Doctor, No?

by Trapper John

I was listening to All Things Considered last night with my flu-wracked wife, when we heard a piece about a lawsuit against a medical resident who'd just finished a 36-hour hospital shift. The resident in question, zonked out after an absurdly long shift,  rear-ended a college student and caused the student massive, unrepairable brain damage.  There was a weird tenor to the story, which focused on the safety aspects of residents driving home after pulling two-day shifts -- it was almost an afterthought when one of the commenters mentioned how incredibly unsafe it is to force medical doctors to diagnose patients, prescribe and administer meds, and generally be responsible for the well-being of sick people when the doctors have been rendered incompetent by fatigue.  As the NPR sidebar notes, "[i]nterns working 30-hour shifts in an intensive care unit made 36 percent more serious medical errors, including 5.6 times more serious diagnostic errors, as compared to those same interns when they were scheduled to work no more than 16 consecutive hours."  I don't mean to downplay the tragedy of auto accidents caused by sleep-driving residents and interns, but it seems to me that the bigger problem here is that our teaching hospitals expect doctors to care for patients on no sleep.  As the American Medical Student Association points out, we don't let truckers drive for more than 10 hours straight -- why the hell would we let doctors work longer than that in our hospitals?

Anyway, the NPR piece featured a representative from the Committee of Interns and Residents, the labor union that's had a good deal of success in organizing residents across the US.  The CIR rep spoke about the dangers to both motorists and patients caused by our archaic and willfully stupid overwork of residents and interns.  As my wife and I nodded approvingly, I said something like, "Yeah, the CIR is doing a good job -- but I bet that the NLRB is going to build on their decision that university TAs can't organize, and screw interns and residents too."

Call me Carnac.  I open the BNA Daily Labor Report this morning (subscription only, alas), and what do I see?   (Answer below the fold!)

NLRB 'Likely' to Follow Ruling in Brown,
Reverse Boston Medical, Attorney Predicts

DORADO, PUERTO RICO--Following the National Labor Relations Board's recent decision in Brown University that graduate student teaching assistants and research assistants are not employees covered by federal labor law, it is "very likely" that the board will reverse its 1999 decision in Boston Medical Center that medical interns, residents, and fellows are covered employees, a Philadelphia management attorney said Feb. 28 at an American Bar Association conference. The board ruled in Boston Medical, 330 N.L.R.B. 152, 162 LRRM 1329 (1999), that medical interns, residents, and fellows are employees protected by the National Labor Relations Act. Doreen S. Davis of Morgan, Lewis & Bockius said the same test the three-member board majority used in deciding Brown, 342 N.L.R.B. No. 42, 175 LRRM 1089 (2004 -- whether the relationship between the teaching assistants and the university is primarily academic or economic--leads to the conclusion that medical interns, residents, and fellows have a primarily academic relationship with the teaching hospitals where they work and should not be permitted to collectively bargain.

So the doctors that triage you, diagnose your illness, and order treatment for you when you check into an emergency room aren't actually doctors, according to the management oligopoly -- they're students.  Because it's not enough to work them to the bone in exchange for relatively little pay -- now the hospitals can strip them of employee protections and their dignity as medical professionals. 

This is an abortion from a labor law perspective, but it's even worse from a health policy viewpoint. 

Comments

[emptypockets]

I actually happen to agree that grad students shouldn't unionize (and felt that way as a grad student, too, fwiw) - don't know enough about interns to guess how comparable it is. But no unionizing a total red herring in this story. It is in nobody's best interest for interns and residents to be pulling these ridiculous shifts. It is basically no more than a frat-boy hazing ritual by the MDs who had to go through it themselves. The AMA ought to end it (or, if dollars speak louder than ethics, the hospital insurance companies should start threatening not to cover suits brought involving tired interns).

[Trapper John]

a frat-boy hazing ritual by the MDs who had to go through it themselves

That's it in a nutshell.

As for TA unionization -- there's a big difference between believing that TAs shouldn't organize, and believing that they shouldn't be allowed to organize. Which is your view?

[emptypockets]

TAs shouldn't organize vs. shouldn't be able to:

I'm conflicted on it, as I am on whether marijuana (or coke or cigarettes for that matter) should be legal. It's the conflict of believing I know what's best for myself & believing everyone else has no idea what they're doing and need to be looked after that causes it.

If I were forced to pick a side, I'd say TAs ought to be free to organize and universities ought to be free to drop them as registered students if they strike or otherwise don't satisfy their academic requirements (for example, holding students' term papers hostage).

[emptywheel]

emptypockets

Were you in a non-humanities field (and therefore probably getting more as a TA)?

Did you go to school in the current era, where upwards of 40% of classes are taught by TAs or in the halcyon days when TA taught a small fraction of the classes?

It seems to me the claim that TAs AND Residents aren't employees really ignores the economics of the institutions in question. We can't afford the tuition people pay now--and it's only kept within reason through increasing use of TAs. Ditto hospitals and residents.

[DemFromCT]

It is basically no more than a frat-boy hazing ritual by the MDs who had to go through it themselves.

No, it's a good deal more. it's cheap labor for hospitals. I lived in NYC when Cornell had a famous problem: Libby Zion, daughter of Sidney Zion, then a writer with the NY Times died unexpectedly while admitted at Cornell's New York Hospital (where many well-heeled patrons get admitted). Zion wrote extensively about it; her death was attributed to a combination of poor supervision by attendings over themedical interns and residents, and the long hours that the house staff worked. As a result, the 405 law was passed, limiting the hours they can work. My recollection is the CIR had some input there.

Good idea, mostly yes, but... check this out.

