Dr. Lee Sharma welcomes Tarun Ramesh, a graduating Harvard medical student and incoming Mass General resident, to discuss his NEJM-published work on physician unionization, the ethics of medical strikes, and how global healthcare systems can inform better workforce policy in the U.S.
What happens when a future physician confronts the past, present, and future of medical labor rights? In this thoughtful and timely conversation, Dr. Lee Sharma sits down with Dr. Tarun Ramesh, soon to begin his residency at Massachusetts General Hospital, to unpack his NEJM article, “Striking a Balance,” which examines the ethics, history, and global impact of physician strikes.
Together, they explore why doctors are increasingly turning to unions—from South Korea’s historic 2024 resident strike to post-pandemic organizing in Boston. Dr. Ramesh offers compelling insights on how burnout, corporatization, and lack of clinician voice are fueling a new era of collective action. With historical context and global comparisons, he helps frame a vision for balanced policies that prioritize both physician wellbeing and patient safety.
From the risks of punitive backlash to the policy promise of minimum staffing laws and advanced notice provisions, this episode is a masterclass in labor advocacy, ethics, and modern medical leadership.
Three Actionable Takeaways:
About the Show:
Behind every procedure, every patient encounter, lies an untold story of conflict and negotiation. Scalpel and Sword, hosted by Dr. Lee Sharma—physician, mediator, and guide—invites listeners into the unseen battles and breakthroughs of modern medicine. With real conversations, human stories, and practical tools, this podcast empowers physicians to reclaim their voices, sharpen their skills, and wield their healing power with both precision and purpose.
About the Guest:
Dr. Tarun Ramesh is a medical student at Harvard and incoming internal medicine resident at Massachusetts General Hospital. His article “Striking a Balance” was published in the New England Journal of Medicine, exploring physician collective bargaining through a global lens. His academic work centers on health economics, workforce policy, and the evolving dynamics of clinician labor. He has deep research experience in hospital financial models, and his advocacy work reflects a deep commitment to clinician wellbeing and health system transformation.
Twitter: @TarunR99
LinkedIn: https://www.linkedin.com/in/tarun-ramesh/
About the Host:
Dr. Lee Sharma is a gynecologist based in Auburn, AL, with over 30 years of clinical experience. She holds a Master’s in Conflict Resolution and is passionate about helping colleagues navigate workplace challenges and thrive through open conversations and practical tools.
Connect: scalpelandsword@gmail.com
Speaker: [00:00:00] Hello, my peaceful warriors. Welcome to Scalpel and Sword. I'm your host, Dr. Lee Sharma, physician and conflict analyst, and I am delighted to have on the podcast today, and I'm gonna go ahead and say this, even though he's a week away from graduating, Dr. Tarun Ramesh, he is a medical student at Harvard. He is about to graduate and start his internal medicine residency at Harvard, at Mass General.
We are so excited to have him on the podcast. We were laughing early before. ~He is an, ~he is an Atlanta native and he went to University of Georgia for undergraduate. ~Um,~ I'm an Auburn fan, ~so,~ and my daughter went to University of Alabama, so we have a nice little SEC family going here, which is cool. Dr.
Ramesh,
Speaker 2: welcome to the podcast. Happy to be here Lee. I'm so excited to be here and ~you know,~
Speaker: go. SEC but go dogs mostly. ~Uh,~ you know what? War Eagle? Well, I'll tell you what, we'll leave it at that because we could be here all day doing that. Just talking to smack. So we'll move on. So during, the reason I reached out to you is, ~um,~ I was doing some [00:01:00] research looking at health policy specifically with regards to vision strikes, and I came across your wonderful publication that was in the January, new England Journal of Medicine.
~Um. ~And the title of the article Striking A Balance, advancing Physician Collective Bargaining Rights and Patient Protections. What prompted you to write
Speaker 2: and publish this article? I. ~You know,~ I think it really started with the South Korea strikes. Some of my co-authors, Dr. How Yu and, ~uh,~ Dr. ~Uh,~ Carmel, Secher have a lot of deep expertise in this.
