Correspondence
Collective Bargaining for House Staff
N Engl J Med 2000; 342:1919-1921June 22, 2000
- Article
To the Editor:
Both Dr. Yacht and Dr. Cohen (Feb. 10 issue)1,2 present excellent arguments for and against collective bargaining by residents, respectively.
Dr. Cohen asks residents first to try other means of being heard, not unions. Physicians for Responsible Negotiation, a national labor organization formed by the American Medical Association (AMA) as a professional alternative to bargaining, agrees. Our constitution and bylaws forbid member physicians from striking or withholding essential patient care services.
Dr. Cohen eloquently explains why it may be difficult for residents in some programs to learn professionalism. He emphasizes that programs should treat residents with respect and put education first, stating, “Reliance on residents to perform patient care services of little or no educational value demeans their status as students.” Our organization believes that professionalism includes the willingness to fight obstacles to the provision of good patient care, which may be impossible when a single person must buck the system.
Unfortunately, the Accreditation Council for Graduate Medical Education (ACGME) has a limited range of sanctions for programs with deficiencies. Physicians for Responsible Negotiation believes that other remedies must be available. We have made a commitment not to strike, but there are more sophisticated methods of resolving disputes, such as mutual-gains negotiation, also known as mutual-interests negotiation. In this type of negotiation, the two sides put their concerns on the table, prioritize them, and address them together in an effort to obtain a win–win result. Such methods allow the two sides to work toward common interests.
2 ReferencesSusan Hershberg Adelman, M.D.
Physicians for Responsible Negotiation, Chicago, IL 606101
Yacht AC . Collective bargaining is the right step. N Engl J Med 2000;342:429-431
Full Text | Web of Science | Medline2
Cohen JJ . White coats should not have union labels. N Engl J Med 2000;342:431-434
Full Text | Web of Science | Medline
To the Editor:
As a past president of the University of Michigan House Officers Association who has been in full-time clinical practice in the private sector for the past 14 years, I find Dr. Cohen's position anachronistic and reactionary. In the abstract, some of his concerns seem credible. However, more than two decades of experience with bargaining by house officers have shown them to be unfounded. From the outset, collective bargaining by house officers led directly to improvements in patient care at the University of Michigan Medical Center, improvements that would otherwise have been achieved only much later, if at all. This seems to have been the case at Boston Medical Center as well. I am unaware of any instances in which collective bargaining or job actions by house officers have resulted in harm to patients.
With the current emphasis on the bottom line, patient advocacy by house-officer groups is becoming more important. This advocacy depends on the ability to negotiate from a position of strength and independence.
Mark L. Beauchamp, M.D.
Lovelace Health Systems, Albuquerque, NM 87108To the Editor:
Dr. Cohen has it backward. Physicians' unions are not a cause of the commercialization of medicine, but a result. The reason that white coats should have union labels is that the health care system has been hijacked by Armani suits with corporate logos. Does Cohen really believe that an individual physician is able to bargain as an equal with a $10 billion hospital chain or a $50 billion health maintenance organization (HMO)?
Some teaching hospitals have already been swallowed up by for-profit hospital chains. Nonprofit hospitals are under pressure from HMOs to put the bottom line first. Although the directors of residency programs may see residents as students, hospital administrators see them as a source of cheap, exploitable labor. If interns and residents are doing the work of orderlies, it is because the hospital has refused to hire enough members of the support staff. The program director cannot hire more orderlies, but the hospital administrator can.
The concern about strikes is a red herring. A job action need not adversely affect patients. House staff members could, for example, continue to treat patients as before but refuse to sign the forms that the hospital needs to obtain reimbursement from Medicare, Medicaid, and private insurance plans.
It is time to be honest with ourselves. Internship and residency are the only contexts in which it is still considered acceptable to require that human beings regularly work for 36 hours straight without sleep. In any other situation, chronic sleep deprivation would be considered a not very subtle form of torture.
Robert J. Yaes, M.D.
15 Quantum Pl., Gaithersburg, MD 20877To the Editor:
Dr. Cohen states that he could understand the need for unions if house staff had no alternative means of airing grievances. He fails to acknowledge that the alternatives are weak and have been developed only recently in the hope of preempting unionization.
As a past chairman of the AMA's Resident Physicians Section (1996 to 1997), I know that organized medicine and the academic community can be dismissive of residents' concerns. Take the ACGME, which only recently required that the memberships of residency-review committees include representation of residents. (The ACGME itself has minimal representation of residents in its governing structure.) This requirement was fought by the academic community, including representatives of the Association of American Medical Colleges. Although such representation does not begin to solve the problems, the fierce opposition to it raises serious questions about whether the directors of residency programs are truly interested in improving conditions. In addition, one need only look at the number of programs put on probation by the ACGME. Surely, no one would believe that less than 20 percent of programs have work-hour violations. House staff members are turning to unions because organized medicine and the academic community are not doing enough.
