A collective stand: The rising trend of physician unionization

By Shamard Charles, MD, MPH
Published December 18, 2023
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Healthcare unions are gaining steam across the country, as evidenced by the 2023 Kaiser Permanente strike—billed the largest healthcare worker strike in US history. While nurses are leading the way in organizing efforts, doctors and residents are also joining labor movements, demanding better pay, benefits, and working conditions.

Related: Physician compensation 2023: The good, the bad, and the ugly

MDLinx surveyed 50 practicing physicians to better understand their beliefs, insights, and experiences with unions. The survey results shed light on the ramifications of unionization efforts throughout healthcare, highlighting perceived benefits and detriments to medical practice, patient care, compensation packages, and work-life balance.

How interested are you in physician unions?

The majority of surveyed physicians (73%) were over the age of 55, and nearly 45% of all respondents worked in private practice. Almost three-quarters of physicians surveyed (73%) said they were very or somewhat interested in unionizing. Only 2% of respondents indicated they were currently a union member, perhaps partly explained by the fact that 80% did not have a union at their place of employment.

Who takes care of the caretaker?

Unions have fought for and won many of the general US workplace standards we now take for granted, such as the 8-hour work day, the 5-day work week, sick pay, vacation pay, maternity and paternity leave, retirement benefits, and healthcare coverage. These benefits were won through the hard work and sacrifice of union members. And that's what continues to drive labor movements today.

Case in point: In October 2023, 75,000 HCPs employed by Kaiser Permanente went on strike to demand better working conditions after contract negotiations failed—it became the largest ever healthcare labor dispute in US history. Workers won across-the-board wage increases totaling 21% over 4 years, improved performance rewards, and commitments to address staffing crises with increased training, education, and mass hiring events.[1] 

While the number of physicians in unions is on the rise, relatively few doctors are actual card-carrying members of unions today. Approximately 70,000 active physicians belong to a union as of October 2022, translating to 8.0% of the physician workforce.[2] These numbers are up 26.8% from 2014.[3] An article published in JAMA on labor unionization trends found that union members include all types of physicians, as well as nurses, healthcare technicians, and healthcare staffers.[4]

Physician unionization rates are still relatively low compared with other industries. For example, industries with high unionization rates, as of 2022, include utilities (19.6%) and motion pictures and sound recording (17.3%).[5] 

Given the well-known work-life imbalance within the profession, many wonder why it has taken so long for doctors to join the movement.

Despite the potential benefits joining a union offers, it's still a hot-button issue among doctors, with many of the physicians MDLinx surveyed expressing concerns about the ramifications of unionizing.

Why aren't you a member of a union?
Concerns about physician unions

What we heard from HCPs: Detriments of joining a union

  • “They are too political and increase the cost of doing business.”

  • “They create unnecessary hassle.”

  • “They decrease the drive to be productive.”

  • “We are professionals, not blue-collar workers. I think unions would further cheapen the profession in the eyes of the public.”

  • “I don’t believe there is a place for unions in medicine, or any occupation that is necessary for the well-being of the general population.”

Stigma, concerns over how they would be viewed if they walked off the job, and fear of retribution from healthcare employers have kept many HCPs from joining unions, says Calvin Lambert, MD, an OB/GYN at The Mount Sinai Hospital in New York City. But now, many are at the end of their rope.

"Doctors have been asking themselves the question, ‘Who takes care of the caretaker?’ for as long as I can remember."

Calvin Lambert, MD, The Mount Sinai Hospital, New York City

Up until recently, Dr. Lambert says, society has told physicians that increased self-care was the "answer" to their woes, but the truth is, the system has not made long-term holistic solutions—such as adequate staffing and efficient sign-overs—a priority.

“In a system in which profit and performance are standard bearers of one’s worth, how can one possibly create a space in which they can comfortably and intentionally reflect on their own well-being and how that can impact that of the patients they are responsible for?” Dr. Lambert asks.  

Advantages of collective bargaining

With physicians no longer willing to accept working conditions, they are looking to more systemic reasons for their discontent. And unionization has emboldened them by providing basic human rights protections at the local, state, and federal levels, while also putting physicians in a position to be more proactive than reactive.

The right to unionize and strike was guaranteed under the Clayton Act (1914) and the Norris-LaGuardia Act (1932) and extended to physician employees under the National Labor Relations Act in 1935.[6] Since then, physicians have found great benefits in collective bargaining, with unions offering physicians increased bargaining leverage, negotiating power, and a unified voice. 

