The Fault in Our Systems – On Physician Unions
We are the future doctors of America.
Uneducated in finances, untrained in business and wholly ignorant of the structure of our healthcare institutions. Overwhelmed with increasing patient loads, unending sleep deprivation and the lack of a belief that any change in structure is possible, we trudge along our training tunnel clinging to the light of a six figure salary and a one day gentler lifestyle. And yet, as we travel, our inward cries, our quiet suffering cannot be ignored. Increasing rates of addiction (1,2) more and more frequent suicides (3) and the daily frustrated sighing on the hospital wards all echo through the corridors intermittently; a silent scream, begging to be heard.
I never wanted to be a doctor, nor did I really choose this path, but I found myself in this system one day, propelling towards an end goal amongst a demographic who had a different story. I looked around and saw a sea of people fervent for humanity and hoping to make a difference. But as we progressed through our residency training, the bright light I once saw inside them on that first day of medical school seemed to have somehow dimmed. No longer was there a daily vitality and a palpable enthusiasm, but instead, in their eyes, seemed a weariness, a brokenness, a desire just to survive.
What happened along the way?
I rarely hear a resident complain about the unfathomable mountain of debt they are under. That 200,000 dollar average seems a reasonable price to pay for a philanthropic career with a guarantee of future compensation. Nor do I often hear chagrin over the staple over 60 hour work week required (4)- they understand that this is necessary to shorten the duration of their training. What I do, however, often hear about-on a daily basis even; is the culture in which resident physicians are systematically treated, the manner in which they are interacted with and the conditions in which they work.
First to working conditions.
Residents are allocated an average of 112,000 dollars per spot by Medicare and government funding. A New York Times article in 2013 found that this number could in no way be justified by resident salaries and benefits or “direct” costs as they are known, and instead, the hospitals turn to “indirect” costs to justify the figure (5): a nebulous concept at best. Ask any resident in the country, and they will tell you that they are some of the most cost effective employees in the world. The bare minimum equipment necessary to perform their work is present in the hospital already – usually for the attending physicians to perform their jobs; they barely have call rooms where they attempt to get some rest on a 24 hour shift and these are furnished often with patient stretchers and hospital linens in tiny stark corners, and next to nothing is provided to these physicians on tiny salaries in the way of meal or book allowances. While a resident, in essence, lives in the hospital, they make do with whatever is allocated to them and rarely even ask if conditions can be improved. Certainly, the majority of residents, in my experience are largely unaware that this figure of government funding is allocated for their education. While residents take breaks when their work is finished, and not at scheduled times, often in contrast to nursing and ancillary staff, as well as attending physicians, they have no place to get away from the rat race and instead, resign themselves to eating cafeteria food, or warming a home made meal in a public microwave. These things may seem small, but we are talking about the most highly educated and well trained individuals in the world. The degree of respect offered is in no way equitable to the effort and sacrifices which are being made.
To the culture in which residents operate.
While the exception and not the rule in my experience, the disregard for resident value can also extend to a much more serious degree. In order for a resident to be terminated when they are judged incompetent by a program director, a thing called “due process” must occur. This means fair treatment through the “normal judicial system”. But what is this judicial system? Standards may vary widely depending upon the hospital resident employee by-laws. At some institutions, this may mean an unstructured probation period may be offered in which the allegedly incompetent resident is largely expected to improve his or her performance with little to no direction and oftentimes little help, the right to grant or refuse probation and the outcome of the same lies solely with the administration and superiors. When the resident is finally terminated, there is an appeals process. The appeals panel which the resident appears before is chosen by – you guessed it – the same people who decided to terminate the resident. Most program directors are resident advocates and people who genuinely care about resident education. They do not discriminate and do not favor residents. They are however, human, and a small percentage are neither fair nor just, and can take up a wholly personal grievance with a particular resident and get them to a place where they are up against this arbitrarily appointed appeals panel with little chance of remediation. No accountability is provided by an external body in this process. The law of the hospital is, in essence, the law of the land and the resident is now left with a once unfathomable, now unscalable mountain of debt and no qualifications with which to create any other means of income.
Finally to the manner in which residents are treated.
