In yet another sign of the growing crisis in the U.S. healthcare system, doctors are increasingly joining unions.
While many Americans may think of labor unions as structures for factory workers and cops and teachers, nurses have been unionized in many places for many years, and a surge in nurse labor unions is not particularly surprising. But doctors have not joined in large numbers until recently.
The specter of a doctor going out on strike when you need a heart transplant is daunting for many patients. But unionization of doctors has come from a very hard place, where doctors feel that unions are the only way to protect themselves from exploitation by corporate giants, according to Joe Crane, an organizer for the Union of American Physicians and Dentists, affiliated with A.F.S.C.M.E. and the A.F.L.-C.I.O.
Unionization of doctors really picked up within the last 10 years, he said. Before that, most physicians were still self-employed, largely; owners of practices didn’t have a reason to join. But that has “drastically changed,” he said.
A push from Covid
“When Covid happened, to let no good crisis go to waste, the hospital systems and these corporate practice management groups came in and promised all kinds of things,” he said in a Zoom interview. “If you give us your practice, you become an employee, and we’ll take care of all the headaches for you. And physicians are finding out what other people in this country have been experiencing when you work for somebody else.”
In October 2023, the largest healthcare strike on record, against Kaiser Permanente, resulted in a settlement. Kaiser and its unions disagreed on pay and investments in staffing. Clearly, the union action was a deciding factor.
“Unionization is neither a rash reaction to professional frustrations nor an upstart, leftist political movement; it is a natural consequence of hospital consolidation and the corporatization of health care delivery,” Kevin Schulman, M.D., and Barak Richman, J.D., Ph.D. write in the New England Journal of Medicine. “Physicians can find that management seems to view their service as a financial drain on the organization. Executives may also consider physicians to be largely interchangeable, despite such matters as clinical focus or tenure in a community or at a facility. Amid shifts in practice structures, physicians may experience a deterioration in their working conditions, job satisfaction, and — most important — involvement in the governance of health care delivery, which has prompted some critics to warn that physicians are becoming ‘cogs of capitalism.’”
Doctors as employees, as opposed to private practice owners, are becoming more common. “Between 2012 and 2022, the share of physicians working in private practices declined by 13 percentage points from 60.1 percent to 46.7 percent,” Victoria Bailey writes in RevCycle Intelligence, citing an American Medical Association study. “The share of physicians directly employed by or contracted directly with a hospital grew from 5.6 percent to 9.6 percent. Similarly, the share who worked in a hospital-owned practice increased from 23.4 percent to 31.3 percent. In 2022, 4.5 percent of physicians worked in a practice owned by a private equity firm, the report noted.”
Several unions
Crane said his group is one of the two major unions of attending physicians in the United States, with 7,000 members in California, Washington State, New Mexico, New York and Washington D.C. He is the organizing coordinator for a division in the Pacific Northwest. The union was founded in 1972 by a private practice physician; the site says they work in large hospital systems, nonprofit clinics, state facilities, county facilities, universities and private practices.
He said the Doctors Council, primarily on the East Coast, is another big doctors union. They say on their site: “We are the country’s oldest and largest union of attending physicians.
We believe in quality, affordable, and safe health care as a basic human right.” Doctors Council is affiliated with the Service Employees International Union (S.E.I.U.).
At a Starbucks, Crane said, unionization might focus on things like improving working hours or wages. The stakes are much higher for physicians, he said. “High patient volumes and unsafe working conditions lead to very real negative outcomes, which are possibly death of patients. They’re unionizing because they’re being squeezed by hospital systems, by venture capitalists groups, who are literally making a profit off of your families, who are sick. Doctors have haven’t historically needed to unionize. And now they they need to unionize, or we’re in trouble.”
What are the other big physician unions? The Committee of Interns and Residents, part of the S.E.I.U., he said, with over 30,000 members — with interns and residents fighting not to work more than 80 hours a week for minimum wage. Some Veterans Administration doctors are represented by A.F.G.E. / American Federation of Government Employees. Pacific Northwest Hospital Medicine Association (PNWHMA) is part of American Federation of Teachers (A.F.T.). An S.E.I.U. 1199 unit in Florida that represents one hospital, including doctors, with “random pockets elsewhere” like a California hospital represented by S.E.I.U., Crane said.
