A Primer for Seattle Citizens on UW-UWHA Negotiations

What is a Resident and what does he or she do?
A Resident is a doctor who has completed four years of undergraduate education and four years of medical school who is now pursuing sub-specialized medical training. These areas include, but are not limited to, internal medicine, anesthesiology, surgery, and pediatrics.  After completing all licensing examinations, which typically occurs in the first year of Residency, a Resident can become a fully licensed physician in the State of Washington.
 
Residents are responsible for managing the care of patients in the hospitals and clinics of facilities operated by the University of Washington (UW). These facilities include the University of Washington Hospital, Harborview Medical Center, Seattle Children’s, and the Seattle Veterans Affairs Hospital.  If your life is saved in an Emergency Department, your tumor is removed in an operating room, or your child is cared for in a clinic at one of these hospitals, the doctor that you see most often is a Resident.
 
Residents work nearly 80 hours per week and perform "call coverage" at all of the hospitals in the UW system.  They typically arrive at work around 530 AM and leave about 700 PM, unless they are on-call in which case they work overnight and leave at 1200 PM the next day.  Residents are responsible for the operation of our hospitals throughout the day and night and are the first line of medical and surgical care. They also help to supervise the nurses and nurse practitioners in our system, who are vital components to ensuring excellent patient care.
 
What is the problem?
Resident physicians at the University of Washington sign contracts to care for the people of our region for a term of 3-7 years depending on the area of sub-specialty training.  Seattle is a city that has undergone tremendous growth over the past several years, and the University of Washington has failed to keep pace with these rising costs when it comes to supporting Residents.  Accordingly, there are many physicians in Seattle who qualify for subsidized utilities, defer having children until after Residency (in some cases age 33 or later), carry educational loans that can be in excess of $300,000 that they struggle to repay, and qualify for “charity care” at the very hospitals where they work.  Read the first hand accounts of some of the hardships Residents face here.
 
How did this happen?
Our country relies on Residents to provide quality healthcare at affordable prices.  To ensure that a large pool of Residents always exists, the federal government created a system where certain hospitals receive federal funding to employ Residents.  These hospitals benefit by having licensed Resident physicians provide a large proportion of patient care, which means that fewer fully trained physicians are needed. Yet little of the money generated by Resident physicians is actually used to support Residents.  A 2014 New England Journal of Medicine paper by leading health economists found that by all estimates, revenue generated by Residents more than covered their salaries and all associated costs of their training, meaning that the $15 billion in government subsidies being paid to teaching hospitals was not applied towards Resident education or support.  A similar study in the Journal of Surgical Education reached the same conclusions.
 
Unlike nurses and faculty members, Residents are not part of a free market system where they can negotiate salaries, benefits, or even leave a job where they are unhappy or cannot afford to stay.  They are bound to their institutions, which are assigned by a computer matching system after medical school, and cannot change locations without a significant impact on their professional career development or finances.  Even if a Resident were willing to transfer to another program, in most cases positions are not available as they are filled annually by the computer system.
 
Thus, the UW has used this leverage for years to simply say “no” to Residents who were asking for more support.  The UW has averted previous organized Resident labor movements through nominal increases in salary and benefits. Yet even with these increases, UW Resident salaries remain at a level where many residents are not able to afford the costs of living in Seattle, raise a family, or stay out of debt.
 
Residents work all over the country.  What makes the situation in Seattle unique?
Seattle is one of the fastest growing cities in America with one of the highest costs of living.  The UW likes to say it compensates its Residents fairly by paying them “near the national average.”  But this ignores the fact that Seattle is not an average American city.  A simple internet search shows that Seattle has the 7th-10th highest cost of rent in the country (Business Insider and SF Gate) with rents ranging from $1600-2100 per month for a one-bedroom apartment.  This average rent alone is over 60% of a Resident’s monthly salary. Programs in other expensive cities, such as San Francisco and New York City, recognize this problem and provide additional stipends or subsidized housing.  For instance, the University of San Francisco pays a higher salary than the University of Washington AND offers a $10,000/year housing subsidy.  Overall, the cost of living in Seattle is 20% higher than other cities based on the consumer price index. Thus, residents in more affordable parts of the country do not face the same challenges (read UW Resident stories here).
 
One might ask: “why can’t a Resident just live in a cheaper part of the city?” In order to care for our patients and be at the hospital within 30 minutes to provide care for an emergency, we are forced to live near all of the four hospitals that we cover.  These neighborhoods thus include Downtown, Belltown, Capitol Hill, Queen Anne, Pioneer Square, Wallingford, and their nearby areas.  All are amongst the most expensive parts of our city.
 
What would make things better?
1.       A fair salary that reflects the costs of living in Seattle and the value Residents provide to the care of our region’s patients.  The individual who most functions like a Resident in the UW system is a Physician Assistant or Nurse Practitioner.  These individuals typically have six years of post-high school education and typically practice under the license of a physician. Unlike Residents, they are not required to do additional “on the job” training after completing their graduate school. Within the UW system, they provide care for hospitalized and clinic patients often in conjunction with Residents and often under Resident supervision.  They typically work 40-60 hours per week with no overnight or call coverage and do not perform complex procedures. 
 
