Emotional exhaustion among doctors soared during the COVID-19 pandemic, with a record 62.8% reporting signs of burnout in a 2021 study. Now, there appears to be a ripple effect: A growing number of physicians are joining labor unions.

They are still in the minority – only about 10% of doctors and dentists are union members, according to a study published last year in JAMA – but the trend is picking up steam. Earlier this year 82% of 1,200 residents and fellows at Montefiore Medical Center in Bronx, NY, voted to unionize. Doctors at Allina Health Mercy Hospital in Minneapolis and Providence St. Vincent Medical Center in Portland, OR, did the same – and the list goes on. The Committee of Interns and Residents (CIR) represents some 30,000 residents and fellows. That’s a 76% increase in membership in the last year alone.

What caused this surge? Although COVID was clearly a catalyst, the trend predates the pandemic. Another contributing factor is a shift away from private medical practices. Today 75% of physicians are employees rather than owners. As a result, they have little control over their working conditions and minimal autonomy when it comes to clinical decision-making.

Organized labor is especially appealing to residents and fellows – licensed physicians who’ve completed medical school and are now undergoing additional training. A residency program is a grueling apprenticeship that can last from 3 to 8 years, depending on the specialty. A fellowship may entail even more years of training, usually in a subspecialty. These early-career doctors work up to 80 hours a week, often in 28-hour shifts, and have virtually no say over any aspect of their jobs. That’s one reason young doctors are increasingly attracted to unions.

“We have little to no agency over our working conditions,” says Kendall Major, MD, a third-year resident in internal medicine at the University of Pennsylvania’s Penn Medicine, where 88% of more than 1,000 residents and fellows voted this spring to unionize. As Major points out, individual residents typically cannot negotiate for higher pay or better benefits, and it’s difficult, if not impossible, for them to move to another residency program if they’re not being treated well in the one they’re in. Major herself is now a union member.

The first union for resident doctors was established in New York in 1957, a time when labor movements and the civil rights movement were gaining strength. Back then, public hospitals were “extremely underfunded,” according to CIR spokesperson Sunyata Altenor. But in other respects, residents faced fewer hardships than they do today. The young doctors tended to be white men who had “some financial support,” says Altenor, and their student debt was “nothing like what it looks like now.”

Today, with women accounting for nearly half of the residents in American hospitals, family planning and fertility benefits are increasingly important issues, Altenor adds. For this and other reasons, she says, “We’re seeing sort of a resident revolution for the first time.”

Contracts are the crux of the matter for employed doctors, who often can be fired at will, without due process. Many are required to sign non-compete agreements that prevent them from starting their own practices or working for another health care company in a given geographical area if they leave their jobs. Emily Onello, MD, now associate professor of medicine at the University of Minnesota, was among a group of physicians at Lake Superior Community Health Center in Duluth who formed a union in 2013. It is restrictive contracts, she says, that motivate doctors to join or form a union.

The goal is not only to achieve what’s best for the doctor, but physicians are also motivated to unionize so that they can better serve their patients. When a union in North Carolina began negotiating its first contract, one of its demands was a greater voice in clinical decision-making, according to a Jacobinarticle. Pressure to squeeze in a high number of patients per day and make decisions based on the bottom line are two of the most common complaints among doctors who work for corporate health care companies.

Improved working conditions can benefit patients as well as doctors. But unions may also negotiate specifically with the patient in mind. Take Alejandra Vélez, MD, a union member and family medicine doctor in her fourth year of residency at the Greater Lawrence Family Health Center in Lawrence, MA. Vélez, whose clinic caters in large part to the economically disadvantaged, cites a union effort to establish a fund to pay for things that patients need but can’t afford – and aren’t covered by insurance – such as walkers or transportation vouchers for getting to appointments.

Many physicians don’t see an increase in unionization as a good thing.

“Unions risk minimizing the focus on education and placing it on the job,” says Jennifer Bauer, MD, chief of spine surgery at Seattle Children’s Hospital, in an article in AAOS Now, a magazine published by the American Academy of Orthopaedic Surgeons. Bauer and others maintain that medicine is a calling, medical training is an apprenticeship, and unions have no place in that venerable arrangement.

But Onello maintains that there’s another reason for this resistance. Doctors who oppose unionization, she says, often retain a business owner’s mindset, even though most no longer own their own practices. “Doctors used to be rich, and they just haven’t realized that they’re not the 1% anymore,” she explains.

Patients, meanwhile, have an additional concern: the potential for strikes. What happens if you’re in the throes of a health crisis, or need routine care for a chronic illness, and your doctor joins a picket line? Will you be forced to scramble to find a replacement or put essential health care on hold?

Pro-union doctors dismiss that worry. You may have to do without new TV shows when writers and actors stage a walkout, but the ethical obligations in medicine are ironclad. “As doctors, we’ve taken an oath to provide the best care we can and to cause no harm to our patients,” says Vélez.

Unions have plenty of tools short of striking to press their case. One, for example, is a “unity break,” not a work stoppage but a kind of rally in which doctors walk out at lunchtime or during a break and carry signs and give speeches to generate public support. “Strikes,” says Onello, “are a last resort,” to be used only when good-faith negotiations have broken down.

In the unlikely event of a strike, Major says, the hospital would be notified well in advance so that they could provide coverage. “But our goal in the union,” she says, “is to avoid a strike and to negotiate with the hospital for a fair contract.”