Researchers are increasingly finding that doctors can transmit prejudice under the guise of objective descriptions.

This story was published on Monday, September 26, 2022 in Kaiser Health News.

By Darius Tahir, Kaiser Health News.

David Confer, a bicyclist and an audio technician, told his doctor he "used to be Ph.D. level" during a 2019 appointment in Washington, D.C. Confer, then 50, was speaking figuratively: He was experiencing brain fog — a symptom of his liver problems. But did his doctor take him seriously? Now, after his death, Confer's partner, Cate Cohen, doesn't think so.

Confer, who was Black, had been diagnosed with non-Hodgkin lymphoma two years before. His prognosis was positive. But during chemotherapy, his symptoms — brain fog, vomiting, back pain — suggested trouble with his liver, and he was later diagnosed with cirrhosis. He died in 2020, unable to secure a transplant. Throughout, Cohen, now 45, felt her partner's clinicians didn't listen closely to him and had written him off.

That feeling crystallized once she read Confer's records. The doctor described Confer's fuzziness and then quoted his Ph.D. analogy. To Cohen, the language was dismissive, as if the doctor didn't take Confer at his word. It reflected, she thought, a belief that he was likely to be noncompliant with his care — that he was a bad candidate for a liver transplant and would waste the donated organ.

For its part, MedStar Georgetown, where Confer received care, declined to comment on specific cases. But spokesperson Lisa Clough said the medical center considers a variety of factors for transplantation, including "compliance with medical therapy, health of both individuals, blood type, comorbidities, ability to care for themselves and be stable, and post-transplant social support system." Not all potential recipients and donors meet those criteria, Clough said.

Doctors often send signals of their appraisals of patients' personas. Researchers are increasingly finding that doctors can transmit prejudice under the guise of objective descriptions. Clinicians who later read those purportedly objective descriptions can be misled and deliver substandard care.

Discrimination in healthcare is "the secret, or silent, poison that taints interactions between providers and patients before, during, after the medical encounter," said Dayna Bowen Matthew, dean of George Washington University's law school and an expert in civil rights law and disparities in healthcare.

Bias can be seen in the way doctors speak during rounds. Some patients, Matthew said, are described simply by their conditions. Others are characterized by terms that communicate more about their social status or character than their health and what's needed to address their symptoms. For example, a patient could be described as an "80-year-old nice Black gentleman." Doctors mention that patients look well-dressed or that someone is a laborer or homeless.

The stereotypes that can find their way into patients' records sometimes help determine the level of care patients receive. Are they spoken to as equals? Will they get the best, or merely the cheapest, treatment? Bias is "pervasive" and "causally related to inferior health outcomes, period," Matthew said.

Narrow or prejudiced thinking is simple to write down and easy to copy and paste over and over. Descriptions such as "difficult" and "disruptive" can become hard to escape. Once so labeled, patients can experience "downstream effects," said Dr. Hardeep Singh, an expert in misdiagnosis who works at the Michael E. DeBakey Veterans Affairs Medical Center in Houston. He estimates misdiagnosis affects 12 million patients a year.

Conveying bias can be as simple as a pair of quotation marks. One team of researchers found that Black patients, in particular, were quoted in their records more frequently than other patients when physicians were characterizing their symptoms or health issues. The quotation mark patterns detected by researchers could be a sign of disrespect, used to communicate irony or sarcasm to future clinical readers. Among the types of phrases the researchers spotlighted were colloquial language or statements made in Black or ethnic slang.

"Black patients may be subject to systematic bias in physicians' perceptions of their credibility," the authors of the paper wrote.

That's just one study in an incoming tide focused on the variations in the language that clinicians use to describe patients of different races and genders. In many ways, the research is just catching up to what patients and doctors knew already, that discrimination can be conveyed and furthered by partial accounts.

Confer's MedStar records, Cohen thought, were pockmarked with partial accounts — notes that included only a fraction of the full picture of his life and circumstances.