While they are incredibly valuable members of our patient care teams, they have fewer years of graduate education (i.e. 2 years for PA school vs 4 years for medical school), work fewer hours, and, in many cases, are part of a team supervised by Residents.  However, since they are part of a free market system unlike Residents, they receive a salary that is 40-50% greater than a Resident.
 
But aren’t Residents technically in training?  While this is true, please recall that Residency is typically 3-7 years, and by the time an individual reaches the more senior years they have a very broad set of skills and training.  The initial UWHA salary ask was to be paid the same amount as a first day Physician assistant in our system, or roughly the 1st percentile of Physician Assistant salaries nationwide.  In other words, we asked that our most senior Residents, which includes surgeons who are fully trained and licensed to operate independently in the final stages of their 6-8 year training, be paid the same amount as a person who just completed their Nurse Practitioner or Physician Assistant schooling.  In what other setting do individuals with more education, more training, and who work longer hours make 40-50% less than the people who in many cases they supervise? While this is an unfortunate result of the Residency system itself and not the fault of the UW, the situation in Seattle is becoming dire and change needs to occur.
 
Finally, some have argued that Residents are compensated for their lost wages by the education that they receive.  While the educational component of Resident training is important, we should remember that new Physician Assistants are often coached and mentored by senior physicians (in many cases Senior residents), attend many of the same lectures, and are given graduated responsibility based on experience just like Residents.   
 
2.       Free or subsidized parking.  Due to the times that Residents work (i.e. 530 AM – 700 PM) and the fact that Residents need to be at any of our four hospitals within 30 minutes for emergency care (i.e. potentially travel from the Seattle VA to Seattle Children’s), Residents are required to have a car to care for their patients.  Public transportation options are simply not available at the hours needed and do not transport Residents in the most efficient manner.  Finally, since Residents cover four hospitals spread throughout the city, it is impossible to live near every facility.
 
The cost of parking at the University of Washington and Harborview Medical Center can be as much as 10% of a Resident’s salary.  Thus, a large portion of our money goes directly back to our employer simply to care for our patients.  This coupled with a low salary in comparison to the cost of living creates an unsustainable situation.  As a comparison, a UW-commissioned survey of other residency programs showed that 84% of programs offer free or subsidized parking to its Residents, including Seattle based Virginia Mason and Swedish Hospital.  
 
3.       Other benefits including maternity and paternity leave.  According to a UW-commissioned survey of residency programs, 88% offer paid maternity leave (UW offers none), 89% offer paid paternity leave (UW offers none), and many programs offer paid holidays (UW offers none).  While the retirement benefits offered by the University are generous and appreciated, they do not help to address the financial burdens that are affecting Residents right now.
 
Why don’t you just go somewhere else?  Hundreds of people would take your spot.
Residents love their jobs and believe it is a privilege to care for the people in this region.  But this should not allow the University to have created and reinforced the current situation.  The University of Washington is a top training program and institution because it attracts the best and brightest.  Ask any faculty member and they will likely say one of the most rewarding aspects of their jobs is working with talented and intelligent Residents.  Almost every breakthrough discovery, new procedure, and life-saving medical advancement involved a Resident physician either working in the lab, performing the “leg work”, or doing the procedure.  Residents are not simply a labor force that can be easily replaced.  The Residents here graduate from the top medical schools in the country and are a vital part of the success of the UW.  It is illogical to think that the UW can afford to stop attracting the best and brightest and still maintain its current caliber. All of the top hospitals in this country are affiliated with top residency programs, including programs such as Harvard, Johns Hopkins, and the Mayo Clinic.  There will always be less qualified or talented people eager to take any position, whether it be in medicine, business, or any other field, but those institutions will not be able to maintain the same quality.
 
Well aren’t you going to make a lot of money when you finish Residency?
The future of medicine is very unclear.  Some analysts have even called going to medical school the “1 milion dollar mistake.”  Residents do not go into medicine to make money.  They go into medicine to care for people, which they love doing.  But regardless of how much they may or may not make in the future, what can they be reasonably expected to sacrifice now?  Should they make less than the city’s hourly minimum wage, be unable to pay medical school debt and continue to accrue more, and defer starting a family until their mid-thirties simply because of where they were assigned to live after medical school?  The UW, with minimal effort, can help make things a little better.
 
What does the Seattle City Council have to do with this and what can I do to help?
Before the Residents voted with an over 75% majority to unionize, the UW simply ignored our requests for help.  Then, despite 12 months of negotiations, the University refused to budge on salary, parking, and child care.  We appealed to the Seattle City Council to help us and are grateful for their support.  All Residents at the University of Washington are voting citizens of our community, and most of us felt we were being unfairly treated and were having difficulties making ends meet.  Members of the council heard the pleas for help and they responded.  Not only are all UW Residents citizens of our city who are represented by council members, but this issue directly impacts the quality of the healthcare delivered to the members of our community.  Our Union now comprises almost 20% of the physicians in King Country and we hope that the people of our city will continue to support us.  Our goal is not to be the highest paid Residents in the country, but simply to be able to afford living in Seattle and to continue to be able to care for its people.