Dr. Yu's work on the physician workforce ~has, ~has really been, ~um,~ extraordinary. And he really pointed out to what's going on in South Korea as being very unique at this point. We had ~kind of~ started researching this article maybe in June of 2024. Mm-hmm. And at that point, ~uh,~ south Korean. Medical residents had been on strike for about three months since about February, and so it's quite interesting to see, ~you know, how long, ~what a substantial duration of time that had been and what that means in this whole [00:02:00] moment, especially when we see an increase of unionization amongst residents and
Speaker: trainees in the United States as well.
Wow. This whole phenomenon in South Korea is so fascinating, especially when you look at the impetus for the strike. What was the reason these residents went on strike in February
Speaker 2: of 24? Definitely. So for some background, the South Korean strikes started when there was a bill passed or ~kind of~ discussed in the South Korean legislature about increasing ~the number, ~the number of medical school, ~uh, ~slots and increasing the caps for enrollment.
And ~kind of~ on the surface level, from my understanding was that seems like a very good idea, ~you know,~ to augment, ~uh, ~the South Korean workforce, which amongst. High income countries has one of the lowest physician density populations. The United States is also ~kind of~ in that, ~uh, ~mix of, ~you know, ~low physician density countries, but despite, ~you know, the, ~that increase ~in, ~in medical school enrollment residents and trainees, as well as some of the older physicians in the workforce felt that the government was not being [00:03:00] really responsive.
To the reasons why they felt that burnout was so high, why they felt that younger physicians were leaving the occupation and, ~uh, ~not necessarily working, ~uh, ~in private practice, not necessarily working in large academic hospitals. And all of these contributing factors ~kind of~ led to this desire to make some change.
And I think that for the South Korean residents and trainees, this is the way that they felt was ~the. ~The most active,
Speaker: ~um, kind of voice for change. ~Wow. And it's so interesting, I think when you start looking at ~like~ so many challenges they have in South Korea, ~um,~ not just the physician to patient ratio, which what you said is one of the lowest, but also the work hours.
I mean, Korean residents work 36 hours at a stretch, and that's. Definitely different than what our 24 hour restrictions are. ~Um,~ they also have an extremely high rate of malpractice suits, which I think is just so crazy. Like one in three South Korean physicians will be sued at some point in a five-year window.
I mean, it's really, there are so many stressors that are going on. ~Um,~ I think this was interesting too [00:04:00] because as you mentioned, this was a policy that was being discussed at the governmental level. They were trying to improve a workforce, but also trying to improve a distribution of specialties. They were trying to get more essential workers into some of these roles, and so this idea of trying to, ~well,~ we're just gonna admit more people and we're gonna see if we can fix this problem.
~Um,~ when the strike was initiated, there was also some significant
Speaker 2: backlash from the government, right.~ There was ~the government ~gave, that ~gave the residents and trainees, ~you know, uh, a, ~a multi-day notice, maybe a 15 or 30 day notice, that they would start suspending licenses, that there could be punitive action taken from the state, uh, from the governmental medical boards.
~Um, ~and even ~per ~perhaps criminal charges, ~um, ~be brought upon some of those resident and trainees. And let's be clear, while I think a lot of the organization began at the resident trainee level, you saw attending physicians ~kind of ~join in, ~um, ~whether they, ~you know, ~were fighting for the same reason. It's unclear, but it's clear that there was some kind of collective action occurring [00:05:00] amongst physicians in South Korea.
And a lack of forum for them to really voice ~their dis ~their displeasure, their concerns
Speaker: about the government's actions. Mm-hmm. And the government, as I think that strike grew, also began to try to attack the residents and the attending physicians in the media. They were trying to cast them as bad guys.
These people don't care about you as patients. They're just trying to make money and. Unfortunately, I think that also put a lot of the onus on the striking health professionals because they were trying to make them look so punitive in the public. I think that was really hard. But you also, it's really cool 'cause you're talking about that this is not the only country, of course by far, this has taken place in, we ~see, ~have seen strikes, ~physicians, ~resident physicians all over the country and all over the world.
And you mentioned the strikes in the UK as well, that ~you know,~ the resident physicians in the UK went on strike ~also striking. ~Not only reimbursement, but also
Speaker 2: work hour protections. Exactly. And I think, ~you know, to your, ~to your first point, there was ~a lot, ~a lot of [00:06:00] public outcry about the South Korean residents going on strike, ~which, ~which really, ~you know,~ makes us, and I think made me ~thought, ~think as a trainee really about the dual nature of physicians in these kind of organizations.
