The cost of medical publishing is shrinking academic presses everywhere, but not at the University of New Mexico. There, a new journal flourishes under somewhat unusual circumstances — as an outgrowth of union bargaining by the residents.
The finishing touches are being put on the third issue of The Journal of Quality Improvement in Healthcare, which the residents themselves inaugurated two years ago. “They came up with the idea, and we — the faculty — were the cheerleaders,” said Betty Chang, MD, an associate dean for graduate medical education at UNM's School of Medicine. In fact, the writing and editing is done almost entirely by UNM residents.
Self-imposed editing duties by resident-union members? Faculty as cheerleaders for a union contract demand?
Welcome to the new world of collective bargaining for physicians-in-training. Often, union advocacy now is less about salary and benefits and much more about quality improvement issues, noted Heather Appel, a spokesperson for the Committee of Interns and Residents of the Service Employees International Union (CIR/SEIU). “There is more concern just about having a voice in that,” she said.
It's been 15 years since the National Labor Relations Board established residents as employees in addition to being trainees in an educational program. That decision gave them the same rights as other workers to organize into unions. The case, now known simply as Boston Medical, made a clear distinction between house staff and other kinds of students. Residents and interns were found to be directly engaged in patient or hospital care rather than solely involved in professional study. The finding also has been applied to teaching assistants at universities, who often are also enrolled in doctoral or other graduate studies programs.
Though the percentage of residents in unions is only about 12 percent, or roughly 13,000 members, union chapter formation has been ticking up steadily if slowly since that 1999 ruling. CIR recently added St. Barnabas Hospital in the Bronx, California Hospital in Los Angeles, and the Institute for Family Health, a Mt. Sinai affiliate in New York City.
The NLRB declined to revisit the residents-as-students argument for St. Barnabas, despite the hospital's request to review the Boston Medical decision. “This likely ends any further litigation over the status of medical residents as students rather than employees,” concluded an analysis in The HealthCare Employer, a newsletter covering current labor issues. (Jackson Lewis, Washington, DC.)
Even so, union membership among residents is relatively low compared with other areas of health care such as nursing, according to the American Medical Association. An article looking at the issue a few years ago found that registered nurses “fueled the trend” toward greater unionization in health care. They and other hospital-based employee groups actually showed union membership to be growing for health care practitioners and technical occupations amid a national descent in unionization. (Amer Med News, Feb. 22, 2010).
The differences between nurse and resident unions aren't surprising, noted Alec Levenson, PhD, a research scientist at the Center for Effective Organizations at the University of Southern California (USC) Marshall School of Business in Los Angeles. Most medical school graduates likely anticipate this notoriously difficult “hazing” phase of training, he said. “This is a period they've learned to expect; it's the way of becoming future doctors,” he said.
These physicians are also developing a special set of skills during this time, which requires building trust in the medical faculty who are instructing and working alongside them. “Union organizing could interfere with these mentor relationships,” he said, adding that residents also know the end-result will be entering a high-level profession. “And, in this situation, you don't see people organizing nearly as much. Graduate students, for example, don't organize this way,” he said, adding that this is true for most groups of individuals who seek postgraduate education in preparation for an occupation.
Four years after the Boston Medical decision, national guidelines to limit residency hours were issued in 2003 by the U.S. Accreditation Council for Graduate Medical Education (ACGME). These limits were refined over several years, culminating in a reduction of resident work hours to not more than 80 a week. An investigation of the decade-old change shows it has not negatively affected medical training, despite the argument made years ago that it would mean lower patient contact, which could adversely affect learning. (BMJ 2011;342:d1580.)
A residents' union can be a force for change, one that supports ACGME objectives, said David Sklar, MD, a professor of emergency medicine at the UNM School of Medicine. “I think we all pretty much have the same goals,” he said, adding that a focus on quality improvement is at the top of the list. The journal launch is just one example of that, he said; it was initiated during a dramatic downturn in academic publishing. (www.mla.org/pdf/schlrlypblshng.pdf.)
Dr. Sklar attributes the UNM union working “relatively cooperatively” with the faculty and administration in part to the medical center itself, the research hub of the state. Albuquerque, New Mexico's only major city, is surrounded by rolling desert, not sprawling metropolis. Partnerships between students, staff, and faculty spring up in this setting where the need to share resources appears to build relationships rather than raise competition, he said.