Graduate medical education committees exist in most teaching hospitals. This meeting consists of administrative figures and resident representatives and is a forum in which residents are asked to bring grievances and suggestions to the higher ups. While some residents do in fact make requests for things they feel will better allow them to serve their patients and ways in which the administration can improve their daily work environment, the majority of residents have reached a state of total apathy. Many requests which are brought up are dismissed as unreasonable, though, in my experience, for any other employee, they would not be deemed so, and of the other requests, while some are acknowledged or acquiesced to, even those are so slowly implemented that the residents themselves often forget that they have even made the request. As well as this, hospitals often and without warning, take unilateral action against existing resident benefits and privileges. Parking structures are changed, book and meal allowances are reduced, call rooms are taken away and so called protected time used for didactic education is systematically used for clinical duties instead. Add to this the daily insidious disrespect of some nursing and ancillary staff and the implicit agreement among all that this person who has MD or DO at the end of their name is not really a doctor yet, and you have the perfect recipe for a very dejected group of people.
The response of many, when the above issues are raised is often something to the effect of “stop your whining, this is how it is”, or if not that, something along the lines of “why are you so lazy? This is what I went through, and why shouldn’t you go through it too?” But is a person who works 80 hours a week and stays awake for 24 hours at their job over 6 times a month truly lazy? Does the concept of prior personal suffering justify the lack of action to alleviate that of someone else if it is within your power? Many program directors consider residents like sons and daughters to them. If your child had a headache, would you tell him to stop complaining and bear the pain because you once were afflicted with one too? Have we lost our humanity?
Or have we merely become deaf towards these trainees? Is the life of a junior physician, their burden, their suffering now unimportant because indeed one day they will make those six figures and have that gentler lifestyle?
But we turn momentarily to attending physicians.
The Wall Street Journal published an article concerning the happiness and satisfaction of attending physicians following their graduation and beyond. Among many disheartening statistics was the saddening fact that only 6% of a 12,000 physician survey describe their morale as positive (6), and in my own experience with my colleagues and superiors, I don’t find this to be untrue. While the majority are “making the best of it” and doing their work “for the love of the game” so to speak, a palpable dissatisfaction is invariably present. Physicians are dissatisfied with their hours, their pay and their lack of autonomy on the job. They feel under-appreciated, disrespected and disillusioned. Does this sound familiar? Perhaps the light at the end of that tunnel is not so bright as we first thought. Minor everyday things which seem to be attainable at first glance by any objective outsider, and which would dramatically improve the wellbeing and care of their patients (as well as the physicians themselves) are systematically and unilaterally refused or delayed by a hospital administration which has little to no medical knowledge or experience and certainly next to no patient interaction.
And herein lies the problem.
Medicine in America has become a business, and a lucrative one at that. My own institution, which is a “not for profit” declared a net income of several million dollars on its last tax return and continues to grow with mergers and acquisitions of other healthcare bodies. Urgent care facilities and clinics are sprouting up all over the country with one goal in mind-to generate revenue for their owners; and the executives who govern and run these corporations are invariably making spectacularly higher incomes than their medical staff (7). While the physicians, both in and out of training, continue to fight and advocate for their patients, ultimately, those in the black suits making decisions from their offices which affect these same patients and the physicians’ ability to care for them are really striving towards a different goal, and are much more concerned with public perception of their institutions, rather than the actual quality of care being provided at the same.
Enter the concept of a physician union.
Unions have long had a bad reputation for creating havoc and bringing to a standstill operations which were previously running smoothly, but in a place where opposing objectives exist, the smaller player in the game must have some backing in order to be able to approximate some equality. If physicians are the ones who know what is good for the patients, who can see where funds, time and resources should be allocated in order to best serve these patients and who themselves need to be functioning at optimal levels in order to provide the best care for their patients, shouldn’t their voice be heard when decisions are being made? But the final word in an organization striving for profits is not that of the physician, but that of the executives. Most physicians I know have no interest in the business aspects of running hospitals and medical institutions, and are happy to leave the functioning of the organization in the hands of those who have more experience and education in such matters; but I have never in my life met a physician who did not at some stage feel that they would like some input into how the clinical aspects of the institution were run. While without a union, the final word on all matters is in the hands of the men in well tailored suits, with a union in place, physicians now have administrative and legal backing in order to have a seat at the table when that final word is being uttered. Problems with working conditions can be brought to the attention of the higher ups and they are forced to deal with them without procrastination, analysis of where the funds are being allocated now must be more transparent, and accountability for why requests are not being granted can be provided by a union employed lawyer, and grievances with the system can be raised without fear of personal retribution. Power in numbers, as well as the oversight that government agencies like the National Labor Relations Board can provide are two invaluable things that are reaped as the result.
