| Volume 9, Number 4 |
Jordan J. Cohen, M.D., President |
January 2000 |
by Jennifer Proctor
 On NBC's show, "ER," character "Rocket" Romano (Paul McCrane) portrays a resident's worst fear -- a harsh attending physician -- who is particularly hard on resident Elizabeth Corday (Alex Kingston) |
The specter of unionization has many teaching hospital leaders nervous about the adverse effects collective bargaining units could have on patient care. These fears were exacerbated by the recent National Labor Relations Board decision that gave the green light to union-building activities.
In an AAMC statement released Nov. 30, President Jordan J. Cohen, M.D., said, in part, "the bottom line is that medical education programs should be the responsibility of the faculty and teaching institution, and should be driven by educational considerations rather than the marketplace. The health care needs of patients and the educational demands of residents cannot wait while labor disputes are settled."
Enter the housestaff organizations-also known as resident councils. These internal, hospital-sponsored organizations help address resident issues and alleviate their many concerns. These organizations work as advisory bodies-as opposed to bargaining or labor units -- and are composed of resident representatives from the various residency programs. Some housestaff organizations are open to all residents, not just elected representatives. Others are composed of only chief residents.
"Resident councils help articulate the things that interfere with education and patient care," says Kathryn Lane, Ed.D., VP of Academic Affairs at Maimonides Medical Center in Brooklyn, N.Y. Dr. Lane says that councils play a dual role: they empower residents, but they also benefit hospital administrators, because information flows from residents on the "front lines" of patient care. A successful housestaff organization can help maintain a satisfied balance between residents, hospital administrators, and patients, she says.
The Accreditation Council for Graduate Medical Education (ACGME) has also come down squarely in support of resident organizations. In order to receive ACGME accreditation, teaching hospitals must provide "assurance of an educational environment in which residents may raise and resolve issues without fear of intimidation or retaliation … This may be accomplished through a resident organization or other forums in which to address resident issues." Hospital GME committees are another outlet for intern and resident concerns. ACGME requirements stipulate that residents, who are nominated by their peers, be seated and cast votes on hospital GME committees.
The AAMC has been a vocal proponent of such housestaff organizations. In its 1998 report, "Commitments, Obligations, and 'Employment' Issues between Residents and Teaching Institutions," an AAMC "Principles Group" stated that "the presence of a well-functioning system for communicating between residents and the programs' and institutions' administration is important to the protection of residents' interests and to ensuring an appropriate environment for education."
Residents want a voice in their institution and in their education, says Rebecca Minter, M.D., a General Surgery resident at the University of Florida and chair of the AAMC Organization of Resident Representatives. "Yet, there is a huge lack of communication between hospitals and residents, and hospital-level decisions can affect residents most of all."
Dr. Minter says administrators benefit by listening carefully to their residents. If hospital administration and faculty create a positive environment by expressing receptiveness to new ideas, resident leaders can, in turn, reach out to all of an institution's residents, and win their trust and confidence. "It's important for residents to realize that there are alternatives to unionization," Dr. Minter says.
Responses to a recent query among AAMC Group on Resident Affairs members suggest that many hospitals have housestaff organizations, but their composition varies widely: Residents may be appointed or elected to the body, committee, or council. Some groups are limited to chief residents from departments, others are open to all interns and residents, and yet others include residents, faculty, and program directors.
At Maimonides, a resident advisory council tackles some of the residents' basic concerns-stipend, food, and sleeping quarters-but Dr. Lane says the council also wants to increase residents' knowledge base. The 28-member council helps identify useful educational sessions. For example, first-year residents may choose to take a doctor- patient communication course, while senior-level residents can opt for the contract negotiation seminar.
The council also meets periodically with the chief operating officer, the director of the physical plant, and the director of Nursing. In all of these encounters, residents offer a different perspective, Dr. Lane says. "They identify things that can be improved, ultimately leading to better patient care."
A recent example was the turn-around time of CAT scans. The resident council recognized that both doctors and patients were experiencing long wait times to receive results, so the council took the problem to the residents, mainly those in radiology. Dr. Lane says the residents came up with a technology-based solution that reports CAT scan results much more quickly.
Another challenge for both the administration and residents was the state of New York's decision to limit residents' work hours to 80 a week. Maimonides had to implement an effective system to monitor residents' time. Dr. Lane's office originally was handling compliance, and she admits to having limited success. The Academic Affairs office opted to turn control over to the resident council.
Resident council members now distribute surveys to ensure that residents are not working more than 80 hours a week, and the council turns the surveys over to the appropriate office. "The residents and chief residents know how much time they spend at the hospital-others don't," Dr. Lane says. She refers to the housestaff as "problem-solvers."