Cohen pointed to a write-up of a psychosocial evaluation, used to assess a patient's readiness for a transplant. The evaluation stated that Confer drank a 12-pack of beer and perhaps as much as a pint of whiskey daily. But Confer had quit drinking after starting chemotherapy and had been only a social drinker before, Cohen said. It was "wildly inaccurate," Cohen said.

"No matter what he did, that initial inaccurate description of the volume he consumed seemed to follow through his records," she said.

Physicians frequently see a harsh tone in referrals from other programs, said Dr. John Fung, a transplant doctor at the University of Chicago who advised Cohen but didn't review Confer's records. "They kind of blame the patient for things that happen, not really giving credit for circumstances," he said. But, he continued, those circumstances are important — looking beyond them, without bias, and at the patient himself or herself can result in successful transplants.

The History of One's Medical History

That doctors pass private judgments on their patients has been a source of nervous humor for years. In an episode of the sitcom "Seinfeld," Elaine Benes discovers that a doctor had condescendingly written that she was "difficult" in her file. When she asked about it, the doctor promised to erase it. But it was written in pen.

The jokes reflect long-standing conflicts between patients and doctors. In the 1970s, campaigners pushed doctors to open up records to patients and to use less stereotyping language about the people they treated.

Nevertheless, doctors' notes historically have had a "stilted vocabulary," said Dr. Leonor Fernandez, an internist and researcher at Beth Israel Deaconess Medical Center in Boston. Patients are often described as "denying" facts about their health, she said, as if they're not reliable narrators of their conditions.

One doubting doctor's judgment can alter the course of care for years. When she visited her doctor for kidney stones early in her life, "he was very dismissive about it," recalled Melina Oien, who now lives in Tacoma, Washington. Afterward, when she sought care in the military healthcare system, providers — whom Oien presumed had read her history — assumed that her complaints were psychosomatic and that she was seeking drugs.

"Every time I had an appointment in that system — there's that tone, that feel. It creates that sense of dread," she said. "You know the doctor has read the records and has formed an opinion of who you are, what you're looking for."

When Oien left military care in the 1990s, her paper records didn't follow her. Nor did those assumptions.

New Technology — Same Biases?

While Oien could leave her problems behind, the health system's shift to electronic medical records and the data-sharing it encourages can intensify misconceptions. It's easier than ever to maintain stale records, rife with false impressions or misreads, and to share or duplicate them with the click of a button.

"This thing perpetuates," Singh said. When his team reviewed records of misdiagnosed cases, he found them full of identical notes. "It gets copy-pasted without freshness of thinking," he said.

Research has found that misdiagnosis disproportionately happens to patients whom doctors have labeled as "difficult" in their electronic health record. Singh cited a pair of studies that presented hypothetical scenarios to doctors.

In the first study, participants reviewed two sets of notes, one in which the patient was described simply by her symptoms and a second in which descriptions of disruptive or difficult behaviors had been added. Diagnostic accuracy dropped with the difficult patients.

The second study assessed treatment decisions and found that medical students and residents were less likely to prescribe pain medications to patients whose records included stigmatizing language.

Digital records can also display prejudice in handy formats. A 2016 paper in JAMA discussed a small example: an unnamed digital record system that affixed an airplane logo to some patients to indicate that they were, in medical parlance, "frequent flyers." That's a pejorative term for patients who need plenty of care or are looking for medications.

But even as tech might amplify these problems, it can also expose them. Digitized medical records are easily shared — and not merely with fellow doctors, but also with patients.

Since the '90s, patients have had the right to request their records, and doctors' offices can charge only reasonable fees to cover the cost of clerical work. Penalties against practices or hospitals that failed to produce records were rarely assessed — at least until the Trump administration, when Roger Severino, previously known as a socially conservative champion of religious freedom, took the helm of the U.S. Department of Health and Human Services' Office for Civil Rights.