Taking a collective stand can bring wide-ranging benefits, from better compensation and working conditions, to improved patient care and safety measures, to narrowing the racial/ethnic wage gap, and more.

What we heard from HCPs: Benefits of unions

  • “It is good to have open communication with management, and unions are often the only way to accomplish this.”

  • “Although relatively well paid, we have excessive liability, work hours, and stress, and very little power alone to change the steep increase in volume and complexity we face.”

  • “It’s way past time. I think physicians missed the opportunity to unionize a long time ago and have felt disempowered negotiating against very large entities in insurance companies, hospital systems, academic institutions, and etc.”

  • “There’s a louder voice in numbers.”

  • "Physicians have lost power in making clinical decisions."

  • "It would give physicians a voice in contract and pay negotiations."

  • “Without unionization, the physician shortage will only get worse until healthcare collapses, because doctors are sick of being overworked, underpaid, and under-respected.”

unions' top bargaining priorities

The need for change

The ever-changing organizational structure of healthcare, partially due to a rise in mergers and acquisitions among hospital systems, has made joining and forming unions a necessity for many. The new landscape of medicine has made unrealistic demands on managed care even worse, increasing work-life imbalance, imposing structural and staffing changes, and raising the demands for productivity.

According to Avalere—a leading healthcare consulting and advisory firm specializing in strategy, policy, and data analysis for providers, health plans, and government agencies—the percentage of US physicians employed by hospitals, health systems, or corporate entities grew to 73.9% as of January 2022, from 62.2% in January 2019.[7] 

What we heard from HCPs: How unions can mitigate the effects of the corporatization of healthcare

  • “Unions give physicians some protection against hospitals.”

  • “As long as Medicare and insurance cuts fees every year, doctors need a way to improve reimbursement/pay.”

  • “Unions can prohibit hospitals and private equity from owning physicians or physician groups; this is not permitted in the legal profession and should not be permitted in the medical profession.”

  • “Physicians have actually no say as to why they cannot organize when the insurance companies are making the changes to coverages to their patients, which directly affects the physicians.”

Better late than never

Union efforts have been on a slow climb, mainly spearheaded by overworked and underpaid hospital trainees. Stanford resident doctors unionized in 2022, arguing for fair pay commensurate with the rising cost of living in the San Francisco Bay area,[8] and Elmurst hospital residents went on a 3-day strike before their union reached a deal with New York’s Mount Sinai Hospital in May 2023.[9]

In addition, the toll of the COVID-19 pandemic and recent nurses strikes have brought the issue of unionization to the forefront. 

Edison Castro, DO, a family doctor in the US Air Force Operational and Aerospace Medicine Department, says that collective bargaining is the best way to address a multitude of concerns, including long hours, high stress levels, less autonomy, extra demands on doctor's time and attention (such as procuring grants and conducting research), and garnering more resources to improve patient care.

Still, Dr. Castro believes wide-scale unionizing will be an uphill battle. 

"Collective bargaining may help, but widespread unionization might not be as feasible as we think in healthcare, since we as doctors cannot stop seeing patients."

Edison Castro, DO, US Air Force Operational and Aerospace Medicine Department

Dr. Castro echoes a sentiment held by many doctors: The factory mill way of seeing patients—spurred on by increases in corporate mergers aimed at increasing revenue—is stripping physicians of the joy of practicing medicine. 

The impact of unionization of physicians

Physicians who are considering joining a labor union must weigh many factors, says the AMA, including whether the union's objectives are aligned with their values. They also need to consider potential backlash from patients, peers, supervisors, and future employers, and the financial implications of union dues.[10]

Resident physicians face additional challenges, such as lower income and longer hours, as well as the MATCH contract,[11] which negates their ability to bargain for wages and benefits, setting the stage for perpetual disenfranchisement and a culture of abuse.

Even more, residents may be viewed as “free riders” from other dues-paying physicians, or may feel less empowered to voice their opinions during union meetings because of their learner status.  

It’s natural for doctors to take pause before unionizing. Joining a union often means committing to measures that are necessary for change, including going on strike. 

Physicians take an oath to serve, and refusing to work undermines their promise to uphold the values of benevolence and nonmaleficence, even if patient care is not negatively impacted. 

The moral and ethical barriers of going on strike are unique to doctors who risk perceptual backlash while also potentially jeopardizing their patients’ health. 