About ~your, you know, ~your call to duty, your duty to do no harm, as well as. Accepting that physician wellbeing is such a critical piece of this, and balancing those two, which is I think what this piece ~really,~ really tackles. But to your point about the United Kingdom. ~You know,~ in January, and the United Kingdom has had a history of kind of trainee strikes at a level that we don't necessarily see here ~in the, uh, ~in the United States.
In January in 2024, ~uh, ~medical residents went on strikes for about six days, which was the largest ~in the, ~at that point, ~at the national, um, ~in the National Health Services history. ~Mm-hmm. ~And that was because of poor compensation really at that foundation, ~uh, ~level trainees. So those are ~kind of~ trainees that are.
Going through residency very similar to here in the United States. And what I think is unique about, ~uh, ~those strikes in particular was, ~you know,~ this is not a kind of one-time thing. You see that [00:07:00] the United Kingdom has had ~very kind of ~decades of austerity. There's this wonderful piece in the New England Journal, ~uh, ~by Dr.
David Blumenthal that talks about the decades of austerity that have hit the United Kingdom, the lack of investment in the National Health Service, and what that means for physician compensation, physician pay, ~um,~ as well as access to care. You now see a lot of. Individuals in the United Kingdom seeking private care outside of the National Health Service, which a few
Speaker: decades ago was simply not the case.
Mm-hmm. ~It, ~it ~kind of~ speaks to the fact that a lot of these countries that need workforce, they need peoples taking care of the patients. Unfortunately, sometimes trainee physicians become. ~Sort of~ the easy available resource. ~Well,~ we can work them an extra few hours, we can pay them less, and we can actually get more care out of them.
And so as you're seeing more governments and especially government-led healthcare systems trying to capitalize on that, the resident workforce is suffering. So this becomes ~sort of a good. Not a, a kind ~of a natural next step to seeing them exercise their [00:08:00] voice and their power. It's like, this is not about, ~just, ~not that it's not good for us, it's not good for the patients either.
If you've been working for 36 hours at a stretch, do you really think you should be taking care of patients? And so I think you're seeing resident physicians speak up for that. You'd mentioned that I think you're starting to see a rise in this now, but this is actually not the first time. I think you've attempted to see organization, especially in this country.
~Um,~ but I think you're starting to see more of it now. ~Um,~ it's interesting because when you look back at ~like~ the a MA, ~you know,~ they started position for responsible negotiation back in 1999, ~um,~ which was supposed to be ~sort of~ under the N-L-N-L-R-A kind of the organizing body for physicians. But it went belly up five years later, ~um, ~in debt, about 3.6 million in debt.
Um. ~It sort of has,~ I think, declined. But now we're starting to see this sort of peak again. ~Um,~ why now? Why are we seeing this sort of rise in unions and why are we seeing physicians,
Speaker 2: especially residents starting to strike? Right, exactly. I think one of the earliest examples of unions in this country, ~I.~
~It ~is in the 1930s, [00:09:00] 1940s, ~um, ~in New York where there was ~like ~a membership ~of, of kind ~of New York, ~uh, ~city hospital residents that banded together, ~uh, ~at that point in time, ~which is, you know, quite some time ago, um, there were, I. ~Residents were expected, or house staff, ~uh, ~were expected to stay in the hospital, ~you know, ~throughout the day, throughout the night.
~Um, ~were not compensated because it was seen as ~kind of ~an extension of their medical school training, ~uh, ~for that next level. And so it was really in the thirties, forties. And then in, maybe in 1957 when, ~uh, ~house staff union first really emerged and began to say, Hey, ~you know. ~We're working, we are employees and ~kind of~ changing that mindset away from just being, ~you know, just ~an extension of medical school that we have a medical degree.
Mm-hmm. And we are now, ~you know,~ we are still trainees, but ~we're ~not ~necessarily ~just students anymore. ~And I think ~that's when things began to ~kind of ~change. There was a lot of discussion with the ~Amer, uh, ~American Medical Association at that point, and a lot ~of kind ~of unionization efforts throughout the country.
