On a balmy summer day in 2012, Katie Benziger was on her feet. As a second-year resident MD, she was used to perambulating the hallways of Harborview Medical Center, where she healed the sick and honed her craft. There were junior doctors to supervise, patients to advise, nurses to consult, and all the other myriad tasks of running a public hospital. She was also pregnant. Very.
At 36 weeks, Benziger’s belly bulged like a basketball, but as a resident—that is, a doctor who has finished medical school and is completing her multi-year apprenticeship—she didn’t have time to sit on the bench, despite her own doctor’s strict instructions to take it easy. Benziger’s blood pressure had been running high for a month and a half, putting her at risk for health complications as her delivery date edged closer. Her doctor “wanted me to cut back on my hours,” she says, and take some bed rest. So she did, for a couple of days. But in an apprenticeship system where residents regularly work 80-hour weeks, taking any more time off wasn’t a real option.
“Pregnancy,” she says, “was very much an afterthought.”
That afternoon, she got a call from her doctor saying that the results of a recent blood test were concerning. Benziger was to stop work, go home, and come in for a checkup the following day. “My attending basically had to bring me home,” she says, referring to the senior doctor who supervises her.
The next day she went to Swedish Hospital for what she’d thought would be just an ultrasound, only to learn that she’d be staying, under observation, for two weeks.
Benziger remembers feeling both relaxed and nervous: The unrelenting but predictable stressors of work were held at bay, replaced by the gentle, ominous wait of an uncertain patient in a tiny, unfamiliar hospital room. There was another concern. If pregnancy complications ate up too much of her time, she risked—besides lost wages—missing her board exams and, possibly, that year’s deadline for jobs and fellowships.
Still, it was nice to take a load off and just read trashy magazines between the white sheets of her hospital bed. Some friends came by to lend moral support by painting her nails purple. “At this point, it was abundantly clear that work was over and I was just going to sit there until the delivery,” she says.
Then the baby’s heart rate began to drop.
A nurse rushed into Benziger’s room. “I’m your labor and delivery nurse,” she said.
“That’s funny,” replied Benziger. “I didn’t know I needed one.”
She did need one. Benziger’s blood pressure was one symptom of pre-eclampsia, a condition that sometimes shows up in stressed-out pregnant people when the placenta hasn’t adequately dug into the parent’s internal organs. The important part of the term is “pre-,” since eclampsia itself is just a five-dollar word for pregnant seizures of such violence that they can literally kill.
To keep Benziger’s condition from worsening, hospital staff tried to induce labor, even though the baby wasn’t due for another month. When that didn’t work, the knives came out. Covered in sterile blue surgical sheets, awake but numbed by local anesthesia, Benziger could see her colleagues’ eyes as they cut the child out of her.
Residents are the workhorses of the public-health system, constituting about a fifth of King County’s doctors. Highly trained but cheap, these junior doctors run a years-long gauntlet of late nights and early mornings in pursuit of full doctor status. The term “resident” is actually a remnant of an earlier time when apprentice-doctors literally resided at their hospital, often without pay. Even into the 1980s, it was common for residents to work 120 of the 168 hours in a week.
As do truck drivers and pilots, residents become less competent with less sleep. (In one recent study, “serious medical errors” increased by 36 percent when residents were sleep-deprived.)
But it wasn’t until Libby Zion, scion of celebrated journalist Sidney Zion, died under the care of resident physicians at New York Hospital in 1984 that the casualties of overworked residents truly came under scrutiny, leading to state-level reforms in 1989 that gradually spread across the country. In 2003, under threat of federal legislation that would limit residents’ hours, the Accredited Council for Graduate Medical Education (ACGME) capped residents’ work hours at an average of 80 per week. That limit doesn’t include “home call” hours, which require residents to be available by phone for questions and to zip into the hospital if needed. Nor does it include the hour or more most residents spend each weeknight reviewing notes on new patients.
Despite the protections provided by the ACGME’s 2003 decision, residents in Seattle say that they are still struggling. For Seattle doctors—including Benziger and the 1,500 other residents and fellows (doctors doing a second residency in their sub-specialty) at University of Washington hospitals—it is not only the yoke of an 80-plus-hour work week that weighs on them, but also the financial pressures of living in one of America’s most expensive cities. For Benziger, this meant putting her schedule before her pregnancy; for others, it means letting student loans default, borrowing money from family, or otherwise contending with the stresses of working poverty usually endured only by unskilled laborers. It is this combination of superhuman work schedules and sub-living wages that has recently driven UW’s residents to unionize, demanding better pay and better benefits.