Despite the good that can come from prolonged action, doctors often feel coerced to return to work, as patient safety is a top priority. The National Labor Relations Act requires physician unions to give employers 10 days' notice before engaging in a "concerted refusal to work.” It also requires emergency care to be available to those who need it and requires that hospitalized patients continue to receive care. 

While the majority of the physicians surveyed by MDLinx, or 54%, believe it is ethical to go on strike, many noted stipulations—the impact on patient care being the primary concern.

One respondent said, “If patient care will improve as a result [of going on strike], it can be necessary. And since physicians are often the main advocates for their patients, it falls to us.”

Another respondent said, “Society cannot have it both ways—expecting physicians to be totally selfless but not respecting and appreciating [us] at the same time.” 

"Being a physician is a job like anything else. We shouldn't feel required to work for diminishing benefits/salary while other members of the healthcare force can strike."

MDLinx survey respondent

On the other hand, 30% of those surveyed said striking is not ethical, and 17% said they were not sure. 

What we heard from HCPs: Is it ethical for physicians to participate in a strike?

  • “Given the current status of corporate medical care in the US, it is both necessary and unethical not to care for patients—it is a dilemma.”

  • “Only in extreme circumstances, like if the workplace administration is hostile or inconsiderate of physicians.”

  • “We would be striking for less selfish reasons than most. We would fight for our patients and better conditions for all of our coworkers in healthcare, as well as ourselves."

  • “No; patient well-being should be the highest priority.”

  • “Physicians, like with any other profession or job, can be mistreated and abused, and therefore have every right to fight for the same rights that all other humans have.”

  • “No, we took an oath to provide medical care and to first do no harm. Striking and leaving patients who are in need of urgent medical care is a moral issue.”

  • “Yes, if we need to, so they can finally appreciate what we do.”

State-specific laws and regulations can impact how long, and to what end, a strike may continue. To add another layer to this complicated paradigm, self-employed and independently contracted doctors risk violating antitrust laws, as they are not staff-employed physicians (a requirement for union membership), and therefore not allowed to take part in union and collective bargaining efforts.[3]   

Hospital systems often deal with physician shortages at baseline and are usually unable to provide adequate levels of care during work stoppages, leaving patients vulnerable to preventable illness and death. While the institutions have an obligation to deliver quality patient care, the ultimate responsibility to deliver this care—and failure to do so—unfairly falls on the shoulders of healthcare professionals, not corporate America. 

Are unions the answer?  

Physicians are combining their collective resources to match the powers of their employers, recognizing the many advantages of power in numbers. However, it’s unclear whether unions are the ultimate answer. While unions promote economic equality and build worker power, they do not fundamentally change the culture of medicine.

The current system has weaponized the care, compassion, and professionalism of doctors, placing the business of medicine ahead of high-quality patient care. 

Until hospitals and the corporations behind them implement systems that humanize the doctor and the doctor-patient relationship—centering workplace safety, equitable pay, and quality care at the core of its plans—unionization, while beneficial, is capped in the good it can do for physicians.

Sources

  1. Chan M, Kopf M. Surgery and other medical procedures are delayed by the Kaiser strike, patients say. NBC News. October 4, 2023.

  2. Hubbell GP. Physician Unions and Work-Life Balance. Mo Med. 2022 Sep-Oct;119(5):406-407. PMID: 36338004; PMCID: PMC9616465.

  3. Issue brief: Collective bargaining for physicians and physicians-in-training. American Medical Association. Advocacy Resource Center. 2023.

  4. Ahmed AM, Kadakia K, Ahmed A, et al. Trends in labor unionization among US health care workers, 2009-2021. JAMA. 2022;328(24):2404-2411.

  5. Union members — 2022. News Release. US Bureau of Labor Statistics. January 19, 2023.

  6. National Labor Relations Act. National Labor Relations Board. 

  7. Report: Supermajority of U.S. physicians are employed by health systems or corporate entities. Primary Care Collaborative. April 25, 2022.

  8. Chen C. Stanford resident physicians unionized a year ago. They say their demands still aren’t heard. The Stanford Daily. May 8, 2023.

  9. Goldstein J. Resident doctors end strike at Elmhurst Hospital. The New York Times. May 24, 2023.

  10. Howard D. What should physicians consider prior to unionizing? AMA Journal of Ethics. March 2020.

  11. The MATCH Agreement. National Resident Matching Program. 2023.

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