-hour shifts.
In 2003, the Accreditation Council for Graduate Medical Education imposed rules capping residents’ workweeks at 80 hours a week, averaged over four weeks, and capping shifts at 24 hours plus patient handoff time. The organization has since reviewed the limits several times. The current guidelines also require trainees be given at least four days off over four weeks and time to attend medical appointments. Within those guidelines, hospitals can set their own policies, and requirements often vary by specialty.
The change was controversial, with some doctors worrying whether residents would receive enough training and whether patient care would suffer from more frequent handoffs. But studies found no difference in patient outcomes after the reform.
There are trade-offs in limiting residents’ hours — fatigue can lead to medical errors but so can handing off patients. Hospitals must ensure residents are sufficiently trained. With fewer resident hours, hospitals may have to hire more staff, potentially raising costs. Certain specialties, like surgery, may require longer hours to maintain continuity of care. Unionized doctors at private hospitals are allowed to strike.
But long hours have downsides. A recent Massachusetts Medical Society report on physician well-being found that 74 percent of residents and 79 percent of fellows reported symptoms of burnout. No residents felt they mattered to their organization “a great deal” and 29 percent felt they mattered “not at all.” The Centers for Disease Control and Prevention says someone who is awake for 24 hours is as impaired as if they were drunk.
Eighty hours a week is not a magic number. The European Union requires workweeks to average 48 hours (though doctors can voluntarily opt out to work longer) and mandates 11 hours a day of consecutive rest time. New Zealand limits work to 72 hours a week, with shifts capped at 16 hours, while the Australian Medical Association warns that working over 70 hours a week puts residents at “higher risk” of fatigue and negative consequences.
The growing push for unionization by medical trainees makes clear that they want more say in working conditions. The Committee of Interns and Residents at the Service Employees International Union, which seeks to represent MGB workers, grew from 16,000 members nationwide in 2019 to 25,000 members today, according to union officials.
In Massachusetts, trainees at Cambridge Health Alliance and Boston Medical Center have been unionized for decades, while those at UMass Chan Medical School unionized in 2021. Erica Lee, a Cambridge Health Alliance psychiatry resident and regional vice president for CIR-SEIU, said that union in its last contract secured raises, increased residents’ snack budget, and guaranteed free, accessible mental health care.
Unions are not the silver bullet to improving working conditions. A 2021 study in JAMA found no difference in burnout, the risk of suicide, job satisfaction, duty hour violations, mistreatment, salary, or the educational environment between hospitals with a resident union and those with no union — though unionized hospitals were more likely to offer housing stipends and more vacation time.
Individual workforces will have to decide whether unionization is right for them. What’s more important is improving the conditions residents are complaining about: long hours, salaries that are inadequate to pay for housing or child care, excessive paperwork, and having little voice in patient care and work conditions.
Jonathan Jaffery, chief health care officer of the Association of American Medical Colleges, notes that residents are trainees in a “working apprenticeship” who receive a stipend while finishing their education.
But they are also adults, often in their late 20s or early 30s, who owe on average over $200,000 in student loan debt.
Mass General Brigham in 2022 established a committee to address trainee issues. The hospital is increasing salaries so pay for a second-year resident will increase from $70,500 in 2021 to $82,500 in July 2023, plus a $10,000 stipend for living expenses. In comparison, data compiled by MGB found that at five other Massachusetts health systems, including two that are unionized, average pay for a resident one to three years post-graduation ranged from $68,470 at Tufts to $76,520 at Boston Children’s Hospital.
A January 2020 report from a physician burnout task force convened by the Massachusetts Medical Society and Massachusetts Health and Hospital Association described other hospital initiatives to address resident wellness. These include things like offering post-shift Ubers, 24/7 mental health care, on-site fitness programs, and nursing rooms.
The solution cannot be just one of these things. If the state wants to increase its pipeline of physicians, hospitals and residents need to work together to find myriad ways to make residency more livable.
Correction: An earlier version of this editorial gave the wrong institutional affiliation for Caitlin Farrell. She works at Boston Medical Center.
Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.