During Severino's tenure, the office assessed a spate of monetary fines against some practices. The complaints mostly came from higher-income people, Severino said, citing his own difficulties getting medical records. "I can only imagine how much harder it often is for people with less means and education," he said.

Patients can now read the notes — the doctors' descriptions of their conditions and treatments — because of 2016 legislation. The bill nationalized policies that had started earlier in the decade, in Boston, because of an organization called OpenNotes.

For most patients, most of the time, opening record notes has been beneficial. "By and large, patients wanted to have access to the notes," said Fernandez, who has helped study and roll out the program. "They felt more in control of their healthcare. They felt they understood things better." Studies suggest that open notes lead to increased compliance, as patients say they're more likely to take medicines.

Conflicts Ahead?

But there's also a darker side to opening records: if patients find something they don't like. Fernandez's research, focusing on some early hospital adopters, has found that slightly more than 1 in 10 patients report being offended by what they find in their notes.

And the wave of computer-driven research focusing on patterns of language has similarly found low but significant numbers of discriminatory descriptions in notes. A study published in the journal Health Affairs found negative descriptors in nearly 1 in 10 records. Another team found stigmatizing language in 2.5% of records.

Patients can also compare what happened in a visit with what was recorded. They can see what was really on doctors' minds.

Oien, who has become a patient advocate since moving on from the military healthcare system, recalled an incident in which a client fainted while getting a drug infusion — treatments for thin skin, low iron, esophageal tears, and gastrointestinal conditions — and needed to be taken to the emergency room. Afterward, the patient visited a cardiologist. The cardiologist, who hadn't seen her previously, was "very verbally professional," Oien said. But what he wrote in the note — a story based on her ER visit — was very different. "Ninety percent of the record was about her quote-unquote drug use," Oien said, noting that it's rare to see the connection between a false belief about a patient and the person's future care.

Spotting those contradictions will become easier now. "People are going to say, ‘The doc said what?'" predicted Singh.

But many patients — even ones with wealth and social standing — may be reluctant to talk to their doctors about errors or bias. Fernandez, the OpenNotes pioneer, didn't. After one visit, she saw a physical exam listed on her record when none had occurred.

"I did not raise that to that clinician. It's really hard to raise things like that," she said. "You're afraid they won't like you and won't take good care of you anymore."

Darius Tahir: DariusT@kff.org, @dariustahir

Genesis attributes its large margins to excellent management and says it needs the money to expand and modernize services while being less reliant on government funding.

DARLINGTON, S.C. — Just off the deserted town square, with its many boarded-up businesses, people lined up at the walk-up pharmacy window at Genesis Health Care, a federally funded clinic.

Drug sales provide the bulk of the revenue for Genesis, a nonprofit community health center treating about 11,000 mostly low-income patients in seven clinics across South Carolina.

Those sales helped Genesis record a $19 million surplus on $52 million in revenue — a margin of 37% — in 2021, according to its audited financial statement. It was the fourth consecutive year the center’s surpluses had topped 35%, the records showed. The industry average is 5%, according to a federally funded report on health centers’ financial performance.

Genesis attributes its large margins to excellent management and says it needs the money to expand and modernize services while being less reliant on government funding. The center benefits financially from the use of a government drug discount program.

Still, Genesis’ hefty surplus stands out among nonprofit federally qualified health centers, a linchpin in the nation’s safety net for treating the poor.

The federal government pumped more than $6 billion in basic funding grants last year into 1,375 privately run centers around the country, which provide primary care for more than 30 million mostly low-income people. In 2021, the American Rescue Plan Act provided an additional $6 billion over two years for covid-19 care.

These community health centers must take all patients regardless of their ability to pay, and, in return, they receive annual government grants and higher reimbursement rates from Medicaid and Medicare than private physicians.

Yet a KHN analysis found that a handful of the centers recorded profit margins of 20% or more in at least three of the past four years. Health policy experts said the surpluses alone should not raise concerns if the health centers are planning to use the money for patients.

But they added that the high margins suggest a need for greater federal scrutiny of the industry and whether its money is being spent fast enough.

