At first glance, Phil Zakowski looks tired. He is tall, thin fatigued. He had just finished working 36 hours straight on about three hours' sleep. He usually works more than 100 hours a week. He looks tired because he is.
Phil Zakowski is a first year medical resident, what used to be called an intern. and he is typical of the 60,000 or so residents in training programs across the country. Zakowski doesn't claim to work any harder or longer than anyone else in his position. That's why Zakowski and other residents beleive a bill pending in Congress that would allow them to organize unions should be passed.
The bill has gathered an odd alliance of supporters. In addition to the people directly affected, the bill is backed by the AFL-CIO and the American Medical Association. Nobody can remember the last time those two groups were on the same side of an issue.
The principle opponent of the legislation - besides every hospital in the country affiliated with a medical school - is the Association of American Medical Colleges.
Supporters of the bill argue that it will help improve quality of Medical care and make working conditions for house staffs of hospitals more reasonable. Opponents of the bill assert that it will increase medical costs and disrupt the process of medical education.
The central issue on which the debate has focused is: are residents to be considered employes rendering a service or students getting an education? Residents say they spend more time working than learning and hospitals say they are students who perform some work.
"It's almost impossible for an individual to set up practice without that additional experience." Dr. John A.D. Cooper, president of the Association of American Medical Colleges, said in an interview. "The general understanding is that (residency) is part of the general education and training of a physician."
Jay Dobkin, a physician who is president of the physicians National House Staff Association, emphasized in an interview that residents provide a service and that hospitals charge patients for it. Cooper, however, scoffed at the argument that residents perform a service and should be treated as employes. "So does a third-year student," Cooper said. "Are we going to unionize him . . . They're not working. They're learning."
The training residents receive, according to Dobkin, "is by no stretch of the imagination the kind of . . . academic experience that they would like people to believe, and they know it. The training, if anything, is more like an apprenticeship experience than anything else - learning by doing rather than a classroom experience."
Residency. according to DObkin, is something other than the "hothouse, controlled type of experience" that opponents of the legislation project. Residents, he said. "don't have a well-rested professor of medicine standing over them at 3 in the morning when they're trying to resurrect a drug overdose victim."
Dobkin and others who support the bill do not rest their case solely on the employment question. They also argue that residents, by working 80 to 100 or more hours a week, are not providing the best quality medical care.
Zakowski described his schedule as seven days a week, begining at 8 a.m. and lasting until the work is done in the evening, working every third night night and sleeping when he can and working through the following day. "Sometimes I think patient care really suffers the day after you're on call." Zakowski said. "Today I was really dragging myself around. I had to think things through slower. I don't say it's a life or death problem, but throughout the year I noticed a number of minor mistakes I made the day after I was on call."
Cooper indicated he did not believe that patient care suffered because of the long hours residents work. "If they moonlight after 110 hours a week, that quality is all right? Is that correct?" he asked.
Supporters argue that hospitals want it both ways - telling insurance companies that residents perform a service for which the hospitals should be compensated and then telling residents that they are students. Opponents say the legislation will inject the National Labor Relations Board into medical education, forcing it to resolve disputes between faculty and students.
The National Labor Relations Board ruled in 1976 that house staffs are "primarily student" and not employes within the terms of law passed by Congress in 1974 allowing private nonprofit hospital employes to organize. Despite statements during the debate that the bill was intended to cover house staffs, the NLRB ruled first-year residents at George Washington University Hospital receive $13,700 a year and the figure is increased every year so that a sixth-year resident gets $18,300 otherwise. Now Congress is being asked to reverse that decision.
The pay residents receive varies according to their specialty and hospital. The national average ranges from $13,145 for the first year to $17,458 for the sixth year.
"That's not a low wage for someone supposedly not readly for independent practice," said Dr. Ronal Kaufman, vice president for medical affairs at George Washington University.
Although Dobkin said pay was not the main issue, Kaufman said he was skeptical about that. Collective bargaining, he said will "inevitably" lead to demands for higher pay. "The only reason they want to have collective bargaining is to raise pay and benefits." About 12 percent - $5.3 million - of George Washington University Hospital's $45.3 million operating budget pays the hospital's 358 residents.
If the legislation passes, Kaufman said, he he foresees bills to patients going up, too. "It's another aggravating factor which we - and by that I mean the country - don't need."
Kaufman said he did not argue that residents should receive the same low pay that he and others got 20, 30 or 40 years ago when they were residents. "They're a new generation with a different mindset. I don't criticize them for that," he said. "They deserve a decent living. But I think they have that."