Residents’ pay rates are fairly even across the country, a standard kept in order to discourage med-school graduates from shopping around for lucrative programs. On paper, this income puts them solidly within the middle class, earning between $50,000 and $70,000 per year depending on seniority. But that salary pencils out to between $13 and $17 an hour—close to the city’s minimum wage. That’s a little more than the average hourly rate for a telemarketer and a little less than that of a secretary.
Andrew Korson, a 34-year-old gastroenterology fellow in his sixth year of apprenticeship, says that with a wife and two young kids in Seattle, he doesn’t command a living wage. “As far as making ends meet, it’s a challenge to support [my] family,” he says.
At roughly $64,000 per year, how is that possible? Cost of living, says Korson; Seattle is the 10th most expensive rental market in the country. In addition to their regular work hours, most residents have regular “on call” hours during which they must be able to race to their workplace within 20 or 30 minutes. In practice, this means that residents have to own a car and live fairly close to the center of Seattle, where rents are highest. For instance, average rent for a one-bedroom apartment is about $1,800 per month on Capitol Hill, but only $1,600 in the U District and Columbia City, according to renters’ website Zumper. And since most residents are in their late 20s and early 30s, many of them have small children and need a larger, more expensive abode.
Graham Strew is a fifth-year fellow specializing in ear, nose, and throat medicine. With two other residents, Strew covers four hospitals. He says he takes home $3,000 to $3,300 per month, and spends about half of that on rent for his one-bedroom apartment. Strew reckons he pays another $240 every month for parking. He says he can’t afford the $500-per-month minimum payment on his student loans, so “I basically have had to put my loans into forbearance,” meaning that his debt grows by $900 per month during the six years of his residency. Strew is not alone: The average aspiring doctor graduates from medical school with $166,750 of debt—debt that does not go on hold during a residency.
“I wasn’t expecting to come into residency and make a lot of money,” he says. “What I [also] wasn’t expecting was that during my five years here, my rent would go up 30 percent.”
Low pay, long hours, and the inflating costs of Seattle living led residents like Strew, Korson, and Benziger to join the UW Housestaff Association, which became a formal union for residents in the fall of 2014, despite opposition from the UW. That union, comprising about 1,500 residents, is currently in negotiations with the UW for higher pay, free parking, and better child care, according to Amity Neumeister, assistant dean of graduate medical education and a member of the UW’s bargaining team. Specifically, the union wants the same pay as the lowest-paid physician assistants in the country (a wage increase in the neighborhood of 40 percent), a child-care subsidy of $400 per month, and a childcare grant of $5,000 per year.
Neumeister says that the UW wants “to continue to work collaboratively with the union to come up with a collective bargaining agreement that we think supports their education and training, and we are committed to continue with providing them with one of the most excellent educations that they can receive.”
That’s not a “yes.” Neumeister says that free parking and subsidized child care would be inconsistent with the UW’s treatment of other employees. “Everybody pays for parking on the UW campus, including the president,” she says.
On the other hand, UW president Ana Mari Cauce also receives a car stipend of $1,000 per month, according to The Seattle Times. And according to the union, a confidential UW-commissioned survey conducted by the consulting firm Milliman found that 84 percent of residency programs nationally offer free or subsidized parking.
As for the salary raise, Neumeister calls the union’s proposal “what we would consider a relatively significant increase.”
Would the UW consider a smaller raise? “We are in the midst of negotiating that right now,” she says.
Another request that has received less attention in negotiations is maternity leave. UW offers none to residents beyond the 12 work weeks of unpaid leave required by the state Family Care Act, which essentially protects residents who take unpaid leave from losing their job and medical insurance (but which kicks in only after a resident’s first year). Paid leave is limited to three weeks of vacation and two and a half weeks of sick leave per year, which in practice gets used as maternity (or paternity) leave by residents like Benziger. By comparison, according to the Milliman survey, 88 percent of residency programs nationwide offer maternity leave.
Margot Herman had her second child during her first year as a UW gastroenterology fellow. She’d previously completed a three-year internal medicine residency at the Mayo Clinic in Rochester, Minn. “When I was at Mayo Clinic,” she says, “it was very easy for me to have a child there. I had six weeks of paid [maternity] benefits, and then I used up some vacation. So I was basically paid for eight weeks to take care of my child.
“I didn’t realize how great that was at the time,” she says, but she soon learned. Herman and her husband tried to remain financially independent when they moved to Seattle, but after several months of barely seeing her kids, she says, she decided to fall back on family money. “It was a very hard adjustment,” she says, “the first year moving here. I felt a lot of guilt about how much we were spending and how much we were burdening my family.
“I’ll be 35 by the time I no longer need to borrow money from someone,” she says.
