We are vital healthcare providers and deserve to be valued and respected. Read that again.
What do you do when you see an issue that warrants attention? Do you speak up? Do you brainstorm solutions? Do you take action? It can be frustrating and disheartening to see pervasive issues go unaddressed. It can be challenging to advocate for ourselves while facing the demands of training in residency/fellowship. Perhaps that is why systemic issues remain. Because historically residents/fellows (“house staff”) have been overworked, underpaid and unheard. I encourage you to use your voice to impassion strategic action. Here’s how I did it, specifically focusing on raising house staff salary/stipend (“salary”) but these tactics are applicable to other needs. Using this approach, we were able to successfully advocate for an increase in house staff salary of approximately 10-14% (depending on PGY level) at a non-unionized institution.
Get Yourself a Seat at the Table
1. Joined my House Staff Council
During PGY2, I served as a peer-nominated HSC representative of PM&R at my institution. Responsibilities included staying informed about changes at the institutional level while advocating for needs of house staff, particularly those related to physiatry. During my year as a representative, the HSC executive committee advocated for increased salary for house staff and were successful in gaining a 3% raise for the few months remaining in the academic year. This was met with disappointment from house staff as many were facing financial hardship in the setting of historical inflation rates, property tax hikes, increased childcare costs and looming student loan repayments. This was announced at a house staff Town Hall in December 2022 with academic and hospital leaders. We voiced our many concerns but were essentially met with a response stating that the budget had already been approved and the deal was done. I left nearly in tears.
2. Served as President of House Staff Council
After much reflection and consideration, I accepted (admittedly a bit nervously) the role of HSC President in April 2023 as a PGY2 and by May 2023 I was presenting an increased salary proposal to the Graduate Medical Education Committee (GMEC). It was a whirlwind, but I was motivated to see improvements for the 900+ house staff at our institution. Below, I outline what was involved in case you are interested in learning about the process we went through, whether out of pure curiosity or perhaps intention to act.
Learn the System
It is imperative to figure out where and how to formally propose a change. For us, it was through HSC and the GMEC, following the established institutional protocols. GMEC is comprised of program directors, associate program directors, program coordinators, HSC and academic/institutional leaders such as the Designated Institutional Official (DIO). GMEC meets monthly to discuss institutional/program updates and vote on important matters. This was the opportunity for HSC to present a salary proposal. But how to determine a recommended value? How to effectively promote it? It is important to understand the history – what has been proposed before? How was it proposed? What were the results? Then consider – where and how can this be improved to enhance its efficacy? What are other programs in the state/region/nation doing?
Get Data
The HSC predecessors had distributed an anonymous online survey to house staff to assess their expenses including housing, childcare, student loans and prevalence of food/housing insecurity during training. We built upon this survey and re-distributed it to determine the average expenses for a resident with and without children. Using publicly available data, we included estimated cost of utilities, internet, cell phone, insurance, transportation, taxes and food. We used this information to formulate a salary proposal we felt would adequately meet house staff needs and would demonstrate why so many house staff were struggling financially since necessary expenses for many were not being covered by the typical house staff salary.
Present Data
This was first shared with GME/institutional leaders by written proposal which reviewed the issue in context, requested detailed numerical increases by PGY level and by a specified date, and requested a date for them to reply to the proposal by. We were advised that this would have to proceed through GMEC to be heard and voted upon. As President of HSC, I presented this at the May GMEC meeting and it went through the “Robert Rules of Order.” Outcomes here can vary. Ours, fortunately, was referred to an Ad Hoc Salary Working Group comprised of current faculty who were either current or prior program directors. They met with stakeholders including house staff to make their own independent salary proposal which they later presented to GMEC at a following meeting which was voted upon again.
Humanize with Lived Experiences
Meeting with the Working Group took the form of a Town Hall which allowed house staff to share their personal experiences and/or struggles. For those who could not present but wanted their stories heard, I read their anonymous stories aloud at the Town Hall and compiled a document of anonymized experiences that was emailed to the Chair of the Working Group after. These stories were impactful. These stories ranged from house staff experiencing food insecurity and losing significant body weight, spouses losing jobs and caring for children at home due to limited affordable access to childcare, being unable to afford necessary medical appointments and more. And it was not due to a failure of appropriate budgeting on the personal level. It was a failure of the system to provide adequate resources for house staff to thrive. The requested salary increase would go a long way in bridging this gap.
Gather Support
It is important to speak
with house staff to gain support as well as trusted program leaders,
particularly those who are on the GMEC and thus hold voting positions.
This includes your PD/APD. Ultimately, it came to a vote at a GMEC which
voted in favor of a house staff salary increase. It was aligned with
the proposal from the working group which was less than what the HSC
initial proposal was, but still a significant increase. This proposal
was based on comparative salaries in our state/region and illustrated
where the current house staff salary ranked in relation to these. Since
it ranked relatively low, it effectively demonstrated that our salary
was not competitive which has implications for house staff recruitment.
This garnered attention.
Know the Stakeholders and Process Cycles
Institutions may have several partner sites that factor into the overall operating budget, but each of those sites has their own budget cycle which may be separate from the ultimate resident payer. For example, a fiscal year may begin in July whereas another may begin in January or some other month. But budgetary planning is typically happening many months prior to finalizing. This information can help frame when it is most effective to begin discussions relating to budgetary planning. Similarly, if you’re seeking to improve a house staff policy outside of a budget then it would be helpful to know when those policies are reviewed and up for amending. The only way that I know how to learn this information is to get an inside understanding of the policies/protocols which I was able to do with the HSC.
Be Transparent, Be Professional and Trust the Process
This process took many, many months. As stated, we built upon the work of the HSC predecessors before us. The role of HSC President began in April 2023, the final budget determination was in December 2023, and then the first official increased paycheck was received in February 2024. I regularly communicated updates with house staff on the process and progress including details of the various timelines and stakeholders involved. At a certain point, HSC had done all we could do; it was out of our hands and up to the other academic/institutional leaders to discuss in private meetings. Our DIO played a significant role in advocating for this proposal on behalf of house staff and the GMEC.
Prepare for Alternative Actions
In case of disappointment in the outcome, research how you may respond, what you’re legally allowed to do and what would be considered an ethical response. Prepare accordingly, but you can still hope for a better outcome.
Demonstrate Gratitude
Handwritten thank you notes go a long way.
3. Chief Resident
Of course, if you are seeking to make improvements relevant to your individual residency program, consider serving as a chief resident when eligible. This can be an effective way to advocate for the residents in your program and see innovative changes. Again, learning the system will be important as well as the other various points listed above. A similar approach can also be applied when advocating for public health initiatives or patient care.
We are fortunate to be in the field of PM&R, one that values quality of life not just of patients, but of providers. My residency program, from faculty to co-residents, has been incredibly supportive of this journey. I am deeply grateful for their encouragement and understanding. It literally would not have been possible without them or the other house staff that contributed data, stories and patience. If you find yourself seeing issues that need addressing and feel that you have the mental fortitude to advocate for change, I hope that this can help you see that change is possible, even without a union. I hope this can serve as an example of what is possible when institutional leaders and resident/fellow physicians work together toward targeted solutions. You just need to get a seat at the table, communicate effectively and believe. If not you, then who? If not now, then when? We are vital healthcare providers and deserve to be valued and respected. May we lift each other as we rise.