~Uh, ~were occurring. And then I think in,~ you know, as you kind of alluded to, in~ 1974, ~Congress began, uh, to, uh, ~Congress approved the Healthcare Amendments, ~uh, ~to the National Labor [00:10:00] Relations Act, which extended employees of nonprofit hospitals, the legal right to unionize and strike. ~So ~previously they had been ~kind of ~exempted from this.
So, you know, you could unionize ~if you. ~If you are at a kind of non-governmental for-profit hospital, but not for the nonprofit hospitals, which as we know are ~kind of~ the majority of hospitals here in the United States. And, ~uh,~ so you know, that really Congress allowed ~kind of~ that ~to, ~to occur. But the issue is that a lot of.
House staff were not necessarily covered by this because they were not necessarily seen as employees by the National Labor Relations Board and were ~kind of~ deemed as non-employees. And because of that ~re ~regard, ~you know, so that the, the what ~in essence what the ~kind of ~healthcare amendments allowed hospitals to be, or ~kind of~ how union efforts and hospitals look like, were that the nurses and kind of other employees were able to unionize.
Uh, but physicians. Who were in kind of supervisory roles were unable to, and the house staff were unable to until about 1999, which is when the National Labor Relations [00:11:00] Board ~kind of~ changed. Its, ~its, uh, ~ruling to allow house staff to be included ~in this, ~in this interpretation and allowed house staff to
Speaker: formally unionize.
And I think since then, especially. Post pandemic, you're starting to see a lot more resident physicians. I think one of the things the pandemic did was expose a lot of those stressors on house staff, you know, in terms of work hours, in terms of reimbursement, in terms of what they've been asked to do. And then after the pandemic.
Those stressors got magnified. And I think, ~you know,~ now you're starting to see people say, okay, I'm finding a voice and this is how I'm going to make myself known. And collectively we can actually help ourselves get ~the,~ what we really should be getting for our job as house staff. ~Um,~ you mentioned in, ~in~ your paper, ~um.~
Something about Hurst, about Elmhurst Hospital ~in,~ in the Bronx. And I think that was one of, to me, the first big strike that I remember. ~Um,~ because they were pound part of that Mount Sinai system and post pandemic, I ~mean,~ they were [00:12:00] ground zero. So much of what I was doing as a clinician was based on what they were doing at that hospital, and yet they were getting paid, I think it was seven or 8% less than their colleagues in Manhattan.
And. When they went on strike, one of the things that they actually did that I loved is they lobbied for a voice on administrative staff. ~It's like,~ we just don't want more money or more days off. We actually want a voice in controlling policy and how patients get cared for in terms of ratios, in terms of staffing.
We wanna voice in that. I feel like that's something too, that we're gonna see more of that instead of having the public perception, like in Korea, they're trying to say, oh, these are people who want more money. It's like, no, that's not what this is about. This is about good patient care and having appropriate staffing, reimbursed staffing, and house officers that are cared for as part of that.
You have done all this work as a medical student and now you're rolling into a role as a resident. How has this experience in doing this research shaped what [00:13:00] your expectations
Speaker 2: are going into training? Right. Well, you know, I think this brings up a really excellent point, ~right when I am, you know, ~as we were kind of working on this, Boston has seen a lot of unionization in ~the kind of ~the last few years amongst its house staff, mass General Brigham, which is the largest ~employer.~
Healthcare employer in the state of Boston has its house staff unionized, ~and we use unionized, uh, ~two years ago ~and has just ~tentatively reached a deal, ~um, to, uh, ~to ~kind of ~increase, I think it was about a two or 2.5% increase in the salaries for residents and trainees, ~uh, ~which is remarkable. ~Mm-hmm.~
~That this is, that, you know, um, ~that the hospital administration ~is, ~is working with residents to come together and have that collective voice, ~because I think. You're exactly right. ~I think in the early parts of this pandemic, there was a real fear amongst residents and trainees that there was not enough personal protective equipment going around, that they were working past duty hours and that this was all ~kind of straining their, their, their, you know, ~straining not only their wellbeing, but the wellbeing of patients and those who ~that ~they care for.
