Treading Carefully on the Path To Union Membership

As clinicians, house staff have a great responsibility and importance to patients. But as subordinate trainees, they are rather powerless in the administration of the institutions in which they work. When conflicts arise between institutions and house staff, how should they be resolved? What are the tools residents and fellows must have to establish a position and to promote its acceptance? This issue is important because there are problems and conflicts that residents must tackle to improve their lot on both the national and local levels and because some residents have called for the creation of local or nationwide unions of house staff.

Our course on this path must be made with great care so that we retain the professionalism inherent in our clinical work while ensuring that we are not exploited. It is a very complicated topic, but it is one that we face now, and it will become even more complicated in the future as more of us work for health care organizations rather than on our own.

Residents should not be exploited, nor should their working conditions adversely affect patient care. The world of medicine has used many tools to protect trainees and to give them a voice. Local ad hoc medical groups, such as the Bell Commission in New York State, represent the input of senior attendings. National medical organizations, such as APA, AMA, National Medical Association, American Medical Students Association, and Association of American Medical Colleges, spend great amounts of time advocating for house staff. The Accreditation Council for Graduate Medical Education (ACGME) inspects residency programs to ensure they meet standards. And residents have their own organizations: House staff organizations (HSOs) are protected by the ACGME and have the ability to communicate with their institutions. Labor organizations do all that HSOs do, but, based on federal law, once organized properly, they are also able to negotiate wages and benefits and represent workers in contract discussions. Some of the unions that residents belong to are affiliated with national unions. A new labor organization is Physicians for Responsible Negotiation, which serves to bargain for residents but does not advocate strikes. It is highly useful for residents who are unfamiliar with labor law and who do not have the time to come to the bargaining table.

Among these advocates for residents, I generally support some sort of residents’ organization in every institution because it can improve patient care, protect education, provide mechanisms for communication, provide a forum for communication without fear of retribution, develop leaders, and offer services for residents. But some residents have joined, and others are interested in establishing traditional unions that reserve the right to strike or enact other work impediments to advance their cause; that is, they agree on a position for which they will bargain and for which they have the right to strike as a means to force the point. A strike could be collective as well: Others in the same unions may be asked to strike from their positions as a show of solidarity. Ultimately, no matter how nascent and evolving is this area, I think that all residents and all physicians must ask themselves as soon as possible a very fundamental question: Am I prepared to strike or otherwise impede the mission of the institution to achieve my demands?

To my knowledge there is one union that represents residents that uses strike or work stoppage as a tool: the Committee on Interns and Residents (CIR), which is affiliated with the Service Employees International Union, a large national union that represents health care workers from housekeepers to nurses. CIR is proud of its origins in representing house staff at Boston City Hospital (BCH), where in 1967 they held a “heal-in” to force an increase in their compensation. Short of a strike, during the heal-in they filled every bed in the entire hospital with nonpatients whom they refused to discharge, forcing the hospital to divert to the other overburdened hospitals in the city. Their threat to do the same in 1969 brought about further improvements in their compensation. I recognize the courage of these residents, but I also feel that, to the extent that it likely affected patient care, the function of BCH, the function of the other hospitals, the house staff in the other hospitals, and the community’s trust in BCH and its trust in BCH’s doctors in training, the heal-in casts a dismal cloud over the field of resident bargaining tools.

What scares me about nationwide unions for residents that utilize their right to strike or impede the function of the hospital? First is the matter of solidarity with other members of the union, both other residents and other categories of work. In such a situation, a clear conflict of interest may arise: Does the duty to the union supercede the duty to patients with whom the resident has an established caring relationship? A second, and related, concern is of the leadership of such a union. Who would make the decisions about negotiating goals? Who would make the policy? Residents? Union organizers? To be honest, I’d rather not have that responsibility; who of us would?

Finally, I have concerns about the effects that a union would have on the activities of the extant organized medicine. To me, advocating for the highest standards of patient care is the primary mission of any organized medical association, and, as I lamented in the last column, a splintered house of psychiatry or medicine will be less able to do that work if it must compete with different (even if just slightly) positions influenced by national labor organizations. If a union that uses the threat to strike becomes our voice, then we are all sunk because the issues we bring to state and federal bodies will become obfuscated in labor politics instead of being grounded in sound science and patient advocacy.

As you can tell, this is a very complicated topic that deserves intense scrutiny. You can expect your resident/fellow leadership to be providing you with a more comprehensive report on this subject within the next two years. We want to take a snapshot of the current state of affairs and explain the options available to house staff. I expect to tread the path carefully with you, all the while appreciating the slippery slope alongside. I hope that residents and fellows and attendings with experiences in this area will contact me to communicate experiences with labor organizations so that our survey is all the more complete. My e-mail address is [email protected]. ▪