Dr. Cohen also fails to acknowledge that medicine is extremely hierarchical. When one's future often depends on the recommendations of a program director and department chair, it is difficult to voice concern, out of fear of retaliation. Residency programs often view residents who complain as whiners.
I would not choose to be part of a union. However, until organized medicine and the academic community take residents' concerns more seriously, house staff members will need every option available to them to ensure an adequate work and educational environment.
John J. Whyte, M.D., M.P.H.
3823 Porter St., Washington, DC 20016Author/Editor Response
The authors reply:
To the Editor: Arguing that there are alternatives to house staff unions, Cohen stated, “Residents are not powerless. They may be unaware of their power or of how to exercise it, but residents do have the power, both individually and collectively, to improve the conditions under which they learn.” Instead of organizations that engage in collective bargaining, he offers “resident-run house-staff associations, working groups comprising all the institution's chief residents, and regularly scheduled meetings between representatives of the residents and the institution's committee on graduate medical education.” I agree that these are all important “structured avenues for communication,” as he puts it. However, in the event of disagreements over the working conditions of house staff, the provision of ancillary services, or other issues directly or indirectly related to patient care, residents may ultimately find that the avenue of communication is one way and that the employer has the final decision-making ability under these systems. Despite good intentions to include residents in establishing program and hospital policies, without the backing of a contract under the National Labor Relations Act, there are no guarantees that the important voices of residents will be heard. Filing formal grievances through the ACGME can be a powerful final step in establishing local policies, but this approach may be too cumbersome and the results too delayed to be effective in “real time.”
Adelman recommends “more sophisticated methods of resolving disputes” — specifically, mutual-gains negotiation, in which “the two sides put their concerns on the table . . . [and] work toward common interests.” This approach works well in the abstract. Unfortunately, however, one can easily imagine situations in which “common interests” are unrelated or untenable. When an institution unilaterally decides to cut salaries, remove benefits, or reduce services, there is little an employee can offer at the table in the absence of a contract. As for the strike issue, the agreement between Boston Medical Center and the House Officers' Association and Committee of Interns and Residents specifically forbids the house staff from participating in or sanctioning a strike or other disruption of the hospital's operations.1 This point was negotiated and accepted by both parties and in no way reduces the effectiveness of future collective bargaining.
Cohen and Adelman suggest important alternatives for communication and dispute resolution. There remain many approaches to negotiation. When disagreement occurs, however, each party to a collectively bargained agreement understands its rights and obligations. In this way, the parties start on a more equal footing and can reach a more equitable resolution.
1 ReferencesAndrew C. Yacht, M.D.
Boston Medical Center, Boston, MA 02118Author/Editor Response
My opposition to house-staff unions does not stem from a denial of either the merits of unionism in industry or the need for residents to have workable ways to address legitimate topics of concern. I concede both points. But by turning to unions to address their concerns, residents risk the erosion of medicine's principled foundation.
Unions do not merit a place in graduate medical education because they espouse the primacy of self-interest and achieve their ends in an atmosphere suffused with the implied or explicit threat of withholding services. The medical profession, in stark contrast, espouses the primacy of service to others and eschews, as a matter of principle, the abandonment of patients.
Residents are learners enrolled in an educational program in which the tenets of the medical profession must be honored without compromise if they are to be preserved. There is no question that residents deserve to have more clout in ensuring an appropriate learning environment. The means for doing so, albeit often underused, already exist in the absence of unions and are being strengthened continuously. In my article, I urged residents to exhaust those means before turning to unions as an alternative. I also urged program directors, faculty members, and teaching-hospital executives to recognize and address issues of concern to residents before the appeal of unions becomes irresistible.
Adelman suggests that the AMA's new Physicians for Responsible Negotiation offers an alternative to unions. She describes this group as a national labor organization established by the AMA “as a professional alternative to bargaining.” I would describe it as a union in sheep's clothing. Although it disavows strikes, which is commendable, Physicians for Responsible Negotiation is nonetheless organized to step across the time-honored boundary separating professionalism from unionism. Rhetoric about protecting patients aside, the public knows — and residents should understand — that unionism in whatever clothing involves thinking and acting collectively in promoting self-interest.
Beauchamp wants us to be reassured by the past experience of the University of Michigan Medical Center, a public institution. Unions organized under state laws, as I noted in my article, differ fundamentally from those organized under the protection of the National Labor Relations Act. Unfortunately, a seemingly benign past does not guarantee an equally benign future.
Yaes and Whyte emphasize that there is an urgent need to improve working conditions in many training programs. I agree wholeheartedly.1 What I disagree with is the idea that our profession should turn to labor unions to solve a problem that we have allowed to fester and that is within our power to solve.
1 ReferencesJordan J. Cohen, M.D.
Association of American Medical Colleges, Washington, DC 200371
Cohen JJ . Honoring the “E“ in GME. Acad Med 1999;74:108-113
CrossRef | Web of Science | Medline