~And ~I think that was very concerning. ~And ~so ~that's why I think this first part of this trend, uh. ~Hopefully that~ the, the, ~the unionization efforts now can ~kind of ~address that part of the trend, ~um, ~with,~ you know, ~bringing some voice into
Speaker: administrative decision making. [00:14:00] One of the things you talk about in this paper is that.
When you look at other countries that have experienced strikes, ~you know,~ Korea, France, uk, that these are all countries that the United States can learn from in terms of establishing policy, ~and ~part of establishing that policy to me in reading your paper is. Knowing that there are gonna be more strikes.
It's not a question of, oh, ~well~ we've had some strikes. We brought attention to the issue. It's over. Oh, ~no, no, no,~ no. This is something that's going to be an ongoing question, and balancing the idea of we need to have physicians have a voice, especially collectively, but we also need to make sure patients are being taken care of.
What do those policy
Speaker 2: points look like? No, exactly. I think that really draws at this entire point of this piece is ~that kind of dual, ~that dual purpose that physicians. Serve both as employees, but also as public servants who ~you know, ~the greater population. ~We, you know, ~some countries have had a much larger and more robust history of physician strike behavior.
Countries like France [00:15:00] and the United Kingdom, ~and they ~have some ~really ~great. Things that have come out of them. Policy ideas, things like minimum staffing levels to ~make ~sure that employers and employees establish ~kind of ~a minimum staffing level to allow ~cont ~continuity of care to make sure ~that you know, patient harm, ~that there is, ~you know, ~no effect ~on, ~on patient health and wellbeing.
Other things include a 10 day notice for strikes against healthcare institutions that allows ~again. ~Employers and employees and the house staff can ~kind of ~work together, ~uh, ~make arrangements to safeguard patient care and ~kind of ~adding that minimum level of service will ensure that ~physicians', uh, ~physician's, ethical duty to serve their patients can ~also ~be balanced with ~their, um.~
Their duty to themselves ~as well, as well as kind of ~protect against potential allegations of patient abandonment by ~kind of ~state medical boards. There are also things that some countries have done that I think we can veer away from. South ~Korea law ~allowed the penalization, including the suspension of medical licenses or incarceration of physicians who refuse the government return to work orders.
And they ~kind of~ backtracked on that, ~um,~ after potentially, ~you know,~ thinking about using ~these, ~these laws due to [00:16:00] public outcry. But that kind of punitive action just further damages that employer employee relationship, ~you know,~ further compromises working conditions, further exacerbate burnout and job dissatisfaction.
And so I think we can take protections through state medical boards, ~uh, ~to make sure that legal charges associated with union activities don't affect licensure. ~Um, ~making sure that there's not backlash against trainees, ~um, ~as well because, ~you know,~ of course as we know that trainees are very vulnerable in their career, ~uh, ~relative to other physicians, ~uh, ~because of their, in the process of their board certification, as well as I think that we need to consider that unionization.
~Is ~while, ~you know, ~allowed through the NLRB for house staff and residents ~is, ~is not really the same for supervising physicians. So the NLRB ~kind of ~excluded physicians or attending physicians who are in charge of trainees, ~uh, from, ~from being able to unionize. ~And I think. ~We see this trend with the pandemic of course, but there's also this kind of underlying current that we can talk [00:17:00] about further, ~you know, ~through the financialization of American healthcare system and that physicians are really just not in private practice anymore.
~They're, you know, ~you see ~a subset, ~a much larger amount getting acquired, whether through hospital practices. ~I think ~about 33% of physicians were, ~um, in a, ~in a ~kind of ~non-hospital, ~uh, ~based practice in 2012, and that's risen to about 80% ~in, ~in 2020. So there's a lot of these trends that are occurring that with the pandemic kind of affects how physicians interact with their employer.
That's more than just the house staff, but ~it's ~also includes physicians as employees in general, regardless of
Speaker: whether they're supervising, attending or not. Absolutely, and ~I, ~I totally see as we see the shift to more employed physicians, ~you know,~ shifting more at ~eight, you know, ~80% or 20% of us ~are, ~are considered independent.
But that was always ~sort of~ a roadblock to unionization because if you were an independent physician, you tried to unionize, there was all this idea that we could be antitrust, you could [00:18:00] price fix, and that was something that, ~you know,~ from an economic standpoint was not gonna be permitted. So now that you're seeing more employees.
