Physicians Need to Unionize Now

Physicians have lost autonomy. Some believe we've become data entry clerks who are being replaced by less expensive healthcare workers. Stress has escalated as Press Ganey scores rule the day while doctors are asked to overbook already packed schedules.

We can vent, but things won't change unless we unionize. If you still aren't convinced, read these complaints from colleagues taken from various physician groups I belong to:

• "I'm not allowed to take a 10 min. walk because I was told it gives others the perception I'm not busy, but I've had the highest volume of patients."

• "I am a hospitalist. I'll now round on 24 patients and the CNP will round on the other 24, so I'll be responsible for 48 patients/day."

• "We were a well-established private practice. The hospital purchased our referral base. They circled their wagons and even changed the locks on the conference room door. Our work-flow dwindled."

• "Today my boss called to tell me they are doing away with all physician positions and hiring full-time NP's instead. I'm heartbroken. Devastated."

Dr Paul Teirstein

The time is past for the word "union" to conjure images of Jimmy Hoffa and freshly paved parking lots. Paul Teirstein, chief of cardiology at Scripps, founded Physicians United in 2020 "because the idea of being part of a 'union' is a turnoff for many doctors." By email, he admitted that it's been a failure: "I really don't think a cohesive organization of physicians is possible. We just don't have the will.”

But a lot has happened in a few short months, and I see a different postpandemic perspective. I've heard the phrase, “life is short,” more often now from my physician friends who have a real desire for quality time with their loved ones as well as their patients. The lesson I take is that nothing short of unionization will suffice. Given the trend of physician replacement by nonphysicians, our survival demands it.

President Biden's signing of the Executive Order on Worker Organizing and Empowerment in April has created a favorable era to establish physician unions. The order is meant to "encourage labor organizing, particularly in states with 'hostile' right to work laws and in industries that are considered 'hard to organize.' " There is perhaps no industry more difficult to organize than the medical profession, and we should seize this opportunity to make our national push.

Stephen Thompson, an associate professor at National Louis University, and J. Warren Salmon, a professor of health at the University of Illinois, published The Corporatization of American Health Care this year. They point out that for an effective revamping of our healthcare system, healthcare professionals will need "to resist the very corporate financial relationships being foisted upon them."

The word "foisted" is most appropriate. For the first time in our history, more physicians are employed than are in private practice. While no one forces us to sign away our autonomy, we are being chased into the corporate corner by changes in reimbursement, the threat of competition if we refuse, and the increasing costs of malpractice insurance and employee health insurance premiums, among others.

Other healthcare professionals have organized. "Nurses have gotten a whole lot more militant in recent years. The California Nurses Association is one example," Thompson told me. And there are physician unions concentrated in the West Coast. The Union of American Physicians and Dentists (UAPD), which was organized in the early 1970s, has grown into the largest union representing licensed doctors in America. One of their first achievements was a successful strike that prevented a 500% increase in malpractice fees for anesthesiologists.

Yet no national union exists. Despite several thousand physicians signing up to Physicians United, Teirstein said there was little engagement. Even at the height of COVID, very few physicians offered suggestions for advocacy. He believes that doctors mostly love their jobs and want to focus on taking care of their patients.

In November 2020, the UAPD organized more than 100 doctors, physician assistants, and nurse practitioners from urgent care centers across the Multicare system in Washington State to strike for 2 days against unsafe working conditions, including inadequate PPE.

By email, Stuart Bussey, president of the UAPD, wrote, "Physicians have become increasingly frustrated with not having a voice in management decisions that could improve patient care and workplace safety, especially during a pandemic." He has seen union membership among public and private care physicians grow and believes the trend "will continue as more and more recognize the benefits of collective bargaining."

One of the greatest obstacles to organization has been our reluctance to even entertain the idea of using the strike weapon. A complete strike could endanger patients and violate our Hippocratic oath, but creativity can avoid both issues. We might be up for participating in a "no-bill" day, week, or month, or joining together to hire lobbyists to drive insurance reform and changes in electronic health record. In a 2014 editorial, Thompson and Salmon wrote that "we believe physicians, in a bid to reassert their professional authority, could withhold their labor to reduce harm to future patients at the possible expense of current patients." Potentially endangering patients is never going to fly, but inconveniencing both patients and our fellow physicians to drive change by walking off the job in areas other than acute care has already proven benefit. It is a pattern of success that should be repeated.

Thompson believes that having the strike weapon is key: "My sense is that publicly declaring that they were never going to strike automatically allowed employers to realize that MDs would never walk off the job so they could continue to bargain forever without any real consequence," he said in reference to the failure of the AMA's collective bargaining unit Physicians for Responsible Negotiations in the late 1990s early 2000s. Another reason our national organizations failed us according to Thompson is that "they were so focused on encroachment by government that they never saw the corporate threats until it was way too late."

For physicians to successfully unionize and strike (if needed), we will need public support. For that, we must change the public perception that doctors are the "well-off wanting more." Organizations like the AMA could help with national campaigns to highlight that our demands are driven by concerns for patient safety and physician well-being and are not rooted in greed. Remember that Senator John Lewis's quote about getting in "good trouble" has applications beyond racial inequality; it applies to injustice in all walks of life.

Good trouble actions backed by our national medical societies could be crucial to restore and preserve our profession. A few bullet points for the public information campaigns:

• Physicians aren't greedy, they're in debt…upwards of $250K after medical school.

• Around 300 US physicians commit suicide every year. Others quit because of burnout and displacement.

• Know your healthcare provider's credentials ― education is important.

• Unhappy with your medical bill? Medical executives can take home more than $30 million annually counting salary, incentives, stock options, and other benefits

• Physicians' salaries account for less than 10% of healthcare costs.

• If your office visit was cut short, please note that your doctor often has no say in the decision to double book your time slot.

• If you miss eye contact with your physician, remember that corporations and insurance companies, not doctors, drove the push for electronic health record data entry.

What must we physicians be willing to do?

• If negotiations fail, strike in stable patient areas such as offices and wards.

• Walk in picket lines and/or participate in a "no-bill" week.

• Volunteer for radio/television/podcast interviews to explain our issues.

• Band together in a refusal to overbook patients.

• Run for political office or support those with a platform of physician rights.

• Join a national push for unionization by joining or forming a union in your state ― for more information, visit https://www.uapd.com/join/.

As healers, we have a moral obligation to shine a light into the darkness of what the practice of medicine has become, but we also have a moral obligation to change it.

First we must overcome the fear of retaliation and the comfort of apathy, then we should organize around the basic goal of restoration of autonomy. We can improve patient safety by regaining control of our schedules. We should insist that physicians reject the encroachment of data entry on our private time. If we band together, the rejection of corporate intrusion into the physician-patient relationship can be our legacy.  Then, the  restoration of joy in the practice of medicine would soon follow.

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters and parents, and sidelines as a backing vocalist for local rock bands. Follow Melissa Walton-Shirley on Twitter.

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