Medical Unions: Dr. Philip Sossenheimer’s Insight

Dr. Philip Sossenheimer leads Stanford Residency unionization efforts

Dr. Frances Mei Hardin: Welcome to this week’s episode of Promising Young Surgeon. This week, Dr. Philip Sossenheimer joins us to discuss his work as a leader for the Stanford Residency unionization efforts. Today, we’ll begin with just an introduction to resident unions. The committee of Interns and Residents is the largest house staff union in the US. It represents over 32,000 residents and fellows in California, Florida, Idaho, Illinois, Massachusetts, New Jersey, New Mexico, New York, Vermont, Washington, and Washington, DC. In their own words, CIR unites and empowers resident physicians to have a stronger voice within their hospitals. They garner more negotiating power and support for their patients and communities. CIR is democratically run with elected House staff from around the country. So I’m going to say that again, CIR is democratically run with elected House staff from around the country. Their issues include resident well being, immigration, health justice, reproductive justice, racial justice, gun violence, and public health. Goals of the CIR are to take care of residents and fellows with improved wages and salary, having a real voice on the job, unique training and career advancement. Another item that’s highlighted is taking care of patients with physician community partnerships, defending patient care funds and providing services for patients in high need communities. And finally, to raise the standards of residency everywhere with legal protection and due process at work, holding educational organizations like ACGME and ABMs accountable, and providing templates for enhanced contracts and structures to enforce them. There is a Stanford House staff union that is partnered with CIR. Just to give a little background for today’s conversation and guest, I do want to share this quote from a 2023 Stanford Daily article that quotes Ob GYN resident doctor Kaur across the country, residents and fellows are treated as unlimited resources, but the idea of a healthcare hero is a myth that perpetuates exploitation and abuse. Dr. Philip Sossenheimer is a Stanford palliative care fellow and graduate from Stanford Internal Medicine residency and the University of Chicago Pritzker Medical School. He led trainee unionization efforts at Stanford during his internal medicine residency, and he’s a musician playing upright bass in a jazz band. He’s also a big fan of dogs, and his dog cashew joins us in attendance today. Thank you so much for being here, Philip.

Dr. Philip Sossenheimer: Yeah, thank you so much for having me. I’m thrilled.

Stanford Healthcare initially excluded residents from eligibility for COVID vaccines

Dr. Frances Mei Hardin: So let’s just jump right into it. In 2020, Stanford Healthcare initially excluded residents from eligibility for the first round of COVID-19 vaccines, which was reportedly a breaking point for resident physicians. What was that like being there in real time? And what effect do you feel that it had on the resident workforce?

Dr. Philip Sossenheimer: Yeah, I mean, I think this is something that, in some form or another, all of us have experienced in residency, and all of us experienced during the pandemic as well, which is having a realization that the health system, especially for those of us who are residents and fellows, but I think for all healthcare workers in general, often we feel that the health system doesn’t value us much. And I think particularly for residents and fellows, there are times in our training where we realize that, we are in some ways, that management don’t understand our role, that they don’t really think about us or recognize the important role that we serve for the hospitals that we work in. and that’s always been true for a long time. I speak to some of my attendings who felt this way 20 years ago, before the pandemic, that you’re working long shifts, getting paid very little, and the people in the c suite probably have no idea who you are or what you do. but that really boiled over during the pandemic. And at Stanford, the area that we recognized, it was when, like you said, we were excluded from vaccination. I think of the 1500 house staff, only five to seven were included in the first wave of vaccines. This includes all of the anesthesiology residents who are intubating COVID patients in the ICU, all of the ER residents who are doing the same in the ER. Myself, who is on COVID wards and working COVID mICu shifts as an intern. Stanford, for their part, says that it was an oversight. And the way that they allocated that, it was an algorithmic mistake. Whether it was an intentional exclusion or not is beside the point, because I think what it made us realize is that these people who are making the decisions at the higher level have no idea who we are. There’s nobody effectively advocating for us at the decision making level. and in that sense, it makes us feel that we’re viewed as expendable. We’re just bodies that can staff the hospital, and we’re very cheap ones at that. that was the first thing that we realized. And I know many people in healthcare had similar realizations for a variety of reasons. Whether it be access to PPE or being required to work extra long shifts, a lot of people, I think, during the pandemic, began to feel expendable.

Dr. Frances Mei Hardin: Yeah, I agree. That’s such an extreme and kind of systems based issue, so I can definitely see why that boiled over. But, you know, to kind of even talk about a little bit of my experience, I agree with you that that moment of disillusionment is probably pretty universal for a lot of resident physicians and fellows. And my example is honestly not even really pandemic related because, you know, we experienced basically just a lot of pressure to make the attendings lives as easy and smooth as possible and kind of in return for very little teaching. And if that wasn’t done, then we were really treated like we had failed at the task. And so that’s where you start to see, like, especially with surgical residents, you know, they’re just standing nervously at the board trying to get cases to run sooner than they are. Like, I’ve personally rolled patients myself from their room into the operating room just to make it happen faster. Not necessarily because it has to happen faster, but because one of my bosses wants it to happen faster, you know what I mean? And that’s a, kind of cultural way where you just start to look around and say, like, who was this system built for? Definitely not to teach residents, you know, or provide clinical, vigorous education. So, yeah.