Physicians, you are going to see more of those unions. But also too, you are running into more of these, ~um,~ problems with hospitals that have these physicians that are pushing them to work longer hours that are not enforcing appropriate staffing ratios. And so this is the only way they can talk. So ~I'm gonna, ~I'm gonna throw back a little bit because I'm significantly older than you are.
So I trained back in the nineties. ~Um,~ my parents were physicians who trained in the sixties, so I remember when my parents literally lived a hundred yards from the hospital. They were truly resident physicians. Like when dad was on call, he literally could walk the hundred yards as a general surgeon to his hospital.
Mom was pathologist. Didn't happen as much for her, but I remember that. I'm also old enough to remember what life was like before work hour restrictions. ~Um,~ when I was a resident, we didn't have that, so it was not unusual for us to [00:19:00] pull a 30 hour. It didn't happen very often, but it did happen. ~I. ~It was very interesting watching ~sort of~ that culture shift when A-C-G-M-E introduced the work hour restrictions, and there were definitely some doctors of my generation who said, I don't know why we're doing this.
We didn't do it. Why are they doing it? And yet now we're seeing countries, whole countries of physicians that are going on strike because they don't have something. We have, ~they, ~these residents are being pushed in a way that we know is not good for them, but it's also not good for their patients. So do you feel like maybe having some of these policies already in place, maybe part of the reason why we haven't seen these large
Speaker 2: ~scale strikes in the United States?~
I totally agree. I think in some ways the A-C-H-U-M-E has really protected residents. Wellbeing. I think they can go further, of course, but I also think that the landscape of American healthcare has changed a lot in the last two decades. ~You know,~ you see ~the, like ~the proliferation of the electronic medical record, you see the passage of the Affordable Care Act.
Now, ~you know, in, ~in Boston, for example, and I'm sure across the country [00:20:00] since COVID, ~you see~ huge backups in ~kind of ~nursing homes that are ~kind of ~creeping into the hospital. It looks like there's a lot of hospital beds, ~um, kind of over overstuffed, ~overfilled, ~uh, ~a lot of the hospitals are at capacity and because of that, the lists are, ~you know, ~longer perhaps.
~Um, ~and I think that the federal government is taking steps to ~kind of. ~Deal with this. They've increased residency slots, ~uh, ~by a thousand over ~kind of ~a five year period, ~uh, ~predominantly in ~kind of ~rural and underserved areas. But there are things that we can still do to support the workforce. And I do ~see, ~think that the level of corporatization and financialization that we see ~the ~in the United States is perhaps.
Greater than the corporatization that we're seeing in other countries so far. ~Right. ~And I do think that unionization offers a voice, a distinct voice, ~um, in that, ~especially when you see, ~you know, bands ~like physician ownership of ~hospital ~hospitals, ~uh, ~things like that where we're not really seeing physician voices necessarily.
Making decisions at a business level, at a like administrative level ~that ho ~that, ~you know,~ hospitals are okay with. And [00:21:00] so I think unionization efforts is one way to ~kind of~ bring that voice mm-hmm. Into that discussion. On the other hand, I think ~I. ~There are some drawbacks. There's potentially higher costs for healthcare, potentially loss of autonomy for individual physicians, as well as maybe inequities between kind of physicians who are independent or in private practice and those who are employed.
~Uh, ~there are also ~alter ~alternatives to physician unions as well, including medical staff committees. And that allows you to have kind of a voice in hospital leadership without necessarily being a formal union. ~Um,~ and having the kind of ~the, ~the protections and rights that kind of come with that as well.
And so all to say is I think that there are, you know, this is a response a very. ~You know,~ clear response that physicians do need more voice in kind of policymaking in hospital administration to protect patients as well
Speaker: as protect their own wellbeing. One of the things that you talked about, I loved in the [00:22:00] article that you just mentioned was ~that the fact ~that there's not just one avenue to physicians to make their opinions and make their voices known, it doesn't have to be just unionization.
It can be getting involved in the hospital. Through medical executive positions, ~um, ~even doing organized medicine, ~a ~MA specialty organizations, those are ways you can help to develop policy that can influence the way that healthcare is delivered in our country. So there's a lot of different ways to do that.