But there is no such thing in life as a free lunch. There must be some downfall to the process. Surely a union does not now provide a utopia where physician’s voices are always heard and administrations always listen without any fallout. And it’s true; this scenario does not exist. Unions are themselves a third party in the conversation, with their own agenda included in the mix. One of the primary objectives of the union is to generate profits for themselves, and these profits can only come from the people whom they represent. A percentage of your income as a physician is taken by these organizations in order to keep the wheel of their organization turning, to pay salaries to those who provide legal and business advice and to cover overheads of offices and accommodations etc. While this percentage seems more than justified during negotiations with administration, it is systematically removed from your paycheck whether or not any conversation is ongoing, and physicians can feel after the initial hoopla of contract negotiations that they are paying money and receiving no service at all. The second problem that arises with these organizations is that generating revenue is not the only objective of the external body. Often these organizations have global political agendas for how they think healthcare and government should be run, and this can escape into your dealings with your own hospital. There is, in effect, nothing to stop them from using you as a pawn and the institution as a platform for what they would like to portray to the media in order to further this agenda, whatever it may be. And finally, when you sign on the dotted line, you are in essence, handing over all your rights to negotiate with your own governing bodies independently. While unions often do not have a strong interest in intermediating between members and their superiors on a daily basis, it only takes one union member to contact them before every member is now obligated to communicate through them, a cumbersome and time consuming process for all involved. Finally, during the unionization process, unions often present a very strong case in their own favor on what is possible. When the rubber hits the road, sometimes the promises that seemed so plausible in verbal terms become less possible in concrete ways when negotiators on both sides and much legalese is involved.
As with anything else in life, there are pros and cons on either side, but because of the inherent conflicts in the end goals of physicians and medical institutions, the author feels that the presence of union representation, while not a panacea for all employment ails, can be a way to more closely approximate optimal conditions for its members and ensure that the front line implementers of medical care are able to have some input into the final appearance of their working environment. For residents especially, who tend to be undervalued and overworked as collateral damage of a system steamrolling towards its bottom line, unions can provide the protection, support and accountability that is so often absent if no such structure exists. Ideally, an open dialogue and cooperative conversation would be possible between physicians and their administrative colleagues in an environment where compromise is regularly reached, but if you feel like you’ve tried this path, and for whatever reason, no progress is possible, maybe it’s time to call a union; and finally have your voice heard.
1 Deborah Brauser, Substance Abuse in Medical Residents Rising; medscape.com; December 11, 2013 http://www.medscape.com/viewarticle/817608
2 A T McLellan et al; Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States, BMJ 2008; 337; a2038 http://www.bmj.com/content/337/bmj.a2038
3 Pamela Wible; Three young doctors jump to their deaths in NYC; idealmedicalcare.org; September 1, 2014 https://www.idealmedicalcare.org/blog/three-young-doctors-jump-to-their-deaths-in-nyc/
4 Neil Chesanow; Residents Salary & Debt Report 2016; Are Residents Happy?; medscape.com; July 20, 2016 http://www.medscape.com/features/slideshow/public/residents-salary-and-debt- report-2016#page=36
5 Catherine Rampell; How Medicare Subsidizes Doctor Training; nytimes.com; December 17, 2013 http://economix.blogs.nytimes.com/2013/12/17/how-medicare-subsidizes-doctor-training/?_r=0
6 Sandeep Jauhar, Why Doctors Are Sick of Their Profession; wsj.com; August 29, 2014 http://www.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361
7 Elizabeth Rosenthal; Medicine’s Top Earners are Not the MDs; nytimes.com, May 17, 2014 http://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html