Well, this has been hard to write. As three of the housestaff organizers (Grant, Jessie, and Lawrence), we also served as your GME Council housestaff representatives for the past year. We have debated the benefit of openly sharing our experience with the current “process for dialogue.” Given the continued misleading messaging from GME regarding the effectiveness of the current process, though, we now feel the need to substantiate our stance: A housestaff union is necessary to create a sustainable path forward to effect meaningful change in our working conditions at Stanford.
If we vote to unionize, the GME office does not go away. Housestaff representatives do not go away. Dialogue does not cease to exist. In fact, unionization only enhances this dialogue by elevating the housestaff voice within the hospital. With a union, the hospital will have a legal obligation to bargain with housestaff (and by extension, GME) in good faith. As GMEC representatives, we exhausted ourselves trying to use the current processes for dialogue at a hospital-wide scale, but the current process is not effective. These positions often feel like they exist not to ensure housestaff representation in essential decisions, but rather merely to satisfy ACGME requirements. Rather than collaboration or even willingness to listen to our housestaff voice, we have experienced strategies to avoid and delay real change that would improve our working conditions. We have included several examples from this past year where our attempts to advocate for housestaff were met with unnecessary delays, and in some cases outright belittling and gaslighting of our efforts.
There is no doubt that housestaff have had different levels of success negotiating within their individual departments, and our union has no intention to interfere with these productive conversations. Still, it is painfully evident that there are many situations where housestaff cannot get or protect what they need due to a lack of bargaining power. It is in these situations where we can stand together with our collective strength to amplify not only our own voice but also that of our departments and the GME.
It is important to emphasize that there are multiple levels of decision making. Our departments do not have the power to make sweeping changes, and for many of these issues, neither does the GME office. There is no doubt that many of our frustrations on a GME level are significantly influenced by decisions made on an HR or hospital level. However, with a union and its obligation for the hospital to bargain in good faith, we will finally be allowed to have true insight and influence into these processes. By claiming our legal right to a seat at the table beside our GME and department leaders, we amplify all of our voices. We look forward to strengthening our relationships on all levels and working together towards making our work sustainable so that we can focus on taking care of our patients.
We wanted to make sure you had all of the context before reading further. But here’s why the current state of housestaff advocacy is a broken process. These are some of the topics we have tried to address in 2021-2022.
Housestaff voice
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Sought to use Housestaff Leadership Council (HLC) to hold regular town halls and meetings with hospital executive leadership; give real voice to housestaff in advocating for changes and addressing unmet needs | – Asked to remove the word ‘leadership’ from HLC (“you’re more of an advocacy group, than a group that makes directive decisions”) – Requested to minimize the number of housestaff present at meetings with C-suite; first and only meeting was not scheduled until Jan 2022. |
Background: The Housestaff Leadership Council was created in Spring 2021 as one of the four tenets of the GME Engagement Committee. This committee was a direct response from our collective action and protest around the vaccine rollout. (The main tangible outcome from this was our retirement benefits).
One of the explicitly stated goals was to establish bi-directional communication between housestaff and executive leadership. In practice though, most attempts were met with resistance based on:
- Semantics: GME did not feel that the word ‘Leadership’ was appropriate in the name, as they do not appear to actually want us to lead or make real decisions.
- Representation: While there are 5 GMEC reps and 4 Chief Resident Council reps who make up the HLC leadership, there was insistence that only 2 individuals be allowed to meet with the CEOs – preferably individuals who had been “less vocal” in previous GMEC meetings.
- Delays: Scheduling discussions began in August, but after several delays our first meeting did not occur until January. (This meeting was scheduled the day after we held a town hall with Niraj Sehgal (CMO), in which there was lively discussion around whether residents should receive extra pay for extra work).
We finally met with the SHC and LPCH C-suite in late January, in which we presented an honest summary of the low morale, high burnout, and persistent unmet needs of the housestaff. See below for the response to my summary/follow-up email. This was followed by a meeting with GME leadership in which we were repeatedly questioned whether we thought we “did the appropriate thing” or “achieved our goals.” They hoped that we would equivocate. Our answer was that we did what was right for the housestaff.
Internal moonlighting
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Advocated for Stanford to lift its blanket ‘ban’ on internal moonlighting, since January 2021; Elevated housestaff concerns about being “volun-told” and used for cheap labor and posed moonlighting as a viable solution in August 2021 | – Cited misinterpretations of CMS policies on billing to prevent moonlighting – Deferred further conversations to ‘committees’ that did not materialize – Silenced GMEC reps in Zoom meetings regarding COVID surge staffing – Did not open up internal moonlighting until things had reached a crisis point (Jan 2022 with Omicron), despite months of previous attempted discussions |
This brings us to the topic of internal moonlighting – Stanford’s policy with regard to internal moonlighting has been inconsistent and without good reason. We started conversations in July 2021 to try and reverse this, and GME cited a “compliance” policy put in place by the hospital which disallowed internal moonlighting by an ACGME resident/fellow in their field of training, as this would violate CMS (Medicare) rules. While in some instances the hospital may not be able to bill for this work, there is absolutely no language that says the hospital cannot pay the resident for this work. Further attempts to have conversations about this were met with meetings derailed by conversations on other topics (see: semantics about HLC) and vague commitments to reconvene a ‘moonlighting task force’.