~Um, ~one of the things that I so enjoy looking at your CV and look at the work that you've done, you've done a lot of work on economics in hospitals and how hospitals work from an economic standpoint. I feel like you've spent a lot of time looking at that. ~Um. ~A lot of the countries you talk about in the article, uk, France, South Korea, those are all nationalized state run healthcare systems.
So the fact that we don't have a state run insurance program or a federal uniform health system that we have independent hospitals, does that make it more likely that we're gonna see more union activity? Because now that you're seeing sort of these different hospital [00:23:00] systems being run
Speaker 2: so differently.
I think perhaps, ~um,~ I don't know if that is necessarily true. ~Um,~ I think ~in,~ in some ways, ~you know,~ there are a lot of heterogeneity in how hospital administrations run their hospitals and in some ways residents may want to unionize. For example, I think the New York Presbyterian, ~um,~ hospitals that include Cornell and Columbia have not unionized and you haven't really seen unionization, ~um,~ in Georgia as well.
And. ~Do, ~do I necessarily think that hospitals that have unions are doing a worse job for their residents? I don't necessarily think so. I do think that perhaps there's a lack of inclusion of resident voices. ~Um,~ but I also think that all of this just speaks to a broader frustration with how hospital leadership ~kind of~ have dealt with kind of trainee voices.
And ~I, ~I think it's hard, ~uh, for, uh, for,~ in a lot of ways for us to kind of. Get a better sense of what this means for patients long term. Because on one hand, ~you know,~ obviously if physicians ~are,~ are [00:24:00] striking, you're gonna see delays in care and in the US you know, I try to get ~a,~ a dermatology appointment and ~it takes,~ it takes so long ~to, ~to get one and.
You know, the research that we've seen ~is,~ is very limited in the United States, and I think that is a key part of this, right? We just don't know what physician strikes look like. All of the research has been ~kind of~ done in the
Speaker: seventies when maybe this was
Speaker 2: more common. ~Mm-hmm. ~And from other countries.
Our hope is. Once we have a sense of what does this look like in the next few years, ~um, kind of~ can we look at the strikes that have occurred in this two year period and see what the implications
Speaker: of that are for patient care. Yep. I, it's gonna be as we get more and more unions and as we're seeing more and more strikes, I think we're going to have, like you said, absolutely more data to see the ripple effect of what has occurred as a result of those strikes.
And it's not just ripple effect of what's happening with patients, it's also ripple effect of what's happening with clinicians. ~Um,~ if clinicians are striking because of lack of resources, because of [00:25:00] burnout, because of lack of reimbursement, because of work hours. Are those things improving after that strike has occurred?
Are these things that we're actually seeing get better? And as we get more and more of that data, I think we'll see more and more one of two things ~or,~ or possibly two things. We'll see those things get better because they'll have to be addressed. But we'll also see larger healthcare bodies making policies like, okay, ~well~ this is an overarching problem.
Burnout is an issue. Moral injury is an issue. How can we address this? And one of the things that I saw in Elmhurst that I was very impressed with is, I think on some level, the hospital did start to take responsibility for what those residents had gone through. They actually said, okay, we have not addressed the fact that we were complicit in the struggles you've had.
It's not just about paying you more money, it's about giving you more power. And ~to, and~ strikes are almost all, and tell me what you think. Strikes are so much about power. This is what we are [00:26:00] doing to reclaim a voice. So ~I, I, ~I agree with you. I think it's gonna be really cool to see what happens in 10 or 15 years when we see ~the be ~what has happened as a result of those strikes.
~Um. ~I also really do love ~that the fact ~that you are bringing the government into this problem, it's not just a hospital problem. So going forward, I hope you're gonna ~be, ~continue to be active as a resident. You've been so active already as a medical student in terms of your publications and also your research.
So let's just say for example, you are sitting down with ~a. Con, ~a congressional committee, and they're asking you, okay, Dr. Ramesh, we really wanna know, what policies do you think that we can set to improve resident workforce conditions and patient care in the next 10 years? You have a golden ticket.
Speaker 2: What would you say to them?
