Well-being, Learning Environment, and Mistreatment Among Unionized Versus Nonunionized Surgery Residents During the COVID-19 Pandemic.
Publication/Presentation Date
10-2-2026
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.
ISSN
1528-1140
Published In/Presented At
Hughes, A. J., Hunt, M. L., Ruedinger, B. M., Holmstrom, A. L., Eng, J. S., Chung, J. W., Hu, Y. Y., Nasca, T. J., & Bilimoria, K. Y. (2026). Well-being, Learning Environment, and Mistreatment Among Unionized Versus Nonunionized Surgery Residents During the COVID-19 Pandemic. Annals of surgery, 10.1097/SLA.0000000000007226. Advance online publication. https://doi.org/10.1097/SLA.0000000000007226
Disciplines
Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods
PubMedID
42823640
Department(s)
Administration and Leadership
Document Type
Article