Dr. Philip Sossenheimer: Yeah, you know, I think it’s interesting because. And, we’ll get to this later, I’m sure. But during our contract negotiations, the representative of Stanford who was negotiating with us told us that, you know, we were already overcompensated because we should factor in the free tuition, quote unquote, that we get. And I mean, first off, what an insulting thing to say to somebody who’s already finished their degree, you know? And like you said, who’s quote unquote training is mostly on the job. But there’s a couple salient points that I think I realized, which is that, I don’t know, 80%, 70% to 80% of the things that I learned in residency were taught to me by other residents, you know, or fellows. The teaching sessions on rounds, the chalk talks, you know, after rounds, morning report, all of these are things that are done almost always by other residents and fellows. And occasionally I would have a good attending who would make an effort to teach, and do formal teaching. But a lot of the time, it’s residents teaching other residents. And so it just is a little bit silly to say that we’re receiving this great tuition for education where we’re also the ones who are giving it, you know what I mean? If anything, they should be paying us because we’re teaching the med students yourselves.

Dr. Frances Mei Hardin: Yeah, right.

Dr. Philip Sossenheimer: Totally educating ourselves. Educating med students. And then the other thing that I thought was really interesting is that, you know, the teachings that we get are open to any member of the team, right? So, like, on MiCu, we might have a noon conference, you know, and anybody who’s on my can come to the noon conference. And that includes residents and fellows. It also includes attendings who might be there. It also includes nurse practitioners and physicians assistants. And that’s great, because we should encourage a culture of lifelong learning where everybody can. The evidence is always changing in medicine. We should always be learning and educating one another. But for some reason, it’s only residents and fellows whose attendance at those educational sessions is then held against them in terms of their total compensation. My mICu fellow teaches me how to do central lines. he also is teaching the nurse practitioner who’s been newly hired on to do central lines. But only one of us is being paid well below market rate, although, you know, probably the nurse practitioners are generating more revenue for the hospital than they’re getting paid, but it’s substantially. They’re getting paid substantially better than we are, you know, and no one’s telling them that they’re receiving tuition for education.

Dr. Frances Mei Hardin: I’d love to hear that conversation. I’m just fantasizing now about somebody telling the attendings, like, you know, we are going to dock your pay, you know, like 100,000. But you do get those free Mickey lunch.

Dr. Philip Sossenheimer: Yes, exactly.

Dr. Frances Mei Hardin: Like you’re making up for it, and just. I know that’s hilarious to think about.

Dr. Philip Sossenheimer: And, you know, the thing that I just want to reframe here, too, is that. And I know everybody’s experience is different, and there are absolutely attendings and people in positions of power who have abused residents and taken advantage of them. And most of the attendings that I’ve worked with, an overwhelming majority of the ones that I’ve personally worked with, have good faith. You know, they want to do the right thing, and they’re also super overworked. I’m in aunt clinic with an attending who has over 24 patients scheduled in a day, and that system is not. There’s no way that that person can make that happen without exploiting residents. It’s just physically not possible to see that many patients, and it’s certainly not possible to do so in a way that’s empathetic, compassionate, that allows the patients the time and space that they need to talk about and deal with these really heavy issues. And so it’s not just the attendings taking advantage of the residents. It’s also the fact that we are all in a system, the attendings included, where we’re expected to do too much with too little. And so m. It’s unfortunately, those are the types of conditions where exploitation, abuse, all of those negative things arise. So, yeah, it’s a structural issue, and that’s why, I am a big fan of structural solutions.

Dr. Frances Mei Hardin: That’s so well said. No, and I definitely agree. I wanted to bring up that. I loved one of your quotes from the Stanford Daily interview that they published in May of 2023. You said that successfully negotiating a labor contract would, quote, set the standard for residency and fellowship for the rest of the profession. And, quote, you said, this is an opportunity for Stanford, one of the wealthiest and most prestigious healthcare systems in the whole world, to invest in its frontline healthcare workers so we can take care of our community. We are fighting for a healthcare system that values people over profits and we refuse to settle for less.

Stanford residents unionized around the time of the vaccine rollout

Dr. Frances Mei Hardin: So I’d love to use that to kind of launch into, you know, your experience with the Stanford unionization efforts, how it began, and then, of course, the outcome.