“No one is tracking where all their money is going,” said Ganisher Davlyatov, an assistant professor at the University of Oklahoma who has studied health center finances.

The federal Health Resources and Services Administration, which regulates the centers, has limited authority under federal law over how much the centers spend on services and how they use their surpluses, said James Macrae, an associate administrator.

“The expectation is they will take any profit and plow it back into the operations of the center,” Macrae said. “It’s definitely something we will look at and what they are doing with those resources,” he added about KHN’s findings.

Ge Bai, an accounting and health professor at Johns Hopkins University, questioned why some centers should be making profit margins of 20% or more over consecutive years.

A center with a high margin “raises questions about where did the surplus go” and its tax-exempt status, Bai said. “The centers have to provide enough benefit to deserve their public tax exemption, and what we are seeing here is a huge amount of profits,” she said.

Bai said centers must be able to answer questions about “why aren’t they doing more to help the local community by expanding their scope of service.”

Officials at the health centers defended their strong surpluses, saying the money allows them to expand services without being dependent on federal funds and helps them save for big projects, such as constructing new buildings. They pointed out that their operations are overseen by boards of directors, at least 51% of whom must be patients, ostensibly so operations meet the community’s needs.

“Health centers are expected to have operating reserves to be financially sustainable,” said Ben Money, a senior vice president at the National Association of Community Health Centers. Surpluses are necessary “as long as health centers have plans to spend the money to help patients,” he said.

Some center officials noted bottom-line profit margins can be skewed by large contributions earmarked for building projects. Grants and donations appear as revenue in the year they were given, but a project’s costs are allocated on financial statements over a longer period, often decades.

‘We Don’t Take Unnecessary Risks’

The annual federal base grant for centers makes up about 20% of their funding on average, according to HRSA. The grants have more than doubled over the past decade. These federal grants to the centers are provided on a competitive basis each year based on a complex formula that takes into account an area’s need for services and whether clinics provide care to specific populations, such as people who are homeless, agricultural workers, or residents of public housing.

The centers also receive Medicare and Medicaid reimbursements that can be as much as twice what the federal programs pay private doctors, said Jeffrey Allen, a partner with the consulting firm Forvis.

In addition, some health centers like Genesis also benefit from the 340B federal drug discount program, which allows them to buy medicines from manufacturers at deeply discounted rates. The patients’ insurers typically pay the centers a higher rate, and the clinics keep the difference. Clinics can reduce the out-of-pocket costs for patients but are not required to.

For its analysis, KHN started with research by Davlyatov that used centers’ tax filings to the IRS to identify the two dozen centers with the highest profit margins in 2019. KHN calculated bottom-line profit margin for each of the past four years (2018 through 2021) by subtracting total expenses from total revenue, which yields that year’s surplus, and then dividing that by total revenue. Money given by donors for restricted uses was excluded from revenue. After examining the centers’ finances, KHN found nine that had margins of 20% or more for at least three years.

North Mississippi Primary Health Care was one of them.

“We don’t take unnecessary risks with corporate assets,” said Christina Nunnally, chief quality officer at the center. In 2021, the center had nearly $9 million in surpluses on $36 million in revenue. More than $25 million of that revenue came from the sale of drugs.

Nunnally said the center is building a financial cushion in case the 340B program ends. Drugmakers have been seeking changes to the program.

The center recently opened a school-based health program, a dental clinic, and clinics in neighboring counties.

“There may come a day when this type of margin is not feasible anymore,” she said. If the center hits hard times, it would not want to “have to start cutting programs and people.”

In Montana, Sapphire Community Health in Hamilton, which accumulated nearly $3 million in surpluses from 2018 through 2020 and had a profit margin of more than 24% in each of those years, wants to move out of its rented quarters to a building that will cost at least $6 million to construct. “A new facility will enable us to provide services that we cannot provide due to lack of space, such as imaging, obstetrics, and dental services,” CEO Janet Woodburn said.

