Interns’ Rx for Better Care : Medicine: Long shifts and workweeks are taking their toll, residents say. They’re affiliating with unions in hopes of gaining better working conditions.

Before she became a doctor, Dr. Susan Londerville worked as a secretary--in union and non-union shops. “The difference was like night and day,” she said recently. When she searched for a residency program after graduating from medical school, she chose Highland Memorial Hospital in Oakland “partly because it had a residents’ union.”

When you are a doctor in training, “people really abuse you,” she said. Her motivation in going to a union hospital was not just about making her life easier but to seek protection against bad working conditions that could result in poor patient care, she said.

Dr. Stanley Borg, a senior resident at Martin Luther King/Drew Medical Center, is in a union, too, the Joint Council of Interns and Residents. But Los Angeles County sapped the union’s strength--intentionally, according to union members--by transferring some doctors to the University of Southern California payroll, where they are not eligible for membership.

Convinced that neither the people who control hospitals nor the medical establishment would address their concerns, a group of California interns and residents have taken unionization among physicians to a new level. The California Assn. of Interns and Residents, about a quarter of the state’s 8,000 resident physicians, last month signed an affiliation agreement with the Service Employees International Union. CAIR includes a group of house staff organizations that bargain for interns and residents at specific institutions around the state. But its affiliation agreement with SEIU is the first time nationally that physicians-in-training have joined forces with an AFL-CIO member union.

Among CAIR’s major goals is a bargaining agreement with the University of California, which employs more than half of the state’s resident physicians. The agreement includes a provision exempting the doctors from SEIU strike activity.

SEIU, the nation’s largest health-care union, counts a very small number of other physicians who work for public hospitals among its nearly 400,000 health-care workers. But that might change soon, said Dan Stewart, organizing director for SEIU’s health-care division, because an increasing number of doctors are salaried workers instead of professionals with their own business. “They are employees of HMOs (health maintenance organizations), or a group practice, or some doc-in-a-box chain (independent emergency clinics),” he said. SEIU is getting a trickle of interest from HMO doctors who want to know about the union but “aren’t yet sure how their colleagues will feel,” Stewart said.

On the surface, the California doctors’ alliance with SEIU is about a common labor concern: the quest for reasonable working conditions. But the unionization move also highlights a generational difference between young doctors and some in the medical establishment over what it takes to produce a competent, dedicated physician.

“We had approached the administrations. We just found them to be unresponsive,” said Dr. Carole Maccauley, the CAIR president who in June completed a residency in pediatrics at the UC Irvine Medical Center.

The major issue, CAIR said, is working conditions, including workweeks that stretch to 100 hours or more and shifts as long as 40 hours. CAIR also complains of physicians being made to perform tasks that they say are not essential to learning how to be a doctor. Broken promises from hospital administrations are another issue, Maccauley said. Others say they hope SEIU will give them the strength to prevent such tactics as Los Angeles County’s move against the Joint Council of Interns and Residents.

CAIR signed with SEIU less than a month after the American Board of Medical Specialties vetoed a recommendation by the Accreditation Council for Graduate Medical Education to put some limits on work hours for interns and residents. It would have allowed residents to be on overnight call no more than once every third night and would have guaranteed at least one day off a week. The proposal was supported by some teaching physicians, but it faced opposition from surgeons and other academics. The board said the measure was too specific to be applied to all residency programs.

Interns and residents must put in long hours, said Dr. Ralph C. Jung, director of graduate medical education at the University of Southern California Health Sciences Center. “Interns and residents are apprentices. They are learning to intensely apply what they learned in school. This finite period--three to seven years, depending on the specialty--is the last opportunity to give them an intensified training to prepare them for the level of intensity in the profession. The question is, does the level of intensity have to be as harsh, as bad or as severe as some think it is?” he said.

Part of the disagreement among his peers and doctors such as those in CAIR is generational, Jung said. “Young physicians are not willing to accept what physicians of my generation--the over-45 generation--were willing to accept as part of being dedicated to the field of medicine,” he said. “There has to be an element of give and take on both sides. . . . Eighty hours is a reasonable compromise, so long as it isn’t a hard-and-fast rule,” he said.

USC, the UC system and other private medical schools have proposed guidelines to limit residents’ hours on a specialty-by-specialty basis. For its part, UC maintains that implementing the recommendations will require the General Assembly to give more money to the UC hospitals.

The older generation of physicians was overwhelmingly young, single men “who lived in the hospital” when they were interns and residents, said Londerville, who is in her second year of a three-year internal medicine program. “Residents today are adult men and women, people who are married, with a life,” she said.

Additionally, today’s interns and residents must do more during their working hours than the older generation simply because of the advances in the practice of medicine, she said. “There are more drugs to deal with. There are many sophisticated techniques to find out what’s wrong with a patient,” she said.

