Trends and Ideas

November-December 1999

Are Medical Residents' Groups Unions?

The American Medical Association (AMA) has recently found itself embroiled in a question on which its members — especially those involved in physician education — have sharply differing opinions.

According to American Medical News, the AMA has for the past 18 months been helping medical residents form independent housestaff organizations (IHOs) to negotiate with the administrators of nearly a dozen teaching hospitals about such issues as working hours, wages, and patient care.

IHOs are needed, the AMA says, because as teaching hospitals lose federal dollars, they try to make up the difference by increasing residents' workloads, thereby threatening to dilute the quality of both patient care and resident education. IHOs are professional organizations, not trade unions, the AMA maintains. "There are some parallels [with unions]," said Randolph D. Smoak Jr., MD, the AMA's president-elect, "but we are encouraging residents to form IHOs as an option to unions when they have substantive issues and cannot resolve their differences with institutions in any other way."

In some teaching hospitals — those at the University of Michigan and New Orleans' Tulane University, for instance — faculty members have helped their residents form IHOs. "Residents who are actively involved in committees help me do my job better," said Richard F. Foulkes, MD, PhD, Tulane's associate dean for clinical affairs and graduate medical education.

But not all schools are so cooperative. The faculty of New York City's Montefiore Medical Center joined administrators last year in rejecting an IHO proposed to represent its 1,100 residents.

Montefiore's resistance was only strengthened this June when the AMA voted to create a national bargaining organization for physicians. "Any IHO connected to the AMA is a potential labor union," said Spencer Foreman, MD, Montefiore's president.

Foreman, an AMA member and a former chairperson of the Association of American Medical Colleges, added: "The AMA lost its professional standing when it declared itself to be a union. No way will we allow the AMA to come in and help residents form an IHO union. They can't have it both ways."

African Americans Hit Harder by HIV

Although African Americans represent a disproportionate part of the HIV epidemic in America, a widespread distrust in the African-American community for the U.S. healthcare system has hampered efforts to make gains against the disease among blacks. Recognizing this problem, health officials are calling for special HIV prevention and treatment programs aimed at people of color, reports AIDS Alert.

Since 1996, the number of AIDS cases and deaths among African Americans has surpassed that of white Americans. Advances in HIV treatment and education and prevention campaigns have resulted in a decline in AIDS cases among white Americans, but blacks have not shared in this progress. Distrust among African Americans for the U.S. healthcare system and for white clinicians is deeply rooted in memories of unethical experiments conducted on African Americans in the past, and complicating the trust problem is a widespread urban myth that HIV was created by U. S. public health officials to harm black people.

In response, the federal government has stepped up efforts to increase HIV and AIDS awareness among blacks through grants to pay for HIV research and prevention programs in the African-American community. Black leaders and clergy are also pushing for greater prevention efforts in their communities. For example, the city of Philadelphia has joined with Bristol-Myers Squibb Company and other organizations, including the Black Clergy of Philadelphia and Vicinity, to form a partnership called Project New Covenant, which is designed to raise awareness of HIV and AIDS and promote HIV prevention, education, testing, and treatment in the African-American community. The educational efforts are coordinated through Philadelphia's 400 black churches.

Clinicians' efforts to treat African Americans can be helped by acknowledging trust issues, addressing worries about quality of care, being sensitive to the cultural stigma attached to homosexuality and AIDS in the black community, helping African-American patients find support networks, and working on communication and building self-esteem.

Robotic Dispensing Machines May Change the Future

Can robotic devices help pharmacists become more effective clinicians? Addressing this question, Health Management Technology points out that as computerized pharmacy systems grow beyond simply dispensing floor-stock, the role of the pharmacy department in product services can be greatly diminished.

The joke that robotic devices "can work 24 hours a day, in the dark, no coffee breaks, vacation days, sick days, or excuses" has much truth to it. Automated dispensing machines on nursing stations can communicate medication charges, store hundreds of medications, and maintain full patient profiles.

While computer software cannot replace competent pharmacists, fewer ancillary and licensed pharmacy staff will be needed to fill carts. Pharmacy staff can then be removed into clinically oriented roles, spending more time with patients, preventing medication errors, monitoring medication usage, and reducing costs where appropriate. Newer medications often are prescribed without regard to cost by physicians, who rely on pharmaceutical sales representatives.

The real problem may not be automation but convincing administrators of the vital role of clinically oriented pharmacists and their efforts at improving outcomes and containing costs. Pharmacy managers need to promote what is happening in their department to the rest of the facility, or they can "watch more and more paychecks be made to the robot that doesn't take coffee breaks, or sick days; that same hunk of metal that can't improve patient outcomes."

Willpower: Fact or Fiction?

Willpower, or the lack of it, has long been considered a factor in weight loss or gain. Recently, however, the concept of willpower has been discredited as outdated. In an article in the New York Times, James C. Rosen, PhD, professor of psychology at the University of Vermont, says, "there is no magical stuff inside of you called willpower that should somehow override nature." Simply telling an overweight person to use willpower to lose weight is comparable to telling a clinically depressed person to "snap out of it," according to Rosen. Weight loss, like depression, requires psychological or chemical intervention.

Since the mid-1960s behavior modification has been the accepted approach to long-term weight loss. Dieters are encouraged to write down what they eat and their moods before eating, to eat before grocery shopping, and to read or call a friend instead of eating. Evidence also indicates that the brain's chemical balance affects behavior. Drugs like fenfluramine, half of the now-banned fen-phen combination, are used to reduce appetite. "Night-eating syndrome" — overeating in the evening and getting up during the night to eat — has been connected to below-normal levels of the hormones melatonin, leptin, and cortisol.

Michael R. Lowe, PhD, professor of clinical psychology at the MCP Hahnemann University, Philadelphia, believes that the concept of willpower is "explanatory fiction." His behavioral approach to weight-loss includes having a positive attitude and learning to take practical steps before winding up in front of the television with a bowl of potato chips. Lowe also thinks it is important for dieters to be aware of the "toxic environment" — one in which high-fat, high-calorie fast foods are cheap and easily available, and lifestyles are sedentary. These forces work against the dieter's so-called willpower.

However, some experts believe it is a mistake to dismiss willpower altogether. Kelly D. Brownell, PhD, director of the Yale Center for Eating and Weight Disorders, contends that a "collective public loss of willpower" exists due to the same environment that Lowe describes. Brownell believes that people need willpower now more than ever.

Regardless of whether willpower exists or not, the National Weight Control Registry has documented thousands of people who have lost at least 30 pounds and kept the weight off for more than a year. Some learn to live with an apple pie in the refrigerator — exercising their willpower — while others arrange their lives to avoid the apple pie altogether.


Copyright © 1999 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Trends and Ideas, November-December 1999

Copyright © 1999 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.