Dr. Philip Sossenheimer: Yeah. So, you know, it began around the time of the vaccine rollout, and it didn’t start as a formal effort to unionize. what it started with was just collective action. And when we think about, you know, when people talk about union, this, union that, I think it’s important to talk about what we mean. Right? And some people are, you know, our health systems, our employers, in my experience with Stanford, is that the health systems try to spin unionization. Oh, there’s going to be this third party, this union that’s going to be representing you. So what we’re talking about is just collective action, right? It’s all of us who have shared interests and aligned priorities, getting together and doing something to make it happen. Right? So in the instance of the vaccine rollout, which is what I view as the start of our unionization campaign, even though it wasn’t a union campaign at first, is we organized a protest and we had a collective action where a couple hundred residents and fellows walked out over lunch, into the main auditorium of one of the Stanford hospitals and demanded that we be offered vaccination, just like other frontline healthcare workers. And our stance is that all people who are working frontline, environmental services, residents, nurses, whoever it is, hospital techs, they should all be first in line for vaccines over people who are working from home. And that was not the case. And so the first thing that I said that we realized was that the C suite wasn’t thinking about us and making decisions. So we had to do it ourselves with the protest. But the second thing we realized is that collective action can be extremely powerful because within 24 hours of us having a collective walkout, having media coverage on it. Stanford had reversed course, and fellows in residents were eligible to get vaccination. So I think that was sort of a level up in everybody’s consciousness as a resident and fellow, where I think the system is designed to make us feel isolated, make us keep our heads down. You know, the way that you get ahead in residency in academic medicine in general is by being a little bit subservient to authority. That’s the perception that people have. Right. You know, if I just work the extra shift and don’t say something when my attending is inappropriate, then maybe I’ll be able to get a fellowship, maybe I’ll be able to get a job. the types of people that medicine trains are people who are fairly deferential to authority, in my experience, because that’s sort of the hierarchical system of medical training and medical school, and becoming an intern and then a resident and then attending. It’s very structured that way. But what we realized is that in our collective action, we can stand up for injustice and do so in a way where we are all together, where we can’t be singled out, and we can really make change happen. so that’s where the unionization effort then was born. Out of a key group of folks who’d helped organize that protest, began to do sort of an organizing campaign with the committee of Interns and Residents, which is the union that we joined. I don’t know how much you want me to get into the logistics, but that’s perfect.

Dr. Frances Mei Hardin: Well, I mean, I do want to kind of echo what you’re saying. I remember I was in Missouri at the time, and I saw all of those efforts in the news. I remember seeing the Stanford protest in the news in response to, you know, the way that the vaccines were rolled out. So definitely agree with you in terms of, you know, what a major news cycle impact and national impact it had in terms of how many.

How many residents and fellows were involved in leading that collective action

I mean, I guess one question I have. Yeah, I’d love to hear, you know, any of the logistics in terms of a lot of us, especially a lot of us who train in totally non union institutions, like, yeah, we have curiosity, how many residents and fellows were involved in leading that group? Because you described several hundred, in the collective action. But what was kind of the structure of, you know, the seed getting planted there?

Dr. Philip Sossenheimer: Yeah, I’ll tell you, it was, you know, there were many times where it was a pretty small number of people. and I’ll say, you know, the reason, when people ask me what the downside of unionization is honestly the biggest downside is that it is a lot of work for the people who are organizing. And for a group of residents and fellows who are already working a lot and already burnt out, it’s a big ask to organize 1500 folks, you know, to sign union cards, do all the education on what unionization means. So, you know, there were 300 people at the protest. But I think our organizing committee, the core people who were involved from the beginning, was, you know, on average, like ten people, ten to 20, there’d be more people in our groups. You know, like we had WhatsApp groups where we would coordinate. but because people have late shifts, they’re working. there were, you know, never more than, I think, 20 people in one of those core organizing meetings at a time. And sometimes for some of our meetings, there’d only be, you know, five to ten people there because other folks were busy. So I think the thing that I want people to understand from that, though, is that you can do a lot with a small group of people, a lot, because, that’s the core organizing group. But the number of people who we had who supported the effort is way higher. It’s just that then you have to combat their apathy, their sense of hopelessness, their sense of fear, their confusion. These are the tools that the employer will use to organize against you. They’re going to sow fear by telling you, telling folks that, oh, the union is a third party, the union is going to, you’re not going to be able to protect your benefits. You might get less. They’re going to try to sow confusion by, misrepresenting what unionization means by being opaque in the messaging. and they rely on people’s apathy and saying that, well, the system’s not going to get better. I don’t really have an impact. I’m going to graduate in three years anyway, so what’s the point? But if there’s a group of five to ten people who can work hard to reach out, have these conversations at lunch, have these conversations in the workroom, recruit friends just to send out some text messages, to sign up folks to union cards, then you can make a lot happen, even with a small group of organizers, because our membership, you know, our support is over 80%. We won our election with over 80% support. Yeah, it’s just that, people, it’s really hard to get people to commit to doing 10 hours of extra work a week. You know what I mean?

Dr. Frances Mei Hardin: Exactly. Yes. I did read in your interview about how you were putting at least 10 hours a week towards these unionization efforts and your work. So again, of course, like, thank you for all the work that you did.

A lot of residents are leaving in three years, so organizing is crucial

But I want to dig deeper into even one of the pieces you just said, which is that part of the battle is that a lot of residents, they are leaving in three years. Like, the institutions kind of have this benefit, almost like this secret weapon, which is the revolving door of trainees, like the revolving door of residents and fellows. Because, you know, at the end of the day, a couple years from now, the residents will be gone. The institution, the house, kind of wins every time in that sense. And so what I think is so important, I would love to hear from you. How can we convince people to put anything even near, like 10 hours a week towards an effort which, yes, it’s meaningful, but it may not directly benefit them because.

Dr. Frances Mei Hardin: They may be gone by the time that they see the fruits of that, quote unquote, you know?

