Well-being, Learning Environment, and Mistreatment Among Unionized Versus Nonunionized Surgery Residents During the COVID-19 Pandemic

Abstract

OBJECTIVE: To evaluate whether residency program unionization was associated with differences in resident well-being, learning environment, and mistreatment during the COVID-19 pandemic. BACKGROUND: Resident unionization increased following the COVID-19 pandemic, driven by concerns regarding well-being and working conditions. However, evidence regarding the impact of unionization on resident outcomes remains limited. METHODS: This difference-in-differences (DiD) study used data from a national survey administered to general surgery residents following the American Board of Surgery In-Training Examination from 2020 to 2023. We compared responses obtained before the pandemic (January 2020) and during the pandemic (January 2021), with 2022-2023 data included in sensitivity analyses. Residents from 310 programs (94.5% of eligible programs) were included, of which 30 (9.7%) were unionized. Outcomes included resident well-being (burnout, thoughts of attrition, and suicidal ideation), learning environment (duty-hour violations, protected educational time, and program responsiveness to resident concerns), and mistreatment. RESULTS: A total of 13,539 responses were analyzed (response rates: 85.5% in 2020 and 81.2% in 2021). Unionization was not significantly associated with changes in burnout (DiD P=0.06), thoughts of attrition (DiD P=0.83), or suicidal ideation (DiD P=0.25). No significant differences were observed in duty-hour violations (DiD P=0.56) or protected educational time (DiD P=0.51). By 2023, nonunionized programs showed greater improvement in duty-hour violations (DiD P=0.003) and protected educational time (DiD P<0.001). Unionized programs demonstrated a transient improvement in program responsiveness to resident concerns during the initial pandemic period (DiD P=0.04), which did not persist by 2023 (DiD P=0.53). No differences were observed for mistreatment measures. CONCLUSIONS: Unionization was not associated with improvements in resident well-being, the learning environment, or mistreatment during the pandemic, with the exception of a transient improvement in program responsiveness to resident concerns. These findings suggest that unionization alone may not be sufficient to protect resident wellness during periods of systemic stress.