The interns and residents say they typically work 36-hour shifts, but there is no such thing as a strictly defined shift, Londerville said. For example, she said she started one day last week at 7:30 a.m. “I admitted all patients until midnight,” she said. Highland has a “night float” system in which a new group of residents and interns over night take care of patients admitted during the day. But Londerville said she had more work and didn’t get to sleep until 4 a.m. “I was awakened at 6 for a patient with a problem, and I worked throughout the day. . . . You work until the work is done,” she said.

The concern about their long working hours overlaps with concerns about patient care, the interns and resident said. The long hours take a toll, they said. And although a few long weeks is not bad, Londerville said, “after six months of it, you’re hardly human. . . . I’m not safe to drive a car after 40 hours on call,” she added, yet “I’m expected to make life or death decisions.”

Academia’s effort to establish some uniform work rules through the process of accrediting physician training programs came after states indicated that they would put limits on work hours. The New York State Health Department last year became the first to use state authority to mandate that interns and residents in most training programs work no more than 80 hours a week. The rules also ban shifts longer than 24 hours and require more supervision of the young doctors.

The New York rules followed wide publicity of the death of the 18-year-old daughter of a prominent New York City journalist and author. The young woman died while in the care of interns and residents working the late-night shift at New York Hospital in Manhattan. A grand jury investigation found no criminal violations, but the panel was shocked at the residents’ working conditions and recommended major changes in training programs.

“That’s the shame of it. Does someone have to die for action to be taken?” said Borg, president of the Los Angeles County union. Borg’s group supported a bill to impose similar limits in California. But the General Assembly killed the legislation in August. The California Medical Assn. opposed it, Borg said.

“These are health and safety matters. It is increasingly dangerous within these institutions,” CAIR Executive Director Allen Brill said, citing a UC-San Francisco survey showing that a quarter of residents in one department of the teaching facility had accidentally stuck themselves with needles--a frightening statistic in the era of AIDS. “Residents don’t get disability benefits,” Brill said.

Long working hours and accidents are probably related, said Dr. Bill Plautz, a resident at San Francisco General Hospital and CAIR vice president. “Common sense would tell you that if you work people that long, that fatigue will set in, and mistakes and accidents will happen. . . . Interns and residents are handling deadly materials--infected blood and the like. It would make sense to provide them with some protection, just as airline pilots and truck drivers get some protection,” Plautz said.

Exacerbating matters, the interns and residents say, is that many teaching hospitals won’t hire adequate support staff and use interns and residents to fill the gaps. “Interns and residents are the putty that fill in all the cracks at the hospital,” Londerville said. “If a patient needs an EKG and there is no technician on duty on the weekend, the resident has to do it.”

Interns and residents have a harder time in county hospitals, Borg said. “Your exposure is twofold,” he said. The county recently cut staff at its outpatient clinics, he said. The patient load hasn’t decreased, so “the people who pick up the slack are the interns and residents.”

The staff cutbacks make it more difficult for people to take advantage of preventive outpatient services, he said. More end up in the hospital, further taxing “an already stressful situation” for the staff. Interns and residents do some chores because there aren’t enough nurses, he added. “It is not uncommon that, if a patient needs to go to surgery, for the interns and residents to put him on a gurney and take him there,” he said.

Borg said his group--at one time one of the largest unions of interns and residents in the county--decided not to join CAIR because it wants to see how the affiliation with SEIU works out. The union has had a contract with Los Angeles County for nearly 20 years. But it is suing the county because the transfer of interns and residents at County-USC Medical Center to the USC payroll cut the union’s membership to about 800 doctors working at King and Harbor UCLA Medical Center from about 1,500.

The County-USC interns and residents receive a stipend and have no collective bargaining rights, Borg said.

The courts have given the county until 1991 to prove that the transfer of the County-USC staff was designed to save money instead of destroying the union, Borg said.

Although his group did not join the SEIU affiliation, Borg said, he was in favor of the move. “My personal opinion is that the affiliation can only be beneficial. . . . Interns and residents are caught in the middle between being a student and an employee,” he said.

THEIR COMPLAINTS

An organization representing about one-fourth of California’s 8,000 medical interns and residents has affiliated with the Service Employees International Union, the nation’s largest health-care union. The affiliation is the first such alliance with big labor.

The doctors-in-training have these chief complaints:

* Long hours: The workweek sometimes extends to 100 hours, with single shifts of up to 40 hours.

* Safety: Fatigue can compromise patient care and increase the risk of accidents--such as needle pricks--that could expose doctors to infections.

* Irrelevant work: Tasks such as drawing blood, running tests and transporting patients are often done by interns, they feel, because hospitals lack adequate support staff.