House staff unionism

JOURNAL

OF SURGICAL

RESEARCH

22, 161- 164 (1977)

House Staff Unionism Presidential

Address

read at The Association For Academic on Wednesday, November 3, 1976 GERALD

Surgery

Meeting

S. Moss, M.D.

It has given me great pleasure to be President of the Association for Academic Surgery during this 10th Anniversary Year. There are several reasons for this. First, you have placed me in a very select group of eight preceding presidentsGeorge Zuidema, John S. Najarian, W. Gerald Austen, Ward 0. Griffen, Jr., Eric W. Fonkalsrud, Paul A. Ebert, Thomas L. Marchioro and finally Hiram Polk. This is a list of some of the best and brightest minds in American Surgery. To be a part of this group is, for me, heady wine indeed. Second, I am proud to be a part of the history of The Association for Academic Surgery. This Association has successfully filled an important gap for the young academic surgeon. Just a few of its accomplishments include: a liberal admissions policy, an obsession with providing opportunities for its young members to participate in the governance of the organization, a successful Committee on Issues, on-going evaluation of the quality of the scientific presentations, and the development of a Poster Session. In essence, we have participated in the development of a free-wheeling, creative surgical organization. It is the responsibility of the incumbent president to select an important topic for the Annual Address. My choice was simple. It was literally forced upon me last year at this very same meeting. Just as the business session was about to begin I received a call from one of my colleagues in Chicago informing me that seven house officers from Cook County Hospital had just been sentenced to 10

days in jail. They were incarcerated for disobeying a judge’s instruction not to carry out a strike against the hospitala public institution. I decided then to review with you today what has happened nationally regarding house staff unionism, why it happened, and what to do about it. HISTORICAL

BACKGROUND

The story really begins with the development of the house staff concept in the United States. I would like to spend a few minutes recalling some of the details of its evolution. The idea of in-hospital training for physicians is an old one [l]. As early as 1617, young house physicians at Guys Hospital in London were employed as observers and assistants for periods up to seven years. In this Country the first colonial hospital, the Pennsylvania Hospital, took apprentices from its inception in 1751. The duties of these apprentices were apparently not different from those in Guys Hospital. Similar house staff developed at the Philadelphia General Hospital, the Massachusetts General Hospital and the New York Hospital as well as other major institutions. In these early programs there were no full-time teachers and no attempt was made at graded responsibility. A basic modification of the ancient apprenticeship model had to wait until 1889, when Johns Hopkins Hospital introduced the concept which was to become the model for the contemporary way of training residents in accord with the bold

161 Copyright 0 1977 by Academic Press, Inc. All rights of reproductmn in any form reserved.

ISSN 0022-4804

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innovations of those medical giants, Halsted, Osler and Kelly [2]. Their new training concepts prescribed close association with the professor, stiff competition for the top positions, graded responsibility, minimal monetary compensation, teaching of the house staff, and participation in research. Another important element in the model was the creation of a staff of fulltime teachers. Thus, by the beginning of the 20th century, the elements of the modern residency program were created. If we are to believe their memoirs, these residents considered themselves among the most fortunate of human beings. How then, did we descend from this idyllic format of excellence to our contemporary disarrayfacing our young house staff colleagues across the bargaining table as virtual adversaries.

In each of the four strikes the house staff won clear-cut victories. In New York they won an 80-hour week limit. In Los Angeles they won the right to binding arbitration plus control of a 1.1 million dollar fund. Incidentally, equipment bought with this money belongs to the House Staff Association, not the hospital. A common agreement in all the strikes was the creation of “Patient Care Committees” made up of administration, house staff organization and medical staff. These Committees addressed problems relating to patient care and to working conditions of interns and residents. The Role of the National Board (3)

Labor Relations

In late 1974, just as the series of strikes was beginning, the National Labor Relations Board (NLRB) Act was amended to WHATHASHAPPENED? include health care workers in nonpublic The Chronology of the Strikes hospitals. A number of house staff organizations appealed for collective bargainBetween November of 1974 and October ing recognition which would give them of 1975, four major strikes developed. They federal protection for organizing and baroccurred at Freedman’s Hospital in Washgaining. ington, D.C. for 9 days; in New York inThe issue to be decided was: “Are involving the New York League of Volunterns and residents employees of hospitals tary Hospitals for 4 days; in Los Angeles or are they students furthering their eduat the USC-Los Angeles County System for cation?” 7 days; and in Chicago at Cook County In March of 1976, the NLRB ruled by Hospital for 18 days. Although some of a 4 to 1 majority that interns and resithe local details differed, in principle the dents are students, not employees. Bestrikes were similar. The major issue was cause of the historic nature of this ruling the right of the house staff to bargain I would like to quote briefly from the collectively over (1) patient care items, NLRB ruling: and (2) a shorter work schedule. The adWe find that interns, residents, and clinical versaries were, on the one hand, the hosfellows are primarily engaged in graduate pital administration and, on the other hand, educational training at Cedars-Sinai and the house staff organizations. The administhat their status is therefore that of stutration opposed the house staff demands on dents rather than of employees. They parthe basis that they were infringements of ticipate in these programs not for the purpose of earning a living; instead they are managerial and departmental responsithere to pursue the graduate medical bilities. With the exception of Chicago, education that is a requirement for the the medical staffs appeared to remain practice of medicine. passive politically. The medical staffs I would like to point out that this ruling were, of course, expected to, and did fill the gap created by the striking house does not mean that future strikes will not occur. It only means that the NLRB will staff.

