By Emily J. Tipping

Chair of the Pennsylvania Medical Society’s Resident and Fellow Section John Paletta, M.D.

Published October 1999

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Managed care and hospital restructuring have given medical residents and fellows a new group of concerns. And organized medicine and organized labor have proven eager to help housestaff collectively address issues that affect patient care, salary and medical education.

Some residents and fellows in Pennsylvania say they have only nominal interest in and knowledge of housestaff organizations because of lack of time and lack of serious grievances. In certain areas of the country, momentum is growing to unionize or otherwise organize residents and fellows. Although the Pennsylvania Medical Society has adopted a "wait-and-see" attitude, events elsewhere could mean dramatic changes for housestaff and fresh opportunities for medical and labor organizations looking to boost membership:

• The Committee of Interns and Residents (CIR), an AFL-CIO affiliated union founded in 1957, has amassed about 10,000 members—out of 100,000 residents and fellows nationwide—and has forged a first-ever alliance with the California Medical Association.

• CIR has challenged a National Labor Relations Board ruling regarding the employment status of housestaff at Boston Medical Center. If CIR wins its appeal, the remaining 90,000 residents and fellows across the country could suddenly find themselves eligible to organize for collective bargaining without fear of reprisal.

• The American Medical Association (AMA) is gearing up to represent eligible housestaff as part of its controversial June vote to form a national labor organization for collective bargaining purposes. The AMA in the meantime has advocated Independent Housestaff Organizations (IHOs) as a vehicle for residents and fellows to resolve patient care and employment issues with hospital administrators.

Reinforcing the AMA’s support of IHOs is the Accreditation Council on Graduate Medical Education’s (ACGME) decision last year (made at the AMA’s request) to require institutions to have a graduate medical education committee that provides, among other things, an organizational system through which residents can express their concerns.

Many institutions and residents don’t know about the ACGME requirement, said Mike Flesher, director of the AMA’s resident and fellow services department, which has assisted or been in discussions with 15 institutions across the country regarding IHOs. The educational hurdles loom large: Flesher said the AMA spends a lot of time explaining to hospitals and housestaff that an IHO is not a union.

According to the AMA’s booklet, Independent Housestaff Organizations: A Win-Win Opportunity, the AMA will assist only those groups that agree not to take job actions such as strikes and not to affiliate with a traditional AFL-CIO member labor union. The AMA expects to publish in a few months an updated version of the manual with details about setting up IHO constitutions, bylaws and a dues process.

Christopher R. Cogle, M.D., chair of the resident and fellow section of the AMA and a third-year internal medicine resident at the University of Florida, touted IHOs as an organizational tool that doesn’t compromise physician ethics because patients and education come first.

"Housestaff organizations are the operators in making the sum of opinions greater than the parts," he said. "We are in the emergency department at 3 a.m. and on the wards at 2 p.m. and in the clinics at 9 a.m., and we see the inefficiencies in patient care that many administrators can’t see. It’s our obligation to offer ideas to protect high standards for patient care and medical education."

An IHO can help residents with state licensure, Cogle said, and groom physicians to become leaders, since the housestaff organization itself demands a great deal of dedication.

Cogle said the AMA provided legal counsel and other support when he formed an IHO earlier this year at the University of Florida. With the support of hospital administration, Cogle said residents have developed plans to improve housestaff access to sterile equipment (limited access for cost-containment reasons was affecting patient care), give input to a new ACGME core curriculum, and arrange safe transport to hospital parking areas at night.

Adam Gordon, M.D., a second-year internal medicine fellow at the University of Pittsburgh Medical Center, Pennsylvania delegate to the resident and fellow section of the AMA and an alternate Pennsylvania Medical Society delegate to the AMA, said many residents already have informal groups within their departments to communicate concerns to hospital leaders.

A more structured housestaff organization could resolve common issues, Gordon said, such as a hospital using housestaff instead of a night shift worker in radiology or eliminating free parking for residents to save money.

"The big issue is whether you can consider them (IHOs) bargaining units with power. That’s the rub. If something really bad would happen, they have no power," said Gordon.

Cogle said IHOs are and always will be a cooperative alternative to unions, even if residents and fellows are one day allowed to collectively bargain under federal law. But some view them in a more ambiguous light, given the AMA’s decision to organize and represent employed physicians and housestaff for collective bargaining. Administrators at Montefiore Medical Center in New York recently rejected the AMA’s efforts to form an IHO there, calling it a potential labor union.

Michael Erwin, M.D., a third-year internal medicine resident at the Hospital of the University of Pennsylvania, worried that any housestaff organization, no matter how friendly it was with hospital administration, would jeopardize resident education by taking an adversarial position.