We additionally posed internal moonlighting as a way to address COVID surge staffing issues, in late August shortly after we held a town hall (8/23 COVID surge staffing town hall minutes) with housestaff to discuss concerns that they would once again be ‘voluntold’ to unpaid shifts and pulled from jeopardy/electives to meet the labor needs of the hospitals, while we understand that faculty and APPs were given the option to take paid extra shifts. We presented the main themes as 1) staffing should be volunteer only; 2) there will be fewer volunteers this time around because of concerns around sacrificing too much education time; and 3) unpaid housestaff were expected to not only perform the extra work, but to train paid individuals who were unfamiliar with the service/with inpatient Epic. We reiterated these concerns at every meeting we were invited to regarding COVID staffing, and at one point I was DM’d on Zoom asking me to stop talking about it, saying “this is not the audience for it”. In additional email correspondence I was told: “cms policies do not pertain here. issue of covid moonlighting is not a policy issue, but a leadership (CEO/chair/me) issue.”
We raised these concerns in late August/early September and the concerns were not addressed seriously. When Omicron led to another surge and significant staffing challenges due to quarantine, internal moonlighting was finally proposed by the GME (January 2021) with the admission that they had been misquoting the above ‘compliance policy’. However, because there had been no serious conversations about it in the preceding months despite ample opportunity, the strategy was haphazard and inconsistent, leading to significant tensions between housestaff and programs, which could have been avoided.
We have heard the same “slippery slope” narrative regarding internal moonlighting from several people in administration – presumably with the concern that this is a “slippery slope” towards housestaff wanting to be paid fair wages for their labor.
Parental leave
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Advocated for creation of national leading parental/caregiver leave policy replacing current “New Parent Leave” (5 paid days), utilizing momentum from new ACGME requirements (effective July 2022 mandating 6 weeks of paid leave) and Stanford’s Chief Wellness Officer | – “We are in compliance already”, despite being presented with evidence of non-compliance with ACGME requirements – “HR is undergoing transition” – “You just got retirement benefits” (???) |
We discussed parental leave starting in October, with concerns that Stanford only offers 5 days of paid parental leave. This is not only incredibly insufficient, but out of step with our peer institutions (UCSF/UCLA offer 4 weeks paid, U Michigan offers 6 weeks paid), and will not be in compliance with soon-to-be put into effect ACGME policies requiring institutions to offer 6 weeks of paid parental and caregiver leave. Stanford requires the parent to combine CA disability/paid family leave (PFL) (depending on your income PFL pay is about 60-70% of the wages earned in the 5-18 months before the claim start date), unused sick leave, and vacation to meet this requirement.
- Parents who are new hires and have not previously worked in the state of CA may not have sufficient earnings to qualify for PFL pay. They must use up all 4 weeks of sick leave and a week of vacation to meet the 6 week requirement.
- Non-birthing parents who cannot use sick leave would only get 3 weeks max, if they used 2 weeks of vacation.
Similarly, pay during caregiver leave is dependent upon eligibility for a PFL benefit amount, which you would have to supplement with 2 weeks of vacation pay. Even here, that only provides a maximum of 5 weeks of caregiver leave at 100% salary.
Despite presenting these flaws, the response we received was “Our legal team has reviewed it and we are in compliance”. We are absolutely not in compliance. Appeals to Stanford to want to be on the most progressive and leading edge of housestaff wellness (given that we have the country’s first Chief Wellness Officer) by implementing humane parental leave policies were unsuccessful.
These conversations additionally took place shortly after retirement benefits were announced – we were treated as greedy and ungrateful for asking for even more benefits, after just having received retirement benefits which are 40% of what other SHC employees receive.
Disability inclusion
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Created resource to help housestaff navigate the accommodations process, and created educational materials for program directors to help support housestaff with disability and chronic illness | – Minimal and delayed responses filtered through HR – Resource has still not been posted on GME websites despite being ready for months (October 2021) |
To put it bluntly, Stanford Health Care has an absolutely disgraceful track record of how they treat housestaff with disabilities. (People with short-term disabilities (like breaking a leg or recovering from ACL surgery) are absolutely affected by these harmful policies as well.) In addition to HR seemingly having no knowledge of what a resident’s job actually entails, the process of obtaining accommodations (like handicapped parking) is painfully slow, overburdened with unnecessary paperwork, and is harmful.
- There are no free options for handicapped parking near 500P. The California Vehicle Code requires that people with a handicap parking placard be allowed to park for free. The hospital’s response to a resident’s request for parking (a legally protected accommodation for their disability) was that because the garages are privately owned by Stanford Health Care, they are exempt from California Vehicle Code regarding the provision of accessible handicapped parking at no additional cost. This resident has to pay $720/year to come to work.
- The entire 4th floor GME space (GME office, call rooms, gym) is not handicap-accessible and requires users to go up at least one flight of stairs.
- There is only one ADA-accessible, non-reserved call room in the entire hospital. GME will not disclose the location of this room unless an individual files paperwork with HR, and response times are on the order of weeks.