Dr. Philip Sossenheimer: Absolutely. I mean, I think this is the heart of any organizing anywhere, which is, first off, you’re not doing it for yourself. You know, if you’re going to be organizing a new union just like myself, you know, I’m graduating in two months. We just signed our contract three months ago. So the vast majority is benefits I will not personally enjoy. But you do it because it’s the right thing to do and you do it for other people. Right. And I think you have to, as an organizer, have the long term vision and have the dream, you know, about how things could look differently and recognize that the time scales of change are long. Right. And that this process will take a long time. It will take longer than you are in the system for. You know, residency is the same that it was when I started today. You know what I mean? We have not fundamentally changed the relationship between house staff and our employers, especially on a systemic scale, on a nationwide scale. But we’ve started that process. You know, one of the things that gives me a lot of hope and one of the things reasons this is one of the reasons that I think unions are so powerful, is that in this specific instance, they offer a structure for that type of longitudinal change to happen even as leaders turn over, even as residents graduate. There is now a structure for incoming interns to learn from the outgoing residents on how to organize, to be tapped into a national resource, the committee of interns and residents, in this case our union, to be tapped into a national resource to support them in that effort and to hold those long term priorities and values and goals and bring people in to continue that work, even as other people leave. If we want to have change over the long term, we have to think about building structures that will support that effort even after we are gone, and will allow other people to come in and take up that mantle. I went to the convention last year for the national union, the committee of interns and Residents. It was really inspiring to see, because there’s this infrastructure, there’s a framework for thinking about big picture problems in the long term. There’s a framework for training incoming house staff to become leaders, to contribute a little bit to that long term vision, and then to bring other people up and train them how to do it once they’re leaving. I feel that we are fools not to take advantage of that framework. There are many ways that we can change residency, many ways that we can make this practice of medicine better and more holistic. And I support all of them. And unions are federally protected way for us to organize. They’re a federally protected way for us to do so, not just in one hospital, but also across hospitals, through a national union, where we can start to think about bigger picture things and how we can move residency to a more positive direction for everybody. So I think we’d be fools not to take advantage of that. And, I hope that’s what the medical profession writ large is realizing, because I think that this is just as true for attendings as it is for house staff, although I know the focus is here, is on house staff, but a lot of the same problems that house staff face, attendings face in different ways. And, I think we as a profession, are foolish if we don’t use a form of organizing that is available to us and is federally protected. So, yeah, I think, you know, what I tell people, just to get back to your question, is, you have to do it for the long term. You’re not doing it for yourself, and a lot of people aren’t going to do that, but there are a lot of people who will. just like you said, in the past couple of years, since our unionization effort, I feel like we were really lucky that we were one of the first in this new wave. But, we’re also following the folks at UCSF and the folks in New York and folks across the country who have unionized in the past, and now we’re seeing a new wave. Right? I know. Penn, northwestern, MGH, Brigham, University of Chicago, GW are all either recently finishing their unionization efforts or starting them. And it’s really exciting to me to think about you know, I think over 80% of House staff in California are now represented by the committee of interns and residents. And if you think about what that type of power could accomplish, it’s really exciting for actual structural, big picture change.

Dr. Frances Mei Hardin: Very well said. You know, the time scales of change are definitely longer than any person’s residency. Like neurosurgeons included. So neurosurgeons included, neurosurgeon included. And so the fact that there is kind of this existing framework, you know, the handbook and the wisdom that can be passed down, that that’s really something like, I think that’s very powerful. And I definitely, you know, I hope that more and more institutions, like, again, at my institution, there weren’t even whispers of this. And I think a lot of us, not knowing anyone who had done it and not. Not having it at the forefront of our mind, and also being pretty beaten down by the. The daily work, you know, I just kind of think it would have been awesome to know, about these tools. And certainly, I mean, I do things differently if I could turn the clock back, like six years or so. But it’s not too late for any of these institutions to kind of get on the bandwagon here.

Dr. Philip Sossenheimer: One last thing, which is, you know, you’re reflecting on sort of what will any individual get out of this? Because they might not see the benefits right from the contract if they’re organizing and they’re going to be graduating couple of years. But the reality is, I think you get a lot of hard skills in this work, too. You know, you get. You learn how to organize, you learn how to interact with hospital administration, work on contracts, you get connected with politics. So I think of it as also a skill building thing. This has been a part of my residency education in organizing, and people do research projects, people do Med ed. My hope would be that people start to view organizing being politically active, in a sense, as a valid path for medical education as part of their postgraduate training, because there’s a lot that people can learn. And I think it would benefit our profession immensely to have more people who are trained in organizing, in political advocacy, because our profession historically has not been particularly good at that, except when it comes to protecting our own. You know what I mean? Yeah, yeah, exactly. Yeah.

Dr. Frances Mei Hardin: Yeah. I totally agree.

When Stanford successfully unionized, what concretely changed

And so when you guys did unionize at, Stanford successfully, what concretely or effectively did that change? Like, I did read about things like a 21% across the board pay increase, some additional benefits, like, can you go into any details of that?