One of the things I think about is this, you know, with the Affordable Care Act ban on physician owned hospitals. I think that's a very, ~you know,~ interesting. Thing that occurred due to ~a lot,~ a lot of [00:27:00] like intense lobbying from the American Hospital Association as well as ~kind of~ non-profits and for-profit hospitals, ~um,~ where we're ~kind of~ seeing a decrease in kind of the physician voice in some of these aspects.
And in a world where private equity, where you see ~kind of ~large for-profit hospital chains ~kind of~ gobble up smaller independent practices, you're losing that physician voice. And I think that's what this whole unionization effort. ~Um,~ as well as in the response to the pandemic is really talking about bringing back collective voice of healthcare to physicians and their patients rather than ~to, you know,~ someone ~in some, some, um,~ in some firm somewhere.
Right? And I think that physician, ~ho physician, uh, ~owned hospital ban should be one of the first things to ~kind of~ go from that aspect. Not only would ~we,~ we be introducing a potentially more competitive, ~um.~ Kind of facility in place. ~A more ~another way of ownership that can bring some competition to a heavily concentrated healthcare markets.
But ~we're also a lot, ~we're also kind of symbolizing this idea that we're valuing. Physician voice and ~uh, ~physician kind of interests and ~their kind of, ~their relationship with a [00:28:00] patient at a very fundamental policy level that I think is missing from this conversation. Another thing is thinking about how we kind of financing graduate medical education now, which is through Medicare, and what you see is actually one of the largest graduate medical education.
Facilities is not a large hospital, it's HCA, which is a for-profit hospital chain. And you see that there's, you know, clear financial incentives to be training residents. And why is that? Because they make your hospital money. They, ~you know, they're, they're, you know,~ we're taking care of large patient volumes.
Doing, you know, significant amount of hours that at the end of the day, um, advanced practice practitioners are just not preaching or perhaps that they don't have the training enough to do. And so that's ~a,~ a very delicate balance to, ~to~ hold as well. Right. How are we incentivizing graduate medical education to be the best for trainees, uh, rather than be necessarily the best for a
Speaker: large for-profit chain?
Absolutely. Wow. ~I. ~I think ~one of, and~ when you talk about this ban on physician owned hospitals [00:29:00] and you look at the research you did in South Korea, that was one of the biggest things that stood out to me was they specifically did not include clinician voices in making this policy. And if you're blocking physicians from having input on patient care, it's what we do.
We know we're in this world, you are depriving yourself of a really huge resource. And so I think that's such a great point. Um, and I hope you know the points that you're talking about, I think become really good lobbying points for us working in healthcare policy that we can continue to push and advance because you're right, it's gonna be your voice.
People like you coming into the profession, which gives me tremendous hope. Um, watching people like you come into the profession just makes me so happy because~ it,~ it's just going to enhance the care of patients and it's just an honor to have people like you as colleague. And ~it's, ~it's, it just brings me a lot of joy.
But I also think that. We are going to use your thought [00:30:00] leadership to improve patient care, not just for the patients, but also for the clinicians that are in the system. I think so many people are gonna benefit from the work that you've done. Um, if people want to reach out to you and have questions
Speaker 2: about your article, how can they reach you?
Of course. Uh, my Twitter handles torun R 99. Happy to connect with anyone. And I do want to give, ~you know,~ the work that I've done is obviously not in a silo. It's really built upon. The physicians and the trainees and you know, the nurses and employees of these hospitals, as well as the patients that have kind of advocated for physician wellbeing, ~um, you know, for, ~for decades.
And I think it's their kind of leadership, the activists, uh, and Mass General Brigham, who worked to unionize their hospitals, the residents. And ~I know, I, ~I remember being ~a, ~a medical student on rotation there. It was very controversial. Time amongst the residents, but it was really wonderful to kind of see them band together.
And so the residents at that time, I think did such a wonderful job and it was very encouraging, ~uh, ~to see that comradery and that spirit of medicine.
Speaker: Um, and it's a beautiful thing to [00:31:00] witness. Wow. Absolutely. Dr. ~Re ~Ramesh, thank you so much for being on the podcast. Your time has been just completely wonderful and all your work has been so valuable, so I look forward to see what you're gonna continue to do in the future.
All of you who've joined us on Scalpel and Soar, thank you so much for being with us, and until next time,
peaceful warriors be at peace.