Outside Los Angeles, Friends of Family Health Center CEO Bahram Bahremand said his high margins are the result of good management and California’s broad Medicaid coverage for low-income residents.

The center — whose profit margins topped 25% from 2018 to 2020 — opened a $1.9 million facility in Ontario last year and purchased the building that houses its main clinic, in La Habra, for $12.3 million, with plans to expand it, he said.

Bahremand added that the center also keeps administrative costs down by focusing on having more providers in relatively fewer locations.

“You shouldn’t be asking: ‘Why are we making so much money?’ You should be asking: ‘How come other clinics are not making so much money?’” Bahremand said.

Concern About Paying the Bills

In South Carolina, Genesis began as an independent clinic and was sometimes barely able to make payroll, said Tony Megna, Genesis’ CEO and general counsel. Converting to a federally qualified health center about a decade ago brought federal funding and a more solid footing. It recorded more than $65 million in surpluses from 2018 to 2021.

“Our attitude toward money is different than most because it’s so ingrained in us to be concerned about whether we are going to pay our bills,” said Katie Noyes, chief special projects officer.

The center is spending $50 million to renovate and expand its aging facilities, Megna said. In Darlington, a new $20 million building that will more than double the facility’s space is scheduled to open in 2023. And its strong bottom line helps the center pay all its workers at least $15.45 an hour, more than twice the minimum wage in the state, Megna said. Darlington County’s annual median household income is a bit over $37,000.

Megna was paid nearly $877,000 in salary and bonuses in 2021, according to Genesis’ latest IRS tax filing, an amount nearly four times the industry average.

David Corry, chairman-elect of the Genesis board of directors, said in a memo to KHN that part of that compensation made up for several years when Megna was inadvertently underpaid. “We determined early on that providing Mr. Megna an ‘average’ compensation like those of other FQHCs CEOs was not what we wanted. Mr. Megna’s extensive legal experience and education as well as his institutional and regulatory knowledge set him apart from others.”

Megna said his base salary is $503,000.

Genesis officials said the financial security afforded by the center’s surpluses has allowed them to provide extra patient services, including foot care for people with diabetes. In 2020, Genesis used $2 million to create an independent foundation to help families with food and utility bills, among other needs.

Most of Genesis’ revenue comes from the 340B program, according to its audited financial statements. Many prescriptions filled at the clinic pharmacy are for expensive specialty drugs, which treat rare or complex conditions such as cancer. Getting accredited to dispense specialty drugs was expensive, Corry said, but “paid off because it gives our patients access to extremely high-priced, and often lifesaving prescription drugs that would not otherwise be available to many of them.”

Megna, 67, a former bankruptcy lawyer, said it’s vital to keep the center financially secure to stay open for patients.

“We are very careful in how we spend our money,” Megna said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Bram Sable-Smith: brams@kff.org, @besables  

If a screening returns an abnormal result and a provider orders more testing, patients may be on the hook for hundreds or even thousands of dollars for diagnostic services.

This article was published on Tuesday, June 14, 2022 in Kaiser Health News.

By Michelle Andrews   

When Cynthia Johnson learned she would owe $200 out-of-pocket for a diagnostic mammogram in Houston, she almost put off getting the test that told her she had breast cancer.

"I thought, 'I really don't have this to spend, and it's probably nothing,'" said Johnson, who works in educational assessment at a university. But she decided to go forward with the test because she could put the copay on a credit card.

Johnson was 39 in 2018 when that mammogram confirmed that the lump she'd noticed in her left breast was cancer. Today, after a lumpectomy, chemotherapy, and radiation, she is disease-free.

Having to choose between paying rent and getting the testing they need can be a serious dilemma for some patients. Under the Affordable Care Act, many preventive services — such as breast and colorectal cancer screening — are covered at no cost. That means patients don't have to pay the normal copayments, coinsurance, or deductible costs their plan requires. But if a screening returns an abnormal result and a health care provider orders more testing to figure out what's wrong, patients may be on the hook for hundreds or even thousands of dollars for diagnostic services.