Dr. Philip Sossenheimer: Sure. So I’ll say your question was, when we unionize, what concretely changed? And I think the most important thing that concretely changed immediately when we unionized, is that we get to start collective bargaining. Right. And that might not sound, ah, like a lot, but I think for the hospital, they know that that is the biggest already. That is the biggest change. Even before you have a contract in place, once you have, successfully unionized, you have changed, fundamentally changed the power structure within the hospital. Before the union, all of us just get a contract handed to us. We have no ability to negotiate it whatsoever. We have no power right now with the union, even before we had a contract in place. We have federal law that requires our employer to negotiate with us. So we got to have meetings with Stanford hospital leadership to negotiate our contract. And the thing is, that is a big, big change in the power structure, and that’s the reason that the hospitals are fighting so hard against unionization. so I think that’s the foundational thing. And people need to recognize that unionization in and of itself is a big victory, because it creates that opportunity for change. And these contract negotiations happen every three years. Okay? So I think a lot of people at different hospitals, one of the things that I want them to realize is that even if you unionize and then struggle with your first contract, maybe you don’t get a. A great first contract, for whatever reason, you don’t have the support, you don’t have the power. You still have the opportunity to come back three years later, three years after that, three years after that, to renegotiate that contract. And so what you’ve done is built up a structure and a system, change the power within the hospital itself so that future house staff can come and continue to advocate and to continue negotiate. So I think that’s the foundational thing, and that’s the most important thing, because without it, you’re not negotiating at all. So being able to do that is the most important power difference.

At Stanford, total compensation increased by 21% according to the new contract

At Stanford ourselves, in terms of what we actually got in the contract, I think the headline that you read, the 21% across the board total compensation increase, that’s the flashiest. And I think for a lot of our members who are living in the Bay Area and struggling to afford rent, struggling to afford childcare, that is one of the things that they care the most about, because that’s the thing that will actually let them to continue to work without having to worry about finances. And so that money was split between a lot of different things. We had an increase in our housing stipend, we got a meal allowance. we got an increase, in some of the other. In the base salary, some other stipends, but total compensation increased by over 21%. So our PGY ones in 2025 will be making over 100k, which is pretty incredible. and yeah, it’s great, but it’s definitely still not enough, especially in the Bay Area and especially when totally cost of living is so high. And I’ll just tell you for comparison, Stanford has fellowships. They call them fellowships for advanced practice providers who are in their first year out of PA or NP school. These are one year fellowships, what we would call internships in our world. Right. Your first year out of medical school, that’s your intern year. And they get paid $190,000 a year for those, which is great. They absolutely deserve it. And it just shows you the market rate for the work that we do.

Dr. Frances Mei Hardin: Yeah, the value.

Dr. Philip Sossenheimer: Yeah, yeah, we work way more than that, you know what I mean, as interns. And prior to this contract we were barely scraping 80, you know what I mean? And so, there’s a long way to go, but I think that was a big victory for our members was getting those compensation increases. in addition to that we got better language around lactation accommodations, better language around call room access. we got an expanded fatigue mitigation program. So now any resident or fellow is able to take an Uber home, from any Stanford site if they’re too tired to drive, which is something that people cared a lot about because we’ve had a lot of near misses where people have almost gotten into accidents, driving home from 30 hours shifts. And with all of those great wins, I think there’s a lot that we had to let go and that’s because we didn’t go on strike and we didn’t, I think, have the power necessary to commit a full on action like that. there were some things that I really felt strongly about. Things like jeopardy pay. So if you’re on an elective rotation or on a weekend day off, you can be jeopardized call to come in to cover for someone who’s sick. And the unfortunate reality is that that’s a very easy way for Stanford to cover folks. And people were being jeopardized to cover shift that were taken off by advanced practice providers. For example, or there would be residents who quit or got fired and instead of hiring extra residents to bring them on, they would just jeopardize people. And so to me it seems like they’re just over relying on this, what should be a method of last resort. And so we had hoped to have some form of compensation for jeopardy shifts. You get paid a, differential. You get paid extra if you get jeopardized. But we weren’t able to get that language into the contract. And similarly, there were other benefits that we were hoping to get that we weren’t able to achieve. And I think that’s where I encourage everybody who’s going through this process to keep the long term vision in mind and remember that you are building power for the long term. You don’t need to change everything overnight. The first step is the most important one. And now we have a much stronger coalition than we ever did. Our membership now, after the contract was signed, is higher than it’s ever been, and we’re going into the next contract in just two years, and we’re going to be in a much stronger position than we were right now. Exactly. Exactly.

Having formalized grievance process and union representation during disciplinary actions is important

there’s one other benefit of unionization that I want to point out, that I think is really important, which is having a formalized grievance process, arbitration process, and having access to union representation during disciplinary actions. I think the unfortunate reality, whenever you’re in a situation with a really big power imbalance like there is between us and our attendings, us and our management, there’s opportunities for abuse. And I think I’ve heard many stories from residents who’ve felt that, who’ve been mistreated, but for whatever reason, haven’t felt the courage, you know, because of the power imbalance, haven’t felt able to speak up, you know, because their leadership sides with the supervisor who mistreated them, for example. And so having access to counsel, legal counsel, and union representation, who can support you, if you have a grievance against your supervisor, or who can support you if you’re facing disciplinary action, whether it’s justified or not justified, that is really, really important to me.

Dr. Frances Mei Hardin: Yeah, no, that’s incredible. Thank you for bringing that up, because, certainly I did not know that that was one of the benefits. What does that look like, practically? You mentioned legal counsel, but is that a lawyer, truly a lawyer, who is available to that resident?

