Is the accreditation council for graduate medical education a suitable proxy for resident unions?

In 1999, the National Labor Relations Board reversed its own rulings and determined that resident physicians were categorized as employees and not students under the National Labor Relations Act in the private sector. This change opened the door for residents to collectively bargain for employment benefits. Concerns were raised that conflicts in the area of service-versus-educational demands on residents' time were better handled by the Accreditation Council for Graduate Medical Education (ACGME) than by residents' unions. This article explores the extent to which conflicts exist between advocating for working conditions and for educational issues and, more specifically, whether there are any resident interests that are not covered by current ACGME regulations. In other words, has the ACGME evolved into a reasonable proxy for resident unions? The authors describe their experience with the University of Michigan House Officer Association, mutual gains bargaining, the impact that the ACGME 2003 and 2007 institutional requirements have had on employment contracts, and whether these requirements clarify or confuse resident issues. To date, the ACGME continues to revise its requirements, many of which preempt and exceed the power that most local unions have. However, only blunt tools (e.g., removal of accreditation) are available to the ACGME to address violations of requirements. The ACGME, to potentially function as a full resident union, would need to find more precise methods for timely feedback to both resident and hospital parties as well as more powerful tools to deal with violations of its regulations and requirements.