Dr. Lane says it is the hospital administration's duty, at all levels, to take the resident council seriously and to demonstrate follow-through and resolution. "From the level of the president on down the line, we take the council seriously, and it really works." Dr. Lane says even a meal and meeting space make a difference in conveying to residents how seriously the institutions regard the council's work. At Maimonides, the administration furnishes a catered lunch and holds council meetings in its best conference room. And she says the resident council members reciprocate, demonstrating their strong commitment through serious input and deliberation, and regular attendance at meetings, despite their very hectic schedules.
These busy schedules present logistical challenges, and Dr. Minter says meeting schedules should take that into consideration. She adds that resident leaders or organization officers must make council-building a grassroots effort, assuring that residents from all departments are represented.
Consistency with meeting times and format, organizational follow-up, and strong programming combine to make the residents at Maimonides value their resident council, Dr. Lane says. She hopes that effective housestaff organizations serve as a logical alternative to resident unionization. "If a resident council is effective, residents can see a forum where their problems are addressed. There isn't much need for a union."
"Our resident organization enhances our ability to communicate with administration," says Jamal Zarghami, M.D., an Internal Medicine resident and president of the housestaff organization at Providence Hospital in Southfield, Mich. Of the 140 residents at Providence, 18 representatives-one from each program-make up the council, and those representatives elect three officials. One of the elected resident officials also sits on the hospital's medical education committee.
The council sponsors quality assurance lectures, which are mandatory for all residents. "These are successful when the administration or the housestaff needs to relay a message," Dr. Zarghami says. For example, residents helped the hospital improve its medical records processing by emphasizing the imperative to complete the records in a timely manner.
Resident stipends are a point of contention in many programs. At Providence, the hospital left it up to the housestaff organization to devise a reimbursement system. Residents agreed that the stipend should be based on the number of patients a resident sees, so first-year interns get the highest stipend-a rather unusual system. But because the residents were able to devise a cogent, workable plan, both residents and the administration were satisfied, Dr. Zarghami says.
Communication, the ability to address issues, and involvement in quality-of-care concerns make the Providence housestaff organization a success, says Thomas Gentile, Jr., M.D., former director of Medical Affairs and chief academic officer at Providence Hospital. Gentile helped form the organization 25 years ago. "These organizations are imperative for communication and to promote leadership among the house-staff," he says. "The housestaff and the administration don't always agree, but we work together to make things happen."
The Providence housestaff organization also has a social committee that sponsors a variety of activities, some of which include residents' families. Both Drs. Zarghami and Gentile say that these activities help establish camaraderie among the residents, as they can become departmentalized and lose contact with residents in other specialties.
"The council enhances the global aspect of resident education by allowing interaction with all people, and that's what learning is all about," Gentile says.
Information: Sunny Yoder, Group Secretary, AAMC Group on Resident Affairs, (202) 828-0497, syoder@aamc.org.
NLRB Says 'Yes' to Resident Unions
In a Nov. 26 ruling, the National Labor Relations Board (NLRB) voted that house-staff-interns, residents, and fellows-have the right to unionize, collectively bargain, and even strike. The decision overturns a 1976 decision that ruled that interns and residents were primarily students, not employees, and, therefore, could not collectively bargain.
"The AAMC is greatly disappointed by the NLRB ruling that overturns the board's long-standing position that residents and interns are first and foremost students, providing care to patients in the context of physician education," said Jordan J. Cohen, M.D., in a Nov. 30 statement. The statement also points out that ACGME standards already in place require teaching institutions to provide mechanisms for addressing resident concerns.
"The AAMC encourages housestaff to use these well-established mechanisms and to be cognizant of the many downsides of relying on collective bargaining units to resolve their concerns."
In 1997, the Housestaff Officers Association at Boston Medical Center-part of the New York City-based Committee of Interns and Residents-petitioned the NLRB to overturn the 1976 ruling. Many experts say the new NLRB decision could trigger nationwide efforts to unionize housestaff. The NLRB decision bolsters a June AMA ruling to establish bargaining units for certain doctors, although the AMA vowed not to strike.
The American Hospital Association supported the AAMC position, but the California and New York medical societies came out in favor of the NLRB decision. The AMA and the Massachusetts Medical Society favored the decision, but expressed reservations.
There are approximately 103,000 interns and residents in the United States. Under the 1976 decision, only a minority of those residents can be unionized-most work in public hospitals in states that allow public-sector employees to collectively bargain, but not strike. The Committee of Interns and Residents estimates that about 11,000 residents are currently unionized.
Information: Joseph Keyes, AAMC General Counsel, (202) 828-0555.
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