Do Interns and Residents Ever Really Go on Strike?

Over the past several weeks, the interns and residents at two major hospitals in California voted to unionize to facilitate collective bargaining on issues related to compensation and workplace exploitation. If the hospital leadership fails to make key concessions, the union has one ultimate weapon -- to go on strike. In fact, a strike vote is currently being taken at three hospitals in Los Angeles.

Have interns and residents ever gone on strike successfully?

One of the first documented strikes by interns and residents did not take place in the context of an organized labor dispute. In June 1934, all interns at the Hôpital Notre-Dame in Montreal, walked off the job to protest the hiring of a Jewish intern, Dr. Samuel Rabinovitch. Rabinovitch had been the highest ranking graduate from the Université de Montréal, and he was the first Jewish intern to ever be hired by a French Canadian hospital. The protest by interns was blatantly anti-Semitic, but it received widespread support from other hospitals and political figures in Quebec, leading to Rabinovitch's resignation. The Université de Montréal subsequently increased its restrictions on the admission of Jewish students. The events -- collectively known as the Days of Shame -- galvanized efforts in North America to organize hospitals and medical schools that would promote the training and career development of Jewish physicians.

The first effort to organize U.S. interns and residents into a union took place in 1957, when the Committee of Interns and Residents (CIR) was formed in New York City. In 1958, the CIR achieved the first collective bargaining agreement for housestaff anywhere in the U.S., and by the mid-1960s, it established the only housestaff-administered benefits plan. The CIR pursued what would now be labeled as a "progressive" political agenda. But in the 1960s and 1970s, "progressive" did not have the meaning it currently has.

In the 1970s, the housestaff experience for interns and residents in New York City was intense. I did my internship and residency at Jacobi Hospital (Bronx Municipal Hospital Center), the county hospital for the Bronx, from 1973 to 1976. The program was exceptionally demanding, further intensified by the fact that it took place at a "safety-net" hospital, dedicated exclusively to the care of the uninsured and underserved. The internship year was akin to basic training in the marines, except that it lasted for 12 months. The goal was to produce physicians with the highest possible clinical acumen.

What was being an intern like in 1973? Typically, medical interns arrived at 7 a.m. and left at about 8 p.m. (or later) 6 days a week. We were on call in the hospital every other or every third night, working approximately 110-120 hours a week. We carried a service of more than 20 patients and admitted five new patients a day on our days on call. We ate all our meals in the hospital, which provided all food for free, including a meal at midnight for those on call. Dressed in short white jackets and white trousers, we carried most of our essential equipment in our pockets, including a stethoscope, a hemocytometer for doing cell counts, a small flashlight, and a reflex hammer.

Each floor had a fully equipped physician's laboratory, and we were expected to do our own blood smears, Gram stains, and analyses of urine and cerebrospinal fluid. We spun our own hematocrits and hung our own sedimentation rates. Each lab had its own microscope and centrifuge. If the patient needed a stat laboratory evaluation we could not do ourselves, we drew the blood specimen and carried it to the central lab or we wheeled the patient to radiology, negotiating for immediate service. We started all intravenous lines and did our own electrocardiograms, spinal taps, and bone marrow aspirations.

Each morning, after being on call, we presented the newly admitted patients to two attendings. After the chart was handed to the senior attending, we recited each case from memory, inclusive of all the laboratory results. We expected to be intensely grilled on everything we did and everything we did not do. The entire team went to the bedside of each patient, and we reviewed all new x-rays on the service with a dedicated senior radiologist.

There was an unwritten code of honor amongst the "house officers," a term we greatly preferred to "housestaff." First, an intern always knew everything about each patient on their service; you were responsible for your patient even if you were not on call. Second, you never signed out an unstable patient to the intern on call. The on-call intern had so much to do with new admissions that it would have been unthinkable to have added to their burdens. Third, if you did not know or did not do something that you should have, you expected to suffer through intense negative feedback, realizing it was delivered primarily to make you a better physician.

The real goal of the experience was to learn how to see, how to listen, and how to think. "Facts" were not part of the experience; we could read them in a textbook.

There were no hospitalists and no night float. The concepts did not exist.

Does this all sound terribly old-fashioned? Yes, it was. And no one could (or might want to) replicate this experience in today's world. But at the end of 3 years, we were transformed. We learned what it meant to be a physician.

Were we unhappy? We were terribly stressed, but most of us were joyous. But admittedly, the concept of work-life balance in the early 1970s was far different than it is today. No comparisons across a span of 50 years would be informative or warranted.

But our working conditions were far from ideal. Being on-call every other night was exhausting, and the lack of patient transport services meant that the housestaff needed to be personally responsible for the movement of patients for testing. We performed many nursing duties, since our nurses were so overwhelmed.

