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

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.