But because of New York State’s 405 law, which limits the number of hours residents can spend in the hospital, the situation is often more complicated. Once they reach the maximum number of hours, residents have to leave the hospital. No exceptions. And this means that hospitals are frequently left without enough medical staff to handle the caseload. On those nights, taking care of patients can get a little hairy. And at some New York hospitals, it’s a scramble just about every night.

With residents working fewer hours, hospitals have been forced to find ways to fill in the gaps. Most don’t have the money to hire more nurses or physician’s assistants. Even if they did, nurses and PAs willing to work the night shift are in extremely short supply. The well-intentioned 405 law, adopted to prevent exhausted residents from taking care of patients, has instead produced an often dangerous lack of supervision.

Every action has a reaction. And hospitals are hurting for money... newer technologies, the indigent care and competition all put pressure on the hospital dollar.

Not a simple situation.

Hey, in any case, I hope Mrs. Trapper feels better soon.

[Trapper John]

Well, that gets to the next point I was thinking about making, but didn't, because the post already raised two policy issues.

Do we have a doctor shortage? Wouldn't more doctors allieviate a number of the systematic problems in American health care, including the overwork of residents? And could the basis of the problem be how incredibly difficult it is to get into med school in the US? Do we need more med schools?

[DemFromCT]

If that article I cited is correct, it's not so much a doctor shortage as a continuity shortage. Longer hours allow continuity of care and limiting hours limits continuity. In fact, it may be a problem of attending physicians feeling like they've paid their dues and don't want to cover in the wee hours.

Some hospitals supplement the residents with non-physician providers like Physician Assistants. Others add attending physician 'hospitalists'. The trick is not pushing hours worked too far. I don't think there's one answer, but the root cause is undoubtedly the cost structure of American medicine. If hospitals can't afford coverage with trained doctors, they'll assuredly push the envelope on (cheaper) partially-trained ones. And remember, threatened Medicaid or Medicare cost cuts will only make things worse. So kudos to anyone sounding alarms over this, but it's not as simple as legislating hours or providing more doctors. The hospitals have to be able to afford to hire them..

[emptypockets]

emptywheel -- yes, you have called me out correctly. I was a grad student biology, and I know the situation in the humanities is much different. At one university I know of, in fact, I believe the science & engineering grad students were explicitly forbidden from joining the union -- by the humanities grad students themselves!

To answer your other question, I went to college in the modern era. The economics of modern universities are confusing to me. Why DOES tuition climb so quickly? It is not to pay all those TAs, or professors for that matter. Salaries, at least in my field, aren't inflating that quickly.

I think what it comes down to is a utopian vision of the university, where rational intellect and moral fairness prevail, and grad students and mentors engage in respectful debate as peers. Picket lines really expose the seamy underbelly of the modern university as a cash cow. I wish we would scrub that belly rather than wallow deeper.

...and to Trapper: it is not that hard to get into med school but it is incredibly hard to pay your way through it. If we lowered the up-front cost of med school we could select from a wider pool of applicants, select better students, and make more doctors. More med schools would help if it could kick off a 'price war' in tuition, but I don't see that as likely.

[jj]

if your wife is really desperate to get thru the flu, go immediately to amazon.com & get a copy of "Foods that Heal", by Dr. Bernard Jensen - the greatest Naturopath of the Century of Technocratic Medicine - wayyy ahead of his time. Look under "celery". If she's young, even her cough will stop in 10mins; if she's in her 70's she'll be through her usual weeklong flu in 2-3 days. (Juice up 4 stalks celery-3 organic- w/1 peeled grapefruit. Add pinch of cream of tartar. It costs ~$1.00 to get well immediately. I drank 4 in one day & 2 for a few days thereafter for insurance. In years since discovering that in desperation one yr. when I couldn't miss work, I drink one of those/week & have never gotten the flu since. P.S. You need a real vegetable juicer, as in Juiceman, etc. but after seeing what this simple glass of vegetable/fruit juice does to the flu, it'll so radicalize your understanding of health, the body, etc., that you'll be using it everyday thereafter anyway.) Good Luck - Pls. Post if you do it & it works!! It's worked for everyone I've given it to.

[DemFromCT]

My grandmother had the best recipe for colds and coughs. Chicken soup every day while ill, and put ten rocks in your pocket. Each day remove a rock. Guaranteed when the rocks are gone, you're better. And it doesn't always take all 10!

I'm not certain which other additives work (she always made the soup with celery). ;-)

My work place offers flu shots. I never fail to get one and haven't had flu in years. Still, the plural of anecdote is not data.

[jcberk]

University tuition rises because university costs rise. Professors' salaries aren't really the issue, since the neither the salary per professor nor the number of professors rises quickly.

Universities get their income from tuition, state support (for public universities), research grants, corporate sponsorship, and donations (including endowment income). Getting adequate state support is a constant battle with the legislature. In the case of science and engineering, where lab costs are large and rapidly growing, research grants were high around World War II and have declined since then. I don't know as much about humanities grants, but presumably over several Republican administrations they're down too. Corporate sponsorship and donations haven't grown enough to pick up the slack, so tuition goes up. (Often so does the number of undergrads, leading to even more classes being taught by grad students.)

Added to the funding problems, universities have more costs these days. They're building new athletic facilities and student centers to attract students. They have a larger number of professional staff dealing with the university-as-business, trying to recruit students and faculty, install new enterprise management software, and manage new construction. Increased healthcare costs also affect universities, which often have on-campus clinics, administer student health insurance programs, and pay generous health benefits to faculty and staff members.

So tuition goes up, student loan funding depends on politicians having their acts together, and grad students keep becoming employees in everything-but-name-and-benefits.

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