Should Doctors Unionize?

I grew up in the first Mayor Daley's Chicago in the heyday of the unions. Since then the unions have been fading away, largely having done their job to neutralize the untrammeled exploitation of people by corporations and thus raise the living and workplace standards for most Americans.

In health care we have seen the unionization of hospitals and nurses continue as the economic power of the health care sector has relentlessly grown. Physicians — traditionally independent business people — by and large haven't felt the need. But the times "they are a-changin'."

Now more than half of all docs in the U.S. are employed by someone else. All estimates of the future percentage of employed physicians say that number can only go up. Inevitably — with the shift from independent professional to employed service worker (get used to it) — doctors will be monitored and regulated as never before.

This is not all bad. There has never been either a good way to assess what we are doing and how effectively we are doing it nor a practical means to use such information to: a) improve the results of what we do and b) intelligently manage the cost. This increased regulation will require us to sacrifice our (precious) autonomy on the altar of (hopefully, rational) standardization — like it or not.

Of course there will be one-sided injustices and foolish distortions as this process governed by big corporate entities plays out around the country over time. And there will be a natural pushback, including the increasing unionization of physicians. When I recently saw The Wall Street Journal op-ed piece by David Leffell, MD, of Yale University speaking to this revealed insight, it immediately rang true.

For those of you who do not know, the Union of American Physicians and Dentists (UAPD-AFL-CIO) has existed since 1972 but, I'm told, it has only about 3,000 members, mainly in California, who pay dues. Up to now, the union has made a living, largely, off of local brush fires with small employers, insurance companies and legislators. But it looks like they are positioned to grow their numbers and clout as large employers increasingly corral and dictate to doctors. Injustices and disconnects are inevitable, and there really has to be a unified entity to speak on economic and workplace issues for we newly disenfranchised, formerly self-employed professionals.

Our existing guild organizations have a variety of other purviews, professional standards, science, research, ethics, etc., but none of them have the contract expertise, negotiating experience or, so far, the will to take on corporate America. (Are you listening AMA?) The ultimate weapon beyond a new emphasis on collective bargaining is the threat, and use if need be, of the strike. But isn't that unthinkable for physicians concerned about their patients' welfare? Individually, maybe; collectively, not so much.

A personal experience with a strike might be illustrative. When I was an intern at San Francisco General in 1970, our class became the first ever to go on strike. I forget what the issues were; I suspect that it was just because it was 1970, we were in Hippytown and my colleagues thought it might be righteous and/or fun. We were out for about a week. We caught up on our sleep, went on TV, and after some minimal face-saving words, went back to our labors. The important point was that the senior staff took over and no identifiable harm came to any patients.

How this might play out in other circumstances remains to be seen. But let there be no doubt: It is inevitable that doctors will justifiably band together and be persuaded by local conditions to act not only for our patients, but also for our own perceived best economic and work-condition interests. And one or more physicians' unions will be, of increasing necessity, in the mix.