[i] if these docs win, intern/resident unioniztion will sweep across the country... you can only cut corners so much when dealing with human lives. karen[i/]
march 31, 2003
by richard pérez-peña
for a decade, new york hospitals have talked about the need to be more efficient-to trim staff, attract patients, invest in technology and find less costly ways of delivering care.
at many places, it has been little more than talk. but montefiore medical center in the bronx has pulled it off, becoming one of the most financially successful hospitals in the city, a model that other hospitals look to.
now, that very success lies at the heart of a labor dispute that could have repercussions far beyond the hospital walls. many residents and interns, the hospital's doctors-in-training, say the pressure to do more with less is compromising their medical education and patient care, and they are trying to unionize, still an extreme rarity in american hospitals.
officials at montefiore dispute the complaints, and unlike the handful of other hospitals around the city where doctors have organized in recent years, montefiore is waging an aggressive campaign against the union drive. the hospital has taken several steps to delay or defeat a possible unionization vote and, more important, it is asking a federal government agency to rule that residents and interns do not have the standard rights of an employee group to unionize.
to the union, the committee of interns and residents, montefiore represents an enormous opportunity. it is one of the largest hospitals in the city, with more than 1,000 beds, and if the union wins, montefiore's will be the largest corps of unionized doctors anywhere in the country. union leaders hope that if montefiore, after putting up a fierce fight, fails to stop them, then other hospitals, at least those in the city, will fall like dominoes.
in short, montefiore, already a trend-setter, is seen by both sides in this dispute as setting precedents-perhaps national ones-in labor relations.
unlike many labor disputes, this one is not about wages. (montefiore pays interns and residents $43,000 to more than $50,000 per year, according to the hospital, similar to the scales at other premier teaching hospitals.) rather, the doctors' main complaint is that staff cuts have forced them to perform chores that used to be done by less-skilled workers, at montefiore's main campus in bedford park, in the northwest bronx, and at the campus in morris park in the east bronx, adjacent to the affiliated albert einstein college of medicine.
"to have to answer the phones, to have to draw the bloods, to have to wheel the patients to x-ray ourselves, that is not the best use of our time and our resources," said dr. stephen cha, a third-year resident in internal medicine. "that's time not spent on patient care."
the union contends that even as the number of patients treated has climbed rapidly, montefiore has reduced its work force within the hospital by about 5 percent over the last five years. hospital officials say that is an exaggeration, while acknowledging some reduction.
some doctors say that attending physicians-the doctors who have graduated from their residencies and are employed by the hospital-have been forced to spend more time on patient care and less on teaching interns and residents.
to the complaints of the doctors, also known as house officers, montefiore's president, dr. spencer foreman, said, "it was ever thus, and it will ever thus be."
"the house officers' notion of the way it should be is there should be a team of four people standing beside them," he said. "it would be wonderful but you couldn't keep the doors open. so everyone works like hell."
even so, he said, the hospital has listened to their complaints and has worked hard to respond. and he said the hospital has specialists with double board certification on duty-not on call, but on duty-around the clock in each of its critical care units, a rare and expensive investment in quality care.
the central figure in this fight is dr. foreman, universally known as spike, the hospital's leader since 1986, and a suave, canny administrator who is viewed by his staff as a figure of both admiration and intimidation. he is one of the city's longest-serving hospital chiefs, and one of the best paid, at more than $1.5 million a year in salary and other forms of compensation.
no one disputes that he has taken a hospital that was near bankruptcy and turned it into a success story. under him, revenues have doubled, admissions have nearly doubled, and the hospital has invested $1 billion in capital improvements and added one million square feet of space, including a new children's hospital loaded with such eye-catching extras as outer space-themed decor, plasma-screen televisions and internet connections in each room. in 2001, montefiore reported clearing $12.7 million on $1.2 billion in revenue-a 1 percent margin that would be considered meager in most businesses, but qualifies as robust in the troubled world of new york city hospitals.