Patient satisfaction scores
What have been the biggest triumphs in unionization? “Every group is different,” he said, citing three examples.
One hospital-based group was required to “earn back” 10 percent of their salaries based on satisfactory scores at the hospital on the patient satisfaction scores on the Press Ganey survey, he said. “Some of those satisfaction scores at the time were literally how clean was the bathroom, which obviously has nothing to do with an encounter with a physician,” he said. “So we’ve been able to get rid of things like that, so they get all of their salary.”
For another group, he said, they were able to negotiate on closing times at an urgent-care center. Hours were 8 a.m. to 8 p.m., he said, but on occasion when a patient came in right before closing time, members would have to continue seeing patients. The promise of a 12-hour day with 35 patients could become a 15-hour day with 70 patients. So the union negotiated a “stop valve,” meaning if there were a certain number of people in the waiting room at 6:30 p.m., then the clinic would shut.
“Study after study has proven that the longer you work, the more errors happen,” he said. “And errors in healthcare mean bad patient outcomes.”
They have also negotiated professional judgment clauses, meaning that their doctors are the ones who get to say “this is what is best for my patient.” What happens in some workplaces, he said, is the management organization says “we want you to tell patients to get follow-up treatment here, because of a sweetheart deal,” or “I want you to prescribe this drug,” and union members negotiate to get the right to say “no, that’s not the best for my patient.”
Obstacles to organizing
What are the biggest obstacles to organizing doctors?
“Physicians have historically been independently practicing medicine,” he said. “Now they are coming together and being employed. But their training is that is an isolation thing: You’re the person who has to solve this puzzle. So they don’t normally work well together. They’re not used to this collective mentality of how can we make things better as a group.
“Second, they overwhelmingly truly care about their patients. But employers are willing to weaponize that against them, and say ‘if you unionize, you will harm your patients.’ This is what the corporate practice management groups say to them, and this is about the worst thing you can say to a physician.”
A third factor complicating organizing, he said, is that the different specialties have very different working conditions and experiences: An orthopedist has little in common with a hospitalist or a critical care specialist or a family medicine doctor. “Their working conditions are so different that trying to bring them all together is just not a natural thing,” he said.
Their biggest unit in his union is a 2,000-member Los Angeles County group, he said; all the members work for Los Angeles County at public sector hospitals and clinics, serving disenfranchised and vulnerable populations.
Employer resistance
Employers are putting up stiff resistance to unions, he said, hiring powerful law firms to challenge organizers. “If physicians unionize and push back, they can shut down a healthcare system,” he said. “If the pilots don’t fly, the planes don’t fly.”
How did he begin organizing doctors? Crane is not a doctor, he said, but he has been a union organizer for more than 20 years. When he applied for the U.A.P.D. job, he said, he joked to his friends that he would be helping doctors buy yachts.
“My assumption was that they had control and power,” he said. Then when he sat down with doctors, he realized that they had less control and power than he imagined.
He has a relative who is very ill and who has had end-of-life conversations with a doctor. Shortly after he started with U.A.P.D., he met a doctor who said “you’re not going to believe this, but I got into trouble because I took too much time telling one of my patients she was. dying of cancer.”
“From the outside in, my assumption was they had the control and the power,” Crane said. “I sat down and I talked with people who were talking about unionizing. And I was like, ‘Why are you even doing this?’ And every single one of them said, ‘I’m unionizing so I can better advocate for my patients.’
“For me, that was like this light-bulb moment — what if I can unionize these people and I can give someone like him five more minutes, or however many minutes you need to tell someone they’re dying? That’s a fight worth fighting. And then as I got behind the scenes, I found that physicians kill themselves at a higher rate than any other profession. Again, their workloads are the outcomes that determine the health care for my children.
“This is a fight that has to happen.”
New paper on unionizing
The American College of Emergency Physicians put out an information paper recently examining unionization interest among emergency doctors. The paper made a point of saying it was not taking a position for or against unionization.
“The emergency medicine work environment is facing unprecedented challenges: escalating boarding issues, lack of resources, ever-dwindling reimbursement, sub-optimal staffing, due process infringements, loss of physician autonomy, and employment instability,” the introduction reads.
