Over the past few decades, the concept of unionization has taken off among physicians. Once a notion met with skepticism at best and derision at worst, it’s now something that is either being discussed or is actively happening everywhere you turn. In fact, just the other day in the surgeon’s lounge, another surgeon brought up the possibility to me. Moreover, the residents at the medical school that I work with recently unionized and completed a strike.
There are several reasons for this trend. One, more and more physicians are now employed by large institutions. Two, during the COVID-19 pandemic, doctors saw firsthand just how replaceable we are by the health care system. Third, burnout has reached new heights since that time. The culmination of these and other more local factors is that doctors have begun to worry about their place in the health care system and to seek more control — via unionization — as a result. But is unionization actually a good thing?
First, let’s discuss the pros:
1) Better leverage in contract and workplace negotiations.
Individual doctors working within a large health care system feel like cogs within a machine. There is significant concern that their voices are not and will not be heard. Unions offer the potential of combining individual voices into a much larger one that has to be listened to by the health care system. In theory, this leads to better pay and working conditions.
2) Improved doctor well-being.
More leverage leads to more favorable outcomes in negotiations for doctors. And better compensation and working conditions leads to happier doctors. Happier doctors have less burnout.
3) Better patient care.
See above. Subsequently, less burnout equals better patient care. Further, happier doctors would practice longer, reducing the severe shortage in this country.
4) More autonomy for and protection of the professional standards of physicians.
A huge concern for physicians is the aforementioned loss of control of the practice of medicine as the health care model shifts more toward an employment model. Unionization theoretically would protect the professional standards of doctors from any administrations more focused on business issues.
And now for the cons of unionization:
1) Increased health care costs.
This is the main con that health care systems cite. Unions and collective bargaining will increase costs, mainly related to improved working conditions and physician compensation. This, in turn, is reflected in the price of health care which rises even more for the average American.
I’m sorry, but I don’t buy this one. Administrative costs and the number of health care administrators have risen exponentially compared to other health care related costs in the U.S. Fair working conditions along with improved and fair compensation for doctors should not be at the expense of these more significant costs. Especially given that improved doctor well-being translates into improved patient outcomes.
In fact, one could argue that unions, by increasing physician satisfaction and longevity, would decrease costs by reducing physician turnover and its huge associated cost.
2) Strained relationships among doctors.
This may sound wishy-washy or woo-woo. But this is probably the biggest con in my head.
No matter how specific and small, any union represents a broad and diverse set of priorities that differ among their members. Within medicine, there are various specialties, levels of training, experience, and more that factor into one’s professional and personal priorities. No union will ever appropriately represent all of these. Further, not all doctors within a system may agree with unionization. Both of these situations can cause resentment and dysfunction within a working environment that requires collaboration and collegiality to best help patients.
3) Reduced administrative efficiency.
This is a kind way of saying that it is very hard to discipline or fire a union worker. When that union worker is a physician practicing dangerous, impaired, or ineffective medicine, it could create a real problem for patient care.
4) The fall of the independent practitioner.
Let’s say physician unions become the norm and are very successful at negotiating for better working conditions and compensation for doctors. Let’s say they do such a good job that it no longer makes sense to practice independently or in private practice.
Would this be good or bad?
I guess in this hypothetical world where physician unions were always successful, it could be good. But overall, I think this would be a negative development and ultimately result in a greater loss of control for physicians.
5) Worse access to care for patients.
Another argument against physician unions is that better working conditions including better staffing, reduced hours, etc. would result in less access to care for patients. I don’t buy this either, as the argument that the only way for patients to get care is to burn doctors out is a non-starter for me. Further, improved conditions lengthening doctors’ careers would offset this.
The other part of this argument is that a strike would significantly and unfairly impact patients and their care. This is a sticky one. Obviously a strike would be a worst-case scenario. But it need not be long lasting — there could be 15-minute strikes or strikes on documentation of medically unnecessary exams that are pushed for maximum system compensation with little trickle down to the physicians doing the documenting.
6) Misaligned patient-physician priorities.
Unions could theoretically put physicians’ needs and priorities above those of their patients. This could result in a misalignment of interests that hurts patient care. I think this is a bit of stretch and plays into the old and false taboo that doctors shouldn’t think about money. As doctors, we have an oath to patients that I don’t think (maybe naively) this would affect.
7) Bad public optics.
This is maybe the biggest concern of most doctors. It’s certainly possible that patients or the public view unionized physicians as less professional or as breaking an oath to their patients if they strike. After all, doctors make a lot of money. The public don’t necessarily buy the idea that doctors can be burned out or aren’t being paid fairly … despite that being the objective case.
So, what’s the verdict?
There are certainly more ticks in the “con” column than in the “pro” column. But I don’t think that means that physician unionization is necessarily bad.
To be honest, I don’t know where I stand. I certainly understand why physicians want to unionize. And I can see where short-term advantages would lie in this approach. I do have long-term concerns, however — mainly that it would involve giving up more control to non-physicians (union leaders in this case). Of course, this is assuming no physicians lead unions. But I am skeptical we would.
I do know that, at this moment, I stand in a privileged position in this debate. I am employed. But I negotiated a favorable contract and have an excellent clinical situation. So I don’t (at least currently) “feel the squeeze” leading many to favor doctor unions. I can imagine myself in that situation all I want, but can’t say for sure how I would feel in those circumstances.
Thankfully, even for physicians who are feeling that squeeze, or who want to be part of a union but can’t make it happen, there are things we can do individually to improve our well-being, compensation, and work setting. We can start private practices; negotiate our contracts; explore new employment options, and more. These are not collective solutions, to be sure, but they are one way to gain back some of the control we as physicians have lost.
Where do you fall on the topic of physician unionization? Are you part of a union? Do you think physicians should unionize? Share your thoughts in the comments!
Jordan Frey, MD is a plastic surgeon in Buffalo, NY at Erie County Medical Center and the University of Buffalo. His clinical focus is on breast reconstruction and complex microsurgery. He is also the founder of The Prudent Plastic Surgeon, one of the fastest growing finance blogs. There, he shares his journey to financial well-being with a goal of helping all physicians reach financial freedom, practicing on their own terms.
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