Dr. Philip Sossenheimer: Yeah, I’ll share an example, maybe just to give you a sense of what it would look like. I had a friend who was terminated, from a residency program just a couple weeks before graduation. They had already gone through their orientation for their fellowship, which they were not able to start because they got terminated for residency. And we don’t need to get into the details, but, it was a wrongful termination. Even Stanford’s own internal grievance process, pre unionization, found that the termination was unjustified and that there should have been a different disciplinary action. But, you know, this person’s career was ruined because of a program director who was, in Stanford’s words, quote, acting arbitrary and capriciously, being vindictive, you know? and that person obviously was devastated. They tried to go through Stanford’s own internal grievance process prior to the union. So this is saying that I feel like something unfair has happened to me. And I will say the fact that Stanford even had a grievance procedure prior to unionization is unique. Not a lot of hospitals do, and a lot of places, you know, you would. Your only recourse would be to do, file a lawsuit for an unjust termination.

Dr. Frances Mei Hardin: Right.

Dr. Philip Sossenheimer: but anyway, Stanford had an internal grievance process, but what it looked like is a. What I’ll call essentially a kangaroo court where this person was expected to represent themselves. They were not allowed to have any counsel present. They couldn’t have their own lawyer in front of a panel of attendings and chief residents who would decide sort of whether this firing was justified or not or whatever. which you can imagine is just like an incredibly, like, how powerless must this person have felt, you know what I mean? Being in front of a group of people who have been picked by Stanford leadership, who are going to have natural biases in the case, you know, because they’re representing their employer, to have to represent yourself.

Dr. Frances Mei Hardin: yeah, it literally gives me goosebumps. It kind of makes me nauseous to think about it. But, yes, it’s horrible.

Dr. Philip Sossenheimer: It’s horrible. It’s horrible. And you know, this. Even so, for this person, luckily, that group found that the firing was unjustified. But guess what? This person didn’t get their job back. You know, Stanford still appealing their own grievance procedure upward. And so what that would look like now with a union is that that person would have access to a union representative in all disciplinary matters. Stanford would not be able to stop them from having a representative with them. Right. CIR has legal counsel. They have lawyers who could look at these cases and make some recommendations. You know what I mean? not that, you know, this person should. If you’re going to file suit, then you always want to get your own lawyer, too. But being part of a union gives you access to representation in a way that you don’t have if you’re not unionized. So, yeah, for me, that’s a really important piece that I think a lot of people don’t think about because it doesn’t impact everybody. You know what I mean? I think a lot of us can kind of keep our heads down and get through. But if you’re the unlucky person who a, vindictive program director targets for whatever reason, to make an example of you, you know, whatever it is, having protection is really, really important.

Dr. Frances Mei Hardin: But, you know, I definitely, like, I will echo. I have seen many terminations from residency just in people I’ve known over the past years, certainly from my own program and things like that. And I just think that what’s such an important point is, like you said, sometimes people hear these stories, and they maybe think, ah, that never be me. I’m great. Like, I work hard and I stay out of trouble and, you know, but I do think that for a lot of us who have, like, witnessed it, you know, been a third party close to or privy to it, it just really does highlight that I don’t think that being a good and competent resident, being a kind person, showing up on time, all that stuff, 100% protects you because it can be so totally arbitrary and, you know, just very subjective in terms of that hierarchical way that historically it’s been set up. So I love for there to be, like, actually a due process and not more of a kangaroo court, you know?

Dr. Philip Sossenheimer: Yeah, it’s really sad. It’s really sad, you know, especially the impact that this person’s termination had on my co residents and especially the interns at the time, the second years, you know, they were terrified. They were terrified that something like this might happen to them because this person was respected, they were well liked, they were good physician, you know, and so to have this happen, it just. I’ve had so many people who’ve talked to me in private about it just, like, telling me how afraid they are. Like, oh, gosh, you know, I, like, my attending told me to go home early, and I did, but, like, am I going to get fired now? You know what I mean? It’s, like, crazy, crazy. But I don’t know if that’s the point. You know what I mean? If this is a leadership style of leading with fear, maybe that’s the point, but the impact that it has is not healthy, in my opinion.

Dr. Frances Mei Hardin: I have seen programs been adjacent to programs where that is the point. Like, just even when I was much younger, you know, I was exposed to these departments where every couple of years, every handful of years, a resident would be fired. And what the co residents would say about it at the time is, yeah, this happens every few years. They just pick whoever is weakest every few years. Maybe, like technically, maybe surgically, and that person has got to go. But it’s so funny because the way that it was always like, discussed, you know, just again, where I’m like a bystander hearing these conversations, overhearing them, the way it was discussed, wasn’t as if there’s just like a true, genuine competency threshold that everyone needs to exceed. It just really was this curve where it was like, the weakest link of top of mind could still be a phenomenal surgeon, but we do need to keep everybody absolutely on their toes. So anyway, goodbye to this person.

Dr. Philip Sossenheimer: It’s horrible.

Dr. Frances Mei Hardin: Yeah, I’ve seen it.

Common concern that residents unionization will strain relations between residents and attendings

And, you know, this leads me to basically my next big question, which is that a common concern that people will voice or accused, to residents who undertake unionization efforts, is that it will strain relations between residents and attendings, or residents versus the institution, house staff versus the institution. So what would you say to those who are worried about the negative impacts on relations?