GMEC reps have advocated (along with SMADIE, the wider Stanford Medicine disability advocacy group) for SHC/GME to take these concerns seriously and improve disability inclusion. However every single interaction has taken place under the tight grip of HR – from meetings that were delayed multiple months, to a simple presentation to program directors on how they can support their trainees with disabilities (HR reviewed and made edits to our slides).
Even simple requests (like a page on the GME website outlining the appropriate steps to take to seek accommodations) have not been acted upon, despite the content of this webpage being finalized for the last several months.
Space
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Space committee housestaff representatives solicited feedback regarding pressing issues (lack of workrooms, call rooms, and handicap-accessible spaces) in order to present at the bimonthly meeting | – Canceled the next meeting because there was “nothing to talk about” |
When 500P was being designed, a committee with resident representation signed off on a version that included 36 call rooms. Only 6 made it in to the final building. The lack of call rooms and workrooms has led to housestaff sleeping in their cars or on patient stretchers at night; ICU team members needing to sleep a 15 minute walk away from the ICU, and tensions between teams who are competing for limited workspace. When we finally got housestaff representation on the hospital committee for space allocation, we were excited – we held a town hall to solicit feedback on the most pressing issues to present to the committee to try and find solutions to some of them. We even specifically added a housestaff representative to speak about the need for better accessibility for employees with disabilities and the lack of handicapped/wheelchair accessible call rooms. The meeting these topics were supposed to be presented at was canceled, “as there are no topics for the committee’s review and awareness”.
The housestaff representatives also recognized that this particular committee did not have input into the overall renovations and could only re-allocate space that had already been built. Requests to include housestaff voice in different committees which had oversight on the design of new space were treated as inappropriate and “going over people’s heads”. “The residents on [space] committee will have the opportunity to provide commentary…That is what I support”.
Wellness
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Requested funding for happy hours and social events to boost morale and camaraderie (at the beginning of the year were told there was $250,000 available) | – “There’s no money for that” – “There will be one day of free breakfast next month” – “We already gave out $10 coffee gift cards” |
At our on-boarding meeting in August, GME said there is a pool of “a couple of hundred thousand dollars” to use for wellness funding, and asked us to help spend it.
Requests to use this to sponsor happy hours (e.g. Rose & Crown) were denied – first citing COVID, and then once COVID restrictions on social events were lifted, we were told that there were no funds, as the night-time meals cost $5k/week (though this is left-over food from the cafeteria) and they were running over budget for our $10/12 hour shift (pre-tax) meal stipends.
A GME program manager reached out regarding concerns that housestaff feel isolated and have a lack of community, and wanted to form online “interest groups”. I suggested facilitating these interest groups with in-person events funded by the GME. The reply was that hospital leadership had already walked the halls giving out $10 coffee gift cards, and that there would be one day of free breakfast in the near future.
The GME Wellness Committee – proposed in spring 2021 by the GME Engagement Committee – was formalized only in January 2022, and has yet to meet.
Meals
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| GMEC housestaff representative efforts | Response from GME/hospital leadership |
| Requested reversal of the unannounced retroactive lump-sum taxing of meal stipends; Worked with Chief Resident Council to propose a new and more equitable meal plan | – Did repay the lump-sum tax, but have not increased the meal stipend to account for the new tax moving forward – Postponed further meetings to discuss the meal plan due to GME wanting to first survey departments about how much time housestaff spend at SHC (this survey has still not been sent out after several months) |
Background: the meal stipend at SHC is $10 to your paycheck for every 12 hour shift logged in Medhub on an inpatient rotation. This was previously untaxed, but this year Payroll realized that according to IRS regulations, it should have been taxed. The response was to take a lump sum retroactive tax for the entire year out of people’s paychecks without notice, resulting in up to $1000 missing from their paycheck and potentially affecting the ability to pay rent/bills. I can only assume they thought our bank accounts are so well padded that we wouldn’t notice? I would say that this is the only GMEC issue we raised this year that received a semi-satisfactory response, after many individuals raised concerns, but it is no coincidence that this action may have constituted wage theft (docking pay due to a mistake by the employer) and would have had legal ramifications. The lump sum was returned and an apology was issued. However, our meal stipend now remains taxed (effectively $6.50/12 hour shift, which doesn’t really cover any meal from the cafeteria), without an increase in the base amount to address this.
Following this, we and CRC met with GME to discuss changing the meal stipend system. One goal is to de-link it from the 12 hour inpatient shift requirement (as folks working < 12 hours and on outpatient rotations still deserve to eat). However, efforts to schedule a subsequent meeting to discuss our proposal (e.g. $75/week post-tax, on par with peer institutions) in December 2021 were canceled until further notice, citing the need for GME to gather more data (the proposed survey has still not been sent out).
Quotable quotes…
[after several emails requesting feedback from all 5 GMEC reps about whether a faculty member could send a short survey to the housestaff email list] – “This is the type of thing that you are good for.”
[regarding the housestaff at large] – “You know, the common people.”
[regarding discussions on fertility benefits] – “We don’t need your support/you don’t need to be at the table for this right now”