Many patient advocates and medical experts say no-cost coverage should be extended beyond an initial preventive test to imaging, biopsies, or other services necessary for diagnosing a problem.

"The billing distinction between screening and diagnostic testing is a technical one," said Dr. A. Mark Fendrick, director of the University of Michigan's Center for Value-Based Insurance Design. "The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test."

A study that examined more than 6 million commercial insurance claims for screening mammograms from 2010 to 2017 found that 16% required additional imaging or other procedures. Half the women who got further imaging and a biopsy paid $152 or more in out-of-pocket costs for follow-up tests in 2017, according to the study by Fendrick and several colleagues and published by JAMA Network Open.

People who needed testing after other preventive cancer screenings also racked up charges: half paid $155 or more for a biopsy after a suspicious result on a cervical cancer test; $100 was the average bill for a colonoscopy after a stool-based colorectal cancer test; and $424, on average, was charged for follow-up tests after a CT scan to check for lung cancer, according to additional research by Fendrick and others.

Van Vorhis of Apple Valley, Minnesota, did an at-home stool test to screen for colorectal cancer two years ago. When the test came back positive, the 65-year-old retired lawyer needed a follow-up colonoscopy to determine whether anything serious was wrong.

The colonoscopy was unremarkable: It found a few benign polyps, or clusters of cells, that the physician snipped out during the procedure. But Vorhis was floored by the $7,000 he owed under his individual health plan. His first colonoscopy several years earlier hadn’t cost him a cent.

He contacted his doctor to complain that he hadn't been warned about the potential financial consequences of choosing a stool-based test to screen for cancer. If Vorhis had chosen to have a screening colonoscopy in the first place, he wouldn't have owed anything because the test would have been considered preventive. But after a positive stool test, "to them it was clearly diagnostic, and there's no freebie for a diagnostic test," Vorhis said.

He filed an appeal with his insurer but lost.

Preventive care, like screening colonoscopies, is supposed to be free of charge to patients under the Affordable Care Act. But some hospitals haven't gotten the memo.

In a breakthrough for patients and their advocates, people who are commercially insured and, like Vorhis, need a colonoscopy after a positive stool test or a so-called direct visualization test like a CT colonography will no longer face out-of-pocket costs. According to federal rules for health plan years starting after May 31, the follow-up test is considered an integral part of the preventive screening, and patients can't be charged anything for it by their health plan.

The new rule may encourage more people to get colorectal cancer screenings, cancer experts said, since people can do a stool-based test at home.

Nine states already required similar coverage in the plans they regulate. Arkansas, California, Illinois, Indiana, Kentucky, Maine, Oregon, Rhode Island, and Texas don't allow patients to be charged for follow-up colonoscopies after a positive stool-based test, according to Fight Colorectal Cancer, an advocacy group. New York recently passed a bill that is expected to be signed into law soon, said Molly McDonnell, the organization's director of advocacy.

In recent years, advocates have also pushed to eliminate cost sharing for breast cancer diagnostic services. A federal bill that would require health plans to cover diagnostic imaging for breast cancer without patient cost sharing — just as they do for preventive screening for the disease — has bipartisan support but hasn’t made headway.

In the meantime, a handful of states — Arkansas, Colorado, Illinois, Louisiana, New York, and Texas — have moved ahead on this issue, according to tracking by Susan G. Komen, an advocacy organization for breast cancer patients that works to get these laws passed.

This year, an additional 10 states introduced legislation similar to the federal bill, according to Komen. In two of them — Georgia and Oklahoma — the measures passed.

These state laws apply only to state-regulated health plans, however. Most people are covered by employer-sponsored, self-funded plans that are regulated by the federal government.

"The primary pushback we get comes from insurers," said Molly Guthrie, vice president of policy and advocacy at Komen. "Their argument is cost." But, she said, there are significant cost savings if breast cancer is identified and treated in its early stages.