Dr. Philip Sossenheimer: So, you know, I think the relationship between you as a resident, your attending on service, is not going to change at all. You know, people are still going to be focused on patient care. They’re going to be putting their. You’re going to be working hard, you’re carrying a busy census. You know, I think my relationship with my attendings was not impacted at all. And I was one of the most active organizers. Right. I think for people who are not actively organizing, they’re not going to notice any different, any difference whatsoever, because it’s not like you’re negotiating your contract with your attending ever, even once you have a union. You know what I mean? so your relationship to your attendings and the clinical capacity, I don’t think changes at all. you’re still going to be focused on patient care and hopefully education. Your relationship with the hospital as a house staff body will change and I think it will change for the better for you. And I think there is some truth to the fact that the hospital leadership might feel uncomfortable. and I’m sorry, but if you feel uncomfortable about the fact that you’re working these group of people 80 hours a week and underpaying them, I’m okay with that. You should feel a little bit uncomfortable if the GME leadership. I’ll, give you an example. Unfortunately, we have our contract in place now, but Stanford is playing games and we’ve had to file over a dozen grievances, nearing 20 grievances against Stanford for a variety of contract violations that they’re not following the collective bargaining agreement that we’ve already, that we agreed to. That’s what we’re alleging in our agreements is. And, you know, we’ve heard radio silence. We’ve been emailing HR, and they’re not responding to our emails. They’re delaying. And this was their tactic during the contract phase as well, is just to try to go slow, let things wear off. Maybe we’ll lose energy, not take us seriously. And so we gathered a petition, got over 500 signatures, delivered it to the director of GME, to her office. She wasn’t there. So we delivered it to her staff in a very peaceful fashion. And they’re all up in arms, you know what I mean, about how. Oh, my gosh, like, this is so. I can’t believe you did this. This is so unprofessional. Mind you, this is a federally protected labor action, collecting a petition and peacefully delivering it during lunch, on break. but it makes them very uncomfortable. And that’s true. That’s true. And I think that’s a good thing because the status quo right now, we are burying the brunt of the discomfort. You know what I mean? We’re the ones who are going home after work and crying or having strains in our marriages or not spending time with our kids. And so if the hospital leadership start to take a little bit of that discomfort, and if they feel that discomfort because we are starting to advocate for ourselves, that’s not something that I’m going to feel bad about, you know? my hope is that program leadership, like our program directors themselves, who are sort of to the side, you know, because we are negotiating directly with the hospital who employs us, and our program directors lead us educationally, but they’re not the people who set our pay and stuff. So what I’ve noticed at Stanford is that the hospital is trying to isolate program leadership from the residents. You know, they’re giving the program leadership misinformation. They’re telling them they’re trying to create a culture of fear and trying to chill speech, you know, saying, oh, you can’t talk about the union and tell people to vote no, and, gosh, the union’s going to be so bad for you. My hope is that program directors recognize that this is a vessel for advocacy that we can use to support your job as program leadership. I truly believe that a lot of our program directors, some of the bad actors excluded but a lot of our program directors truly have the best interest of residents at heart, and I hope that they could recognize that unionization and having a unionized house deaf body could be a way for them to ally and to work towards shared interests. Okay. My program director wants to reduce the cap on our medicine service. Maybe we can work together through the union to accomplish that. Right? Oh, our program director wants us to have more ability to attend conferences, to present research, because that will get us better fellowship matches. Maybe we can use the union to advocate for that. And so, for me, I hope that our program leadership can see where we can be aligned here. But I won’t lie. It’s true that the hospital tries to separate and create those internal divisions. That’s one of the ways that they try to defeat unionization, is by creating divisiveness and division and saying, oh, you know, you orthopedic surgeons, you don’t want to be with those pediatric residents because you guys don’t have anything in common. And, you know, oh, the peds people are going to want something different. Oh, you program leadership, you don’t want to work with the House staff, but we all have more in common than we do indifference. And so I think, Yeah, you know, that’s a long way of saying that. I think it can be a very positive thing, even for program leadership, that you won’t notice any difference between yourself and your attendings and that the only area where you’ll notice a difference is that the C suite are going to start sweating and they’re going to be feeling uncomfortable.

Dr. Frances Mei Hardin: Yeah. Which I agree. Like, that seems kind of like a fair, price.

Dr. Philip Sossenheimer: Totally.

Dr. Frances Mei Hardin: But it’s so funny, because even when you talk about, like, okay, well, maybe ortho versus medicine, it’s like, yeah, we’re going to pit you two against each other. Like, I would love to take this opportunity to assure everybody that you have more in common with the other house staff. Absolutely do with the C suite. Like, this is just your daily reminder, because I’ve definitely heard rhetoric that’s kind of like, you know, from the house staff level, where the house staff are like, hey, this is a collegiate environment. Like, we’re all colleagues here. Everyone stay cool. And it’s like, they don’t view you as colleagues, you know? Like, I think that words and actions speak pretty loudly from most higher up levels of institutions, as well as depending on the location from the attendings. Like, they’re telling you and showing you that you’re a cog in a wheel, you’re means to an end, and you’re very cheap labor for them. And so the other thing that I wanted to mention in response to, you know, delivering that petition to the GME office is that it really, it doesn’t surprise me, but it grinds my gears to hear unprofessional lobbied at you guys for that. Because this is. Because I do think that this is such, like a sensitive point. Hate the weaponization of the term, quote unquote professional or professionalism at house staff. you know, there’s increasing literature on this topic, but it is used pretty often to justify, you know, probation, suspension, termination, particularly against residents who are not white, you know, or who in some way, like, it might even be a resident who just speaks up for themselves in a respectful way, you know, in a reasonable, non, threatening, respectful way. Or like, in your case, trainees who do something that is protected by labor laws and is still respectful, it’s not, you know, it. It’s not out there. But then someone to call that behavior unprofessional is such a lazy, fast way for them to try to discredit you or, like, tear down, you know, house staff.