Herman acknowledges that her ability to dip into a parental piggy bank is an advantage not available to all residents, and worries that making family support a de facto requirement for residents will keep students from less-advantaged circumstances from being able to become full-fledged doctors. She also thinks there’s an element of women’s lib in this fight: Without maternity benefits like paid leave and child care, she says, women are forced to traverse a harsher road to full doctorhood.
“As a physician,” she says, “it just drives me nuts . . . that we’re [acting] as if this isn’t a major issue for gender equality.”
However fair the union’s demands may be, they’re moot if there’s no way for the UW to fund them. According to Neumeister, there isn’t.
“We are committed to providing our trainees a competitive salary with competitive benefits while they’re here at the University of Washington,” she says. “But . . . it would not be economically feasible for us to provide that level of” remuneration.
Are the residents worth it? As far as the UW’s balance sheet is concerned, the answer has to be yes. A study published last year in the Journal of Surgical Education found that on average, tasks performed by residents bring in about $70,000 in revenue per year—about $95,000 per year if you don’t count first-year residents. On top of that, more than $15 billion in federal funding goes to subsidize graduate medical education nationwide each year, or about $100,000 per resident. In other words, the direct revenue brought in by residents slightly exceeds their salary—yet they also bring in another $100,000 per year in federal subsidy. Another analysis by the Rand Corporation compared the costs of using internal-medicine and cardiology residents versus regular employees (doctors and other medical staff, depending on the task). That analysis found that using residents instead of market-rate staff saves hospitals between $100,000 and $350,000 per year per resident.
These facts gnaw at residents like Korson, who says he once used charity care at a UW clinic when his UW insurance didn’t cover the full cost of treatment. He says another resident recently qualified for food stamps, which requires applicants to have no more than about $1,000 in assets, though the exact number varies depending on family size.
“The bottom line is that . . . it still is a challenge for me as a 34-year-old with a graduate degree to take care of my family,” says Korson. “This is a career. We’re all fully-fledged adults . . . We should not qualify for this degree of state or federal subsidy.”
Some on the Seattle City Council agree. In a letter sent last month, councilmembers Kshama Sawant, Mike O’Brien, and M. Lorena González and then-councilmembers Jean Godden and Nick Licata urged president Cauce to “meet the [union’s] reasonable demands.”
It’s been three and a half years since Benziger’s emergency C-section. Sitting in her home, she watches her son, Theodore, bound across the carpet. Artifacts of domesticity surround them both: The floor is strewn with children’s toys, the kitchen counter with produce and cooking utensils.
Recalling the circumstances of the birth, she’s not bitter. “It’s funny. When you’re going through it, it doesn’t seem so dramatic, but in retrospect it’s like, yeah, that was pretty crazy,” she says.
After half a decade of doctoring, she’s on the cusp of completing her second residency and going into the private labor market, where her income, now about $62,000 per year, will probably at least triple. Depending on specialty, median annual incomes for full-fledged physicians range from about $220,000 to $450,000.
That ain’t peanuts, as her gastroenterological colleague Margot Herman readily acknowledges. She anticipates a starting salary north of $200,000 once she completes her fellowship. “It’s a lot of money,” she says. “I think [my family is] going to be more than comfortable once we’re through this.”
She’d better hope so. Loaded with student debt, Herman is compelled to prioritize salary in her job search. After completing a residency, she says, “You’re $200,000 in [student] debt . . . and you have to pay those loans back, which is a lot. And the other issue is that you’ve either been struggling for a long time and cutting corners, or holding off from having a family, or borrowing money from family and, just—you have to get out of that.
“It makes decisions pretty clear for most people, that they have to earn a good income after training.”
Is this fair? In its own way, perhaps: Residents labor years for their prize. They give a lot, then they get a lot. Starve, then feast.
But as Herman and others point out, however justified this three-year gauntlet may be when applied to ideal residents, there’s also the issue of access. Just who gets the option to slave away for half a decade in hopes of hitting the jackpot later on? Not poor people, if your residency program pays so little that the only way to get through it is to borrow from family. And fewer women, if your residency program dispenses with maternity leave.
Equitable access—making the hard bargain of residency available to all—is part of what spurred Herman and the other UW residents to unionize and bargain, even though they don’t stand to personally benefit from changes that will be years in the making if they happen at all.
“At this point,” says Herman, “this whole union and everything, it’s not going to affect me, probably. I’m at the point in my training where I feel like I’ve gotten through the rough patches.
“I don’t feel like a victim, personally, but I do feel really sorry for other people that have to go through this in the beginning. Especially if you’re going to be at UW the whole time. It’s a really hard place to financially get through because it’s such an expensive city to live in.”
The union’s negotiating platform, she says, is “not really for us at this point. It’s for the people after us.”