A study that analyzed claims data after a breast cancer diagnosis in 2010 found that the average overall costs for people diagnosed at stage 1 or 2 were just more than $82,000 in the year after diagnosis. When breast cancer was diagnosed at stage 3, the average costs jumped to nearly $130,000. For people with a stage 4 diagnosis, costs in the year afterward exceeded $134,000. Disease stages are determined based on tumor size and spread, among other factors.

When asked to provide health plans' perspective on eliminating cost sharing for follow-up testing after an abnormal result, a spokesperson for a health insurance trade group declined to elaborate.

"Health plans design their benefits to optimize affordability and access to quality care," David Allen, a spokesperson for AHIP, said in a statement. "When patients are diagnosed with medical conditions, their treatment is covered based on the plan they choose."

In addition to cancer screenings, dozens of preventive services are recommended by the U.S. Preventive Services Task Force and must be covered without charging patients under the Affordable Care Act if they meet age or other screening criteria.

But if health plans are required to cover diagnostic cancer testing without charging patients, will eliminating cost sharing for follow-up testing after other types of preventive screenings — for abdominal aortic aneurysms, for example — be far behind?

Bring it on, said Fendrick. The health system could absorb those costs, he said, if some low-value preventive care that isn't recommended, such as cervical cancer screening in most women older than 65, were discontinued.

"That is a slippery slope that I really want to ski down," he said.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Trainees are banding together in California and other states to demand higher wages and better benefits and working conditions amid intensifying burnout during the pandemic.  

This story was published on Friday, May 27, 2022 in Kaiser Health News.

By Sarah Kwon

In the early weeks of the pandemic, Dr. Lorenzo González, then a second-year resident of family medicine at Harbor-UCLA Medical Center, ran on fumes, working as many as 80 hours a week in the ICU. He was constantly petrified that he would catch the COVID-19 virus and guilt-ridden for not having enough time to help his ailing father.

In April 2020, his father, a retired landscaper, died of heart and lung failure. González mourned alone. His job as a doctor-in-training put him at high risk of catching the virus, and he didn't want to inadvertently spread it to his family. Financial stress also set in as he confronted steep burial costs.

Now, González is calling for better pay and benefits for residents who work grueling schedules at Los Angeles County's public hospitals for what he said amounts to less than $18 an hour — while caring for the county's most vulnerable patients.

"They're preying on our altruism," González said of the hospitals. He is now chief resident of family medicine at Harbor-UCLA and president of the Committee of Interns and Residents, a national union that represents physician trainees and that is part of the Service Employees International Union.

"We need acknowledgment of the sacrifices we've made," he said.

Residents are newly minted physicians who have finished medical school and must spend three to seven years training at established teaching hospitals before they can practice independently. Under the supervision of a teaching physician, residents examine, diagnose, and treat patients. Some seek additional training in medical specialties as "fellows."

These trainees are banding together in California and other states to demand higher wages and better benefits and working conditions amid intensifying burnout during the pandemic. They join nurses, nursing assistants, and other healthcare workers who are unionizing and threatening to strike as staffing shortages, the rising cost of living, and inconsistent supplies of personal protective equipment and COVID vaccines have pushed them to the brink.

More than 1,300 unionized residents and other trainees at three L.A. County public hospitals, including Harbor-UCLA, will vote May 30 on whether to strike for a bump in their salaries and housing stipends, after a monthslong negotiation deadlock with the county. Since March, residents at Stanford Healthcare, Keck School of Medicine at the University of Southern California, and the University of Vermont Medical Center have unionized.

"Residents were always working crazy hours, then the stress of the pandemic hit them really hard," said John August, a director at Cornell University's School of Industrial and Labor Relations.

The Association of American Medical Colleges, a group that represents teaching hospitals and medical schools, did not address the unionization trend among residents directly, but the organization's chief healthcare officer, Dr. Janis Orlowski, said through a spokesperson that a residency is a working apprenticeship and that a resident's primary role is to be trained.

