We applaud Dr. Meo and colleagues' effort to share their experiences during the COVID-19 pandemic at the University of Washington (UW).1  In Seattle and across the country, residents and fellows remain critical to COVID-19 responses, but many have limited avenues for demanding changes to working conditions without fear of repercussion.

We would know—the Resident and Fellow Physician Union–Northwest (RFPU-NW) represents nearly 1400 doctors at UW. In March 2020, RFPU-NW members faced redeployment, with many union leaders among the first to volunteer in COVID-19 units to serve our patients and community. Simultaneously, RFPU-NW pressed UW for resident and fellow representation in redeployment planning meetings following Meo et al's Guiding Principle 8, through a proposed memorandum of agreement on April 3, 2020, to UW. This request was denied on April 20, as were all subsequent requests for representation.

Despite a lack of input from the elected leaders of the residents and fellows at UW, we support many of the Guiding Principles from Meo and colleagues and encourage other institutions to emulate them. UW consistently respected work hours (Principle 7), in contrast to some institutions in hard-hit locations.2  UW made efforts to balance trainee redeployment with upstaffing of other physicians and advanced practice providers (Principles 6 and 10). Finally, despite initial haphazard training, UW quickly rolled out just-in-time training for COVID-19 care and personal protective equipment (Principles 1 and 5).

Unfortunately, many reasonable requests voiced by residents and fellows seemed unheard at our site. For example, UW did not include residents and fellows in preliminary planning stages, which forced RFPU-NW to the bargaining table to ensure our members received advance notice prior to redeployment, alternative work accommodations for high-risk groups, and paid administrative leave (rather than use of personal sick leave) for required quarantine after work-related COVID-19 exposure. Despite the goal of Meo et al's Principle 8 to “[w]henever possible, involve trainees to critically evaluate the process and provide feedback,” it seemed rare that our voices were heard outside of negotiations.

Now, as COVID-19 cases continue across the country, residents and fellows regularly face disrupted clinical education to provide necessary patient care. Perspectives by trainees in JGME over the last year speak to the challenges they face. We largely agree with the recommendations Meo and colleagues make, with a crucial edit: It is imperative to seek out resident and fellow representation in the early stages of redeployment planning, especially their elected representatives. At UW and a growing number of institutions, those representatives are union leaders.35 

Currently at UW, with strong advocacy from program directors and RFPU-NW, residents and fellows are only being redeployed when faculty are also redeployed and the institution is prioritizing staffing with internal moonlighting and extra-pay-for-extra-duty opportunities (at the same rate as attendings) before pulling residents from educational activities for redeployment without additional pay.

We urge other institutions to treat their residents and fellows similarly to attending physicians. Physicians: if your institutions are not doing this, we implore you to recognize the strength that comes from collective action and unionization. This is how you secure a seat at the table and change institutional culture. We need to be included from the very beginning of surge planning—after all, we are the ones being redeployed.

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