other hospitals in the city tried to economize by merging in the 1990's, and often regretted it. dr. foreman resisted the trend. in an era when the city's hospitals have tried to save by shifting primary care out of their main buildings and into community clinics, montefiore's is one of the few clinic networks not considered a money-loser.
montefiore was an early convert to hospital marketing, holding itself out as a leader in pediatrics, women's health and cancer care, and it has succeeded in drawing large numbers of patients from the more affluent westchester county, improving its bottom line. montefiore has also invested heavily in high technology, becoming one of the first hospitals in the country to adopt a paperless system for tracking all doctors' orders, like prescriptions and blood tests-a practice that advocates say reduces medical errors.
but conversations with doctors reveal a widespread unease. "it's a great hospital and they've done some great things," said rob darzynkiewicz, a fourth-year resident in emergency medicine. "but we've got residents changing bedpans, which prevents us from seeing more patients. the doctor is ultimately responsible, medically and legally. we aren't going to allow these chores not to get done, even if that means doing them ourselves."
the idea of a union remains alien to most doctors and hospitals. attending physicians around the country have long had the right to organize, but they rarely do.
but until recently, the national labor relations board viewed interns and residents as students more than employees. as a result, they did not have the rights that federal law grants almost all worker groups: to unionize by a majority vote, in an election overseen by the board, with management obliged to recognize and bargain with the resulting union. residents' and interns' only real leverage to force management's recognition was to strike, an almost unheard-of step.
then, in 1999, in a case involving boston medical center, the labor board overturned its longstanding policy, and ruled that residents and interns were entitled to the same protections as other employee groups. since then, those doctors have unionized at only about a dozen hospitals around the country, half of them in new york city, according to the committee of interns and residents, an arm of the service employees international union.
montefiore has become the first hospital in the country to challenge that 1999 decision, asking the labor board to reverse itself again-a position that could delay any union vote until most of the residents who began the drive last year are gone. the hospital's request is the subject of a hearing that has been under way at the board's regional office since october. whatever the outcome, it will probably be appealed to the board, itself, in washington.
"the house staff represent a class of person who are indistinguishable from any other class of students," dr. foreman said. "the union-management interface is not the appropriate one in an educational setting. i think the boston decision was wrong."
under the boston ruling, residents and interns at each hospital are lumped into a single bargaining unit with attending physicians, unless both union and management agree to treat them separately. other new york city hospitals that have seen union drives have agreed to divide the two groups.
but montefiore has insisted that any vote, if it comes, must include all the doctors-a position that will make it much harder for the union to win such a vote. montefiore is one of the few teaching hospitals where the hospital, and not the medical school, employs the attending physicians. that means that at montefiore, unlike most hospitals, attending physicians outnumber residents and interns, by about 1,200 to 800.
while an overwhelming majority of residents and interns signed a petition last year seeking a union vote, a fairly small minority of attending doctors signed. in interviews, attending doctors were less likely than residents and interns to be sharply critical of the hospital-and much less likely to allow their names to be used.
doctors say that since the unionization drive began, the hospital has, as one put it, "thrown candy at us," in an attempt to win them over. in the last year, residents and interns have received a $500 textbook allowance, new health benefits and parking privileges and free meals in the hospital cafeterias, and they have been promised a raise in july.
"they're obviously taking this organizing drive very seriously, as are we," said michael phelan, organizing director of the committee of interns and residents. "this one could be a watershed for us and the industry."
montefiore has a long record of milestone labor relations. decades ago, it was one of the first hospitals in the city to recognize and bargain with 1199, the union for most hospital workers, and the committee of interns and residents-well before the law required that they acknowledge the unions.
then, in 1981, residents and interns struck seven municipal hospitals, defying a court order. in solidarity, they struck montefiore, too, enraging its administration. montefiore rescinded its recognition of the committee, and 22 years later, the union still has not regained that status.