The residents' union closely aligned with the goals of the hospital administration when he was a member there, recalled James Heilman, MD, now a fellow at Oregon Health and Science University in Portland. “It's the county hospital. There weren't a lot of resources,” he explained. The union provided the infrastructure to pursue quality improvement measures, as shown by one outcome of collective bargaining: an allocation of $20,000 from UNM hospitals.
Those funds were used over a two-year period for a range of safety-enhancing projects, from a study of handoffs in the ED to generating a new intake form in obstetrics. The money helped launch UNM's journal, which published, among other articles, the results of the handoff study. The funding cycle is now a routine part of contract negotiation, Dr. Heilman said.
The idea for the monetary support actually came from CIR. Dr. Heilman said he couldn't speculate on how such animosity might develop among resident unions that seem to have far more fractious relationships with their administrations. But even UNM's resident union was not without conflict when it was being formed.
“It's probably different in safety-net hospitals,” he said. “It becomes a win-win,” he said, when everyone focuses on quality improvement in meeting the needs of a diverse and underserved population.
That's not to say a residents' union would function the same way in other settings, Dr. Chang observed. “It is a different person who comes here, to New Mexico,” she explained. “They come here because they want to be here, in a place a lot of people might have a hard time finding on a map, where there's an emergency underserved population that's not always easy to care for.”
Most of the emergency medicine residents at UNM seem to regard medicine as a calling, Dr. Sklar pointed out. “And this is what I love about it,” he said. “They're the most enjoyable people to work with, those who go beyond the personal benefit of what they are doing.”
This is one of the hallmarks of productive work with unions, according to studies that compare successful interaction between management and union members with those that have engaged in less effective bargaining. The situation appears to be sure set-up for an adversarial relationship, but in some places that is largely contained by two “commitment” factors: shared goals and a mutual search for the understanding of opposing viewpoints. That seems to have been what happened at UNM. Dr. Heilman proved steady and imperturbable, Dr. Sklar said. “He has enormous ability to encounter difficult patients and accept them and be able to communicate with them. I never once saw him lose his composure. In fact, he seemed to like problem-solving.”
And that's just what Dr. Heilman says about him. The collaborative spirit could be attributed to Dr. Sklar, Dr. Heilman stressed, noting that Dr. Sklar then headed the office of graduate medical education. “He was one of the biggest reasons that this [collaboration] happened,” Dr. Heilman said.
Can behavioral factors have that much influence on union bargaining outcome? Yes, according to labor-relations research by Paul Rainsberger, JD, an associate professor and the director of the labor education program at the University of Missouri, Columbia. He pointed out in an open-access paper (http://bit.ly/1dK3Ql2) on organizational labor that the best negotiation apparently occurs when leaders from both sides recognize a range of concerns and stress common interests; most unions are “neither mobs nor cohesive groups,” he stated.
That same sentiment also seems to have been laid out in literary form by Drs. Sklar and Chang who, along with colleague Benjamin Hoffman, MD, published their own findings about resident union membership.
“Unions, by their very nature as advocates for the needs of their members, risk encouraging resident union members to put their needs above those of their patients, which is an inversion of the most basic principle of medical professionalism,” they wrote. “However, if the union can help create a more equitable, effective institution through the engagement of residents in process improvements and enhanced clinical inquiry, then it may ultimately create a more professional environment and thereby enhance professionalism.” (Acad Med 2011;86:552.)
In fact, as resident unions evolve, they may provide the “leading edge” for a broader organizational process in medicine, the three suggested.
This is how a new kind of union is being hatched across the country. Some residency programs not represented by CIR/SEIU nonetheless have collective-bargaining units; they've formed in-house groups to accomplish that in states such as Washington and California. And recently CIR created an alternate path to union membership by offering a special category for affiliation to physician-residents in programs where no collective bargaining agreement exists. Dues are paid individually, not as automatic deductions from pay, in this form of membership. Residents who go on to fellowships can also retain CIR membership.
Such strides are being made when union membership is challenged, most notably in Harris v. Quinn, which reached the U.S. Supreme Court as of this writing. The high court held in 1977 that a single union could represent a group of public employees who would have to support the bargaining unit by paying dues whether or not they actually joined the union. The rationale was that even employees who were not part of the union were benefiting from its contractual gains. Home health care workers in Harris v Quinn contend that they should not be required to have to pay membership fees, in part because union representation allegedly is not necessarily meeting their needs.
Residents at the University of California, Irvine, in the meantime have filed petitions with the NLRB to have CIR recognized as their union, as have those at Elmhurst Hospital Center and at Mount Sinai Beth Israel.
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