Residents are paid as trainees while they are studying, training, and working, Orlowski said, and the association works to ensure that they receive effective training and support.

David Simon, a spokesperson for the California Hospital Association, declined to comment. But he forwarded a study published in JAMA Network Open in September showing that surgery residents in unionized programs did not report lower rates of burnout than those in nonunionized programs.

So far, none of the new chapters have negotiated their first contracts, the national union said. But some of the longer-standing ones have won improvements in pay, benefits, and working conditions. Last year, a resident union at the University of California-Davis secured housing subsidies and paid parental leave through its first contract.

With more than 20,000 members, CIR represents about 1 in 7 physician trainees in the U.S. Executive Director Susan Naranjo said that before the pandemic one new chapter organized each year and that eight have joined in the past year and a half.

Residents' working conditions had come under scrutiny long before the pandemic.

The average resident salary in the U.S. in 2021 was $64,000, according to Medscape, a physician news site, and residents can work up to 24 hours in a shift but no more than 80 hours per week. Although one survey whose results were released last year found that 43% of residents felt they were adequately compensated, those who are unionizing say wages are too low, especially given residents' workload, their student loan debt, and the rising cost of living.

The pay rate disproportionately affects residents from low-income communities and communities of color, González said, because they have less financial assistance from family to subsidize their medical education and to pay for other costs.

But with little control over where they train — medical school graduates are matched to their residency by an algorithm — individual residents have limited negotiating power with hospitals.

For unionizing residents seeking a seat at the table, wage increases and benefits like housing stipends are often at the top of their lists, Naranjo said.

Patients deserve doctors who aren't exhausted and preoccupied by financial stress, said Dr. Shreya Amin, an endocrinology fellow at the University of Vermont Medical Center. She was surprised when the institution declined to recognize the residents' union, she said, considering the personal sacrifices they had made to provide care during the pandemic.

If a hospital does not voluntarily recognize a union, CIR can request that the National Labor Relations Board administer an election. The national union did so in April, and with a certified majority vote, the Vermont chapter can now begin collective bargaining, Naranjo said.

Annie Mackin, a spokesperson for the medical center, said in an email that it is proud of its residents for delivering exceptional care throughout the pandemic and respects their decision to join a union. Mackin declined to address residents' workplace concerns.

Dr. Candice Chen, an associate professor of health policy at George Washington University, believes that the federal Centers for Medicare & Medicaid Services also bears some responsibility for residents' working conditions. Because the agency pays teaching hospitals to train residents, it should hold the facilities accountable for how they treat them, she said. And the Accreditation Council for Graduate Medical Education, which sets work and educational standards for residency programs, is moving in the right direction with new requirements like paid family leave, she added, but needs to do more.

How far these unions will go to achieve their goals is an open question.

Strikes are rare among doctors. The last CIR strike was in 1975, by residents at 11 hospitals in New York.

Naranjo said a strike would be the last resort for its L.A. County members but blamed the county for continuously delaying and canceling bargaining sessions. Among its demands, the union is calling for the county to match the wage increase granted to members of SEIU 721, a union that represents other county employees, and for a $10,000 housing allowance.

The union's member surveys have found that most L.A. County residents report working 80 hours a week, Naranjo said.

A spokesperson for L.A. County's Department of Health Services, Coral Itzcalli, thanked its "heroic" front-line workforce for providing "best-in-class care" and acknowledged the significant toll that the pandemic has taken on their personal and professional lives. She said limits on hours are set by the Accreditation Council for Graduate Medical Education and that most trainees report working "significantly less" than 80 hours a week.

Jesus Ruiz, a spokesperson for the L.A. County Chief Executive Office, which manages labor negotiations for the county, said via email that the county hopes to reach a "fair and fiscally responsible contract" with the union.

Results of the strike vote are expected to be announced May 31, the union said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Sarah Kwon: @skwonjournalist