GERALD

S. MOSS: PRESIDENTIAL

ADDRESS

163

Related to the problems of bigness is what Max Lerner, a noted social commentator, calls “declining professionalism” [4]. WHY IT HAS HAPPENED? Given the beating most professions have Several elements combined to produce a taken lately, the politicians- Watergate; militant house staff. First, in some resi- the sports world-drugs and gambling; and dency programs the house staff was ex- medicine- Medicare- Medicaid frauds; ploited. That is, they were hired primarily medicine as a professional activity is under to carry out the business of the hospitalattack. Many young physicians denounce do histories and physicals, start IV’s, the concept that medicine is an elite hold retractors, and work long hours. activity-bound by the highest moral and Very little attention was paid to the needs ethical constraints. Instead they believe it of the house staff to be educated. This to be a vocation like many other vocations kind of residency was few in number and therefore unionization and strikes are and is constantly being disaccredited. The within the pale of acceptable activities. majority of programs today have full-time surgical teachers and graded programs of WHAT SHOULD WE DO? increasing responsibility. First, we should proclaim loudly that we Of much more importance than the few exploitive residencies is the problem of are opposed to house staff strikes. Our excessive growth of training programs. opposition is based on the fact that such The number of interns and residents has actions are immoral and unethical. We grown to 60,000 [5]. Along with the should never allow the patient to become a growth of house staff numbers has been helpless pawn in the political squabbles the increase in the size of teaching hospitals. between the house staff and administraMany teaching hospitals are now larger than tion. The idea that a house staff strike does 500 beds; lOOO-bedhospitals are no longer not prejudice patient care is simply not true. unique. In addition, teaching programs A house staff strike may weaken and someoften involve multiple institutions. It is a times destroy lines of authority and lines rare program which is conducted under a of responsibility. For example, during a single roof. The resident rotates from strike, the house staff attempts to dictate which patients they will see and which service to service, institution to institution, rarely getting to know the attending staff areas of the hospital they will cover. until he becomes the senior resident. The The hazards and uncertainties created kind of one-on-one relationships envisioned in such a setting are obvious. Even if the house staff leaders reject the by Halsted in a small program under one roof have been obscured. Many of today’s ethics and morality argument, they should large and complex residency programs realize that hospital strikes represent a suffer from a serious degree of depersonal- losing strategy for change. The fact that ization. While it is true that skills can be patients are victimized in such strikes developed in this setting, character building rapidly erodes any public sympathy. and role-modeling suffer. The human tendSecond, we should join the debate to ency to develop an allegiance to place define the proper role for the house and chief is inhibited. The house staff, staff. We should favor a professional rather frustrated by the inevitable inefficiencies of than a technician-worker role for them. large complex institutions, and deprived of No matter how vividly the difficult life of close association with the attending staff, the intern or resident resembles an exare beginning to view themselves as ploited employee, the resemblance is super“workers” who have a right to resort to ficial and is in no real way comparable collective bargaining. to a factory-bound industrial worker. The

not accept jurisdiction over labor disputes involving house staff organizations.

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American house staff officer’s tenure is brief and transient. More important, he is in the process of securing credentials which automatically catapult him to the pinnacle of economic and social advantage. For house officers, thus endowed, to assume the guise of trade unionist, is ludicrous in its pretensions, and destructive in its effects, we have already witnessed. On the affirmative side, we should emphasize to the house staff the mutuality of their interest and ours. We need to work together to come to grips with the serious problems facing academic surgery; to ensure that adequate resources are allocated to surgery; to limit administrative and government encroachment on our professional lives; and to recapture the warm regard of the public-at the moment lost in a maze of malpractice suits. Third, to meet the wholesome and legitimate concerns of house staff for better patient care, we should act to strengthen the concept of department governance as opposed to “Patient Care Committees.” We are presently at a cross-roads. It is likely that house staff activism will continue. If we remain passive, the results will be that important prerogatives now under the domain of the departments, will pass into Patient Care Committees. In that case, these committees will come to have a major role in deciding how hospital resources are used. For example, when and how much to invest in new equipment, nurse staffing patterns, and acquisition and promotion of resident staff. On the other hand, if we actively meet this challenge, another pattern might emerge. It would involve our surgical house staff in the realities of the nonclinical and administrative problems of the

surgical department. We should activate regular administrative meetings bringing together the house staff and the attending staff. Here is the required ambience where education and work schedules should be reviewed, not in Patient Care Committees. It is possible that interns and residents may have a more realistic understanding of certain hospital needs-such as the need for IV teams or the distribution and adequacy of night laboratory coverage. Their perceptions, where appropriate, should be incorporated into departmental policy and priorities. Then Patient Care Committees would serve no useful purpose and would hopefully disappear. CONCLUSION I believe the academic surgical community has a role to play in these changing times to defend high quality patient care and surgical education. If we have the courage to play that role, and the wisdom to play it well, the traditions of surgical excellence begun by Halsted will be defended and continue to prosper. REFERENCES 1. Curran, J. A. Internships and ResidenciesHistorical backgrounds and current Trends. J. Med. Educ. 34: 873, 1959. 2. Firor, W. M. Residency training in surgery. Birth, decay and recovery. Rev. Surg. 22: 153, 1965. 3. Housestaff Unionization and the Process of Graduate Medical Education. An Amicus Curiae brief filed with the National Labor Relations Board by the Association of American Medical Colleges, April 1975. 4. Lerner, Max. Watergating on Main Street (Special Report), The Shame of the Professions. Saturday Review, pp. 10-12, November 1, 1976. 5. McCord, M. T. Medical education in the United States, J. Med. Educ. 42: 231, 1973-1974 (Suppl., January 1975).