“Unionization is increasingly being discussed as a potential solution to some of these problems. While resident physicians have an established history of unionizing, attending physicians outside of publicly funded ‘county’ hospitals and the Veterans Health Administration do not.
“A.C.E.P. member surveys show that interest is currently high; of the 4804 A.C.E.P. members who responded to a January/February internal survey, 2872 (59.8%) are very interested or interested in joining a union and an additional 1031 (21.5%) are not sure, but interested in learning more. Importantly, there is also member opposition to unionization. The question before us is to examine the viability of attending physician unionization in emergency medicine (E.M.).”
It concludes: “The time is upon us. Several E.M. unions have formed and it is likely that more will follow. History is being made as we contemplate the first EM attending physician strike in the US. A.C.E.P.’s membership is diverse and practices in a wide variety of environments. Our adaptability and resourcefulness are integral to our strength and identity as a specialty. As the preeminent experts in emergency medicine, we stand united in the mission of providing quality emergency care in the best possible circumstances and supporting each other every step of the way.”
Nurses unionize
For nurses, the National Nurses United, Crane said, is the biggest nurses union. The American Federation of Teachers is also big. S.E.I.U. represents a number of nurses, he said. The New York State Nurses Association recently affiliated with the N.N.U.
Last fall, 650 nurse practitioners, physician assistants and nurse midwives at Oregon Health and Science University unionized. Alison Fox, a functional nurse practitioner, and Heather Reed, also an F.N.P. from the union bargaining team, discussed their work.
They started their effort with a private Signal group last fall, of about 10 people. The nurse practitioners and physician assistants are all in different departments, in silos, Fox said.
But when working across departments — she was in primary care, then went to emergency and then to urgent care — she realized that there are benefits in certain departments that are lacking in others. Some nurses have time off for continuing medical education or regular hours, while others with the same degree lack those benefits. “It’s a very different workday and workload,” Fox said in a Zoom interview. “That was the catalyst for us to say ‘this doesn’t seem fair.'”
Her colleague, Heather K. Reed, said the healthcare system has been a mess as long as she can remember — certainly since she graduated in 2011.
“But the degree that it’s a mess has accelerated massively post Covid — not just because of Covid, but in this aftermath of Covid,” she aaid. “The demands on us have accelerated, and there have been promises that they’re working on our workload, or, helping to manage our emails and what have you.
“But it’s gotten worse, and because we have so extra work outside of clinic to do, a lot of us have to reduce our clinical hours, and then we get paid less. So we get paid a fraction of a full-time salary, and then that reduces the clinical availability, and so patients are more driven to give us all this extra work — if you can’t see your primary care provider for two months, you’re going to send them an email and be like, ‘I just have this little thing. Can you please put in a prescription?’ So we’re doing that work for free, and they haven’t figured out a way to capture that. And then the wait to see specialty providers is just ridiculously long in our organization.”
Fox said the effort is “to not only save ourselves, but to save patients. Because in our department, we’ve lost like 30% of providers.”
Reed chimed in: “They are constantly pushing us to see more patients in a shorter amount of time, because there’s so much pressure for us to be financially viable and profitable. Nobody’s ever given me any feedback on the safety of the care that I’m giving. Nobody’s tracking medication errors. There’s no emphasis on that in all our statistic-keeping, it’s all about, how many patients are you seeing? What revenue are we generating?”
Wave of unionization
A wave of unionization that brought 3,000 doctors into unions this year was described by Mari Devereaux at Modern Healthcare. “Last month, more than 1,000 residents and fellows at the University of Chicago Medical Center and 400 physicians-in-training at Kaiser Permanente’s Northern California facilities voted to join the Committee of Interns and Residents/Service Employees International Union,” she wrote. “Several hundred physicians with Wilmington, Deleware-based ChristianaCare petitioned the National Labor Relations Board to vote on joining the Doctors Council, an affiliate of SEIU.
“Earlier this year, more than 1,300 residents and fellows at Northwestern University’s McGaw Medical Center, 130 doctors at Allina Health and 25 physicians working under a contract with Sound Physicians moved to unionize with Committee of Interns and Residents/SEIU, Doctors Council and the Union of American Physicians and Dentists, respectively. The unions have seen record growth in recent years, collectively adding more than 10,000 members since 2021.”