In 1975, the CIR initiated collective bargaining to improve conditions at many facilities, including my hospital. After months of negotiations, when no progress was made, the CIR called for a general strike of all housestaff on March 17, a strike that eventually involved 21 hospitals in New York City. The main issues on the table were the on-call schedule and the use of house officers to perform nonphysician duties. There were no salary demands whatsoever. It was the first strike by unionized interns and residents in the U.S. Humorously, our action was so unusual that the article in the New York Times referred to us as "internes," an archaic British variant that had not been used in the U.S. for decades.

The story made the front page of the newspaper, immediately next to an article on the collapse of the South Vietnamese military campaign, which led to the fall of Saigon the next month.

How could we possibly go on strike? Thousands of very sick patients depended on us completely for hourly care. None of our patients had an assigned attending physician. We could not abandon them. But amazingly, we did not need to. More than 100 medical faculty volunteered to staff all our positions. Even our chiefs of staff signed up to carry out the housestaff workloads.

I remember wondering if the faculty still remembered how to do their own Gram stains or to start an intravenous line. But apparently, their "housestaff reflexes" were still intact even after years of nonuse. We were really impressed.

We manned the picket lines for 4 days. Everyone was on the picket line during the entire time they would normally be working. Many nurses joined us.

During the 4-day strike, the hospital leadership exerted considerable pressure on the department heads to threaten the careers of the striking house officers. The pressures were particularly intense in the Department of Surgery, when the head of surgery announced that he would withhold letters of recommendation for striking house officers. Out of fear, some interns and residents crossed the picket lines, but not many. For the most part, the strike held.

After 4 days on strike, the hospital leadership agreed to the demands of the CIR to end every-other-night on-call schedules and to expand ancillary services. In truth, the hospital leadership had little choice. The hospitals were so dependent on the interns and residents for patient care that their continued absence was not sustainable. And thus, the first and only truly successful and immediately impactful strike of interns and residents in the U.S. ended.

Later that year, the housestaff at Cook County Hospital went on strike for 18 days, although it is not clear that it achieved very much. One year later, the National Labor Relations Board ruled that house officers were "primarily students," not employees, and thus, not entitled to collective bargaining rights. But the decision was reversed in the 1990s. In 1997, the CIR joined the Service Employees International Union (SEIU), which represents over a million healthcare workers nationwide.

So, what does the CIR want in 2022, nearly 50 years after its first successful strike?

The CIR is seeking to improve compensation and working conditions, and create a sense of fairness. Many house officers work 80-100 hours a week, and a typical resident makes about $60,000 to $65,000 per year. (Of note, my salary of $13,600 in 1975 for a 120-hour work week would translate into $73,000 in 2022 dollars, but in 1975, my meals were free, and my housing was heavily subsidized.)

Several foolish decisions of hospital administrators have fueled the ire of house officers. In December 2020, Stanford Health Care rolled out a COVID-19 vaccination plan that excluded nearly all 1,400-plus residents and fellows from eligibility. Viewed as part of a pattern of employer neglect and exploitation, the Stanford house staff voted to join the CIR in early May 2022. One week later, the housestaff and fellows at the Keck School of Medicine at the University of Southern California also voted to join the CIR.

But if hospital administrators ignore demands of the CIR, what can the union do? It can go to the press and seek support from the general public. Or the house officers can go on strike. In fact, interns and residents in Korea and Israel have gone on strike, and the strike in Israel reached a successful outcome in October 2021.

In 2019, there were "strikes" by house officers at the University of Washington and at the University of California San Francisco, but each lasted for 15 minutes, so they were largely "press events." To my knowledge, there has not been a successful strike of U.S. medical house officers -- akin to that which took place in New York City -- since 1975.

To be sure, a strike by interns and residents in 2022 is very different than one occurring in 1975. Most hospital administrators are far less dependent on interns and residents to care for patients, and they are far more focused on their bottom lines than they are on the quality of life of employees with whom they have a defined short-term relationship.

Nevertheless, the 1,300-plus residents at three Los Angeles hospitals (LAC+USC Medical Center, Harbor-UCLA Medical Center, and Martin Luther King Jr. Outpatient Center) have scheduled a strike vote, which started on May 16 and will end on May 31. Their major negotiating advantage is that they serve three public safety-net hospitals, and these hospitals are far more dependent on interns and residents than hospitals in the private sector. A strike, if approved, would take place over the summer.

The strike vote in Los Angeles may yield the first meaningful labor action among interns and residents in nearly 50 years. The world of medicine will be watching with great interest.

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