Dr. Philip Sossenheimer: Totally. Totally. You know, I don’t even know, like, it’s such a vague term and it basically just means anything that management doesn’t like, you know, that’s what’s unprofessional. because I will tell you that in my opinion, a lot of the behavior that Stanford exhibited during our contract negotiations, if we had done, would be considered extremely unprofessional. You know, not responding to emails, delaying showing up late, you know, being rude, that’s, the type of stuff that if we do on rounds, if I did that to a patient, I’d be slapped with professionalism so hard, you know? But, yeah, it’s a weapon that only points one way. You know what I mean?

Dr. Frances Mei Hardin: I know. So I just think we got to call that out when we see it and everything.

What would you say to those worried that unionizing will affect quality of care

I have two more questions left for you. This is kind of our last big, you know, unionization topic, and it’s just because I see this question come up commonly all the time. So if people haven’t gotten this question answered elsewhere, what would you say to those people who are worried that unionizing will affect their case numbers, their quality of education, and their adequate training hours?

Dr. Philip Sossenheimer: So, you know, the union is whatever you make of it, right? You get to choose what you negotiate over. You get to choose what you bargained for. This is something that a lot of our surgeons were worried about, right? That they, for a lot of reasons, feel like it’s already hard to get the number of cases that they needed that they didn’t want to touch work hours. And so we didn’t, you know, we didn’t, We didn’t make any restrictions to our work hours. There’s nothing that changes the quality of their training in terms of the amount of time that they’re working. Right. So what I would say to those people is that you should get involved, and whether or not you want to actively organize for the unionization effort at your hospital, you should at least talk to the people who do, because they’re going to be representing you, and you should tell them what your interests are. And I think that those people will respect your interests. Right. So, that’s the great part about unionization, is that it’s hyper local and it can be. It will be directly. Right. This isn’t a policy that’s happening nationwide. This is going to be for your hospital, and it can be very granular. There can be different things for different departments if you spell them out in the bargaining agreement. So if you get involved, you can shape your hospital to look however you want. You know, one of our cir shops is a family medicine only residency, and they negotiated reduced work hours because that’s what they wanted. And they didn’t have any surgical folks or people who needed procedures that were worried about it. But at Stanford, we have a lot of proceduralists, a lot of subspecialists, and that wasn’t something that they wanted to negotiate for, and so we didn’t. So, you know, that’s the good thing, is that it can be very responsive to what the needs are of the people there.

Dr. Frances Mei Hardin: That’s wonderful. Okay, perfect. I mean, again, I’m sold. You’ve convinced me.

Dr. Philip Sossenheimer: You know, my. Everybody should do their own research and their own thinking. I encourage people to pursue every avenue that they can to make the lives of their fellow humans better. I think that the good thing about unionization is that it is the federally protected form of collective action in the workplace. And if we’re not using that tool, what are we doing? That’s what it is. For me, if there were a better and easier way to do things, I’d be open to listening to it. But this is what we’ve got in the US, and it can be very effective. I think that we would be fools not to take advantage of it.

Dr. Frances Mei Hardin: Agreed.

Do you believe in karma? I like to ask everybody do you believe

So, I like to ask everybody, do you believe in karma?

Dr. Philip Sossenheimer: That’s an interesting question. Do I believe in karma? I think the sort of philosophy of karma to me is that actions have consequences. You know what I mean? And I definitely believe that. I believe that. and I think that sort of part of it is that, like, the intention that you set, the way that you choose to go about the world will influence you internally. You know? I don’t necessarily believe that there’s something divine that’s going to change in that karmic sense, you know what I mean? But I do think that, you know, actions have consequences and that the way that you go through the world will impact the way that you receive the world. And in that sense, I guess you could say, I believe in karma. Wow.

Dr. Frances Mei Hardin: I love that. Very deep.

Frances Mei: It’s really heartening to see residents advocate for others

Well, thank you again for joining me today. It’s been such a pleasure to chat with you and learn from you about this incredibly important topic.

Dr. Philip Sossenheimer: Thanks so much for having me, and thanks for everything that you’re doing as well. It’s really, heartening to see when folks who’ve completed training continue to advocate for those who are still going through it. So thank you.

Dr. Frances Mei Hardin: Next week, we will have Doctor Joanie Lathan, a Med PEDs attending physician in academia, joining us. To discuss the hidden curriculum of medical training. Follow me on Instagram at francesmay, MD M and ethinking residency. Visit my website, rethinkingresidency.com, to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.