Erwin said his main concern as a resident stems from Penn, like most hospitals, adjusting its budget to meet shrinking health care reimbursements.

"The hospital is getting busier and at the same time trimming staff and ancillary support. Housestaff is in a bad position, because we’re salaried and we’re there," he said.

Housestaff has limited interaction with hospital administration, the people who decide how much they work. Still, Erwin said he has no need for an IHO, given the open communication he has with program directors and chief residents. "I’ve never been in a position where I felt I wasn’t being heard," he said.

John Paletta, M.D., a fifth-year surgery resident at York Hospital and chair of the Pennsylvania Medical Society’s Resident and Fellow Section, said an IHO could absolutely help in instances where resident salaries are slashed, like Jefferson Hospital did years ago, or where programs include noncompete clauses in residents’ contracts. He wasn’t sure how successful an IHO would be in a situation like that of the housestaff at the former Allegheny Health, Education and Research Foundation hospitals in Philadelphia, where he said resident education suffered after an exodus of attending physicians.

CIR counts preservation of residency programs at a bankrupt hospital in Queens among its victories for unionized housestaff in New York. A CIR representative did not return calls seeking comment on what a union has to offer housestaff. One obvious benefit that IHOs cannot offer would be protection from hospital administration reprisal.

Fear of backlash surfaced in efforts to talk to residents and fellows on the issue of housestaff organizations at Mercy Hospital in Pittsburgh, Albert Einstein Medical Center in Philadelphia and other institutions; residents declined to discuss their concerns even anonymously, in one case saying they didn’t want to jeopardize future employment.

Although the majority of residents eschew membership in local and national medical organizations (the AMA, at 35,000 resident members, is the largest resident organization in the country), Adam Gordon said he wouldn’t describe residents and fellows as apathetic, but rather as "apprehensive about saying, ‘I’m a union member.’"

As hospitals and health systems continue to merge and as priorities continue to shift at academic medical centers, Gordon predicted that more residents and fellows will be turning to organizations for support.

John Kudlak, D.O., chief administrative resident in internal medicine at St. Francis Medical Center in Pittsburgh, said he sees unionization of employed physicians as a necessity in an industry "where you get back whatever (insurance companies) feel like paying you."

Kudlak said housestaff organizations sounded like they were worth looking into considering changes St. Francis had made to resident benefit contracts with little notification. The changes didn’t affect him that much, but Kudlak, who is heading into a three-year fellowship in Kentucky, said it made him think about what would happen if a hospital had serious financial problems.

"What bargaining power do I have? If they decide to cut my contracted salary by $5000 a year, what can I do about it? I don’t think the majority of physicians got into medicine for the money. It’s a great honor to take care of people. But you don’t want to be abused by the system for taking on that responsibility," he said.

Brandt Feuerstein, M.D., a third-year general surgery resident at Lankenau Hospital in Philadelphia, said he can understand all of the attention being directed toward unions and housestaff organizations, because people are worried about completing training and not being able to afford a reasonable lifestyle afterward. In the past, he said surgery residencies could be compared to a fraternity hazing.

"You’d put up with the horrible hours and the abuse from attending physicians, but in the end you were a member of the old boys club, one of the elite. Now there is no old boys club, and that’s kind of hard to swallow as a resident," he said.

But Feuerstein said he and most housestaff consider residency a temporary situation, and they expect it to be tough—financially and physically. If residents are going to be concerned about anything, he said, it should be the quality of future residents given the number of open resident slots that are often kept open by hospitals to preserve a source of federal money.

"Residency should be about training, not about salary and hours," he said. "I can see where (organizing) comes from, but I’m not all that excited about it. Ninety-nine point nine percent of the time, we’re just getting through our residency. There’s just too much to do."

The biggest obstacle to forming an IHO is lack of time, said Christopher Cogle, and the fact that residents have completed training and moved on in just a few years.

"Residents are busy checking lab results, reading X-rays, talking to families, performing lumbar punctures, spending time with their own families and eating and sleeping. After all that, residents with a bird’s eye view (of issues affecting medicine) are few and far between. And those who have the energy to act on that bird’s eye view are even fewer," he said.

Still, Cogle said more than 200 residents and fellows find the time and energy to travel to AMA section meetings twice a year.

Regardless of the obstacles, Kudlak lauded the AMA’s controversial decision to help physicians, both professional and housestaff, organize for collective bargaining.

"I want to take care of patients. Like I need a mechanic to take care of my car, we definitely need people out there looking after our interests in an organized way," he said.