By Josh Katzowitz, WCI Content Director
About 150 resident physicians at Elmhurst Hospital Center went on strike in May—the first time since 1990 that doctors in New York City had taken such action—because they wanted equal pay to other residents in the city and guarantees of hazard pay. Three days later, the hospital in Queens negotiated a deal that ended the work shutdown, giving the residents a victory and perhaps blazing a pathway for other physicians around the US to collectively bargain to make their work lives just a little better.
The New York Times wrote that “though the strike is relatively small and not expected to result in major disruptions to care, it is heavy on symbolism,” because Elmhurst was one of the first hospitals to be overwhelmed in the early days of the COVID pandemic. And it'll be interesting to see if that symbolism compels doctors to be more willing to organize and to become more active in taking charge of how they’re treated at work and how much they’re paid.
“The pandemic was an eye-opener,” Dr. Sarah Hafuth, one of the leaders during the strike, told the Times. “Physicians really started to question our worth and ask, ‘Are we getting the support we need, given the situation we’re in?’”
The New York City residents aren’t the only physicians who are looking to organize.
In April, tens of thousands of doctors in the UK participated in a strike to protest low pay during a time of high inflation, and they did so again in June. Meanwhile, 17 hospital-employed emergency clinicians (including physicians, PAs, and a nurse practitioner) in Oregon voted unanimously to unionize because of staffing shortages that have produced substandard care and potential burnout. A month earlier, the residents and fellows at Penn Medicine overwhelmingly voted to unionize. Thousands of nurses have also gone on strike in 2023.
As noted by the Emergency Medicine Workforce Newsletter, only about 1.5% percent of physicians are unionized (about 100,000 doctors overall), but according to AMA stats, those numbers are ticking upward (in 1998, only about 14,000-20,000 physicians had joined a union, and by 2019, that number had increased to nearly 68,000).
The potential benefits for physicians to organize include more control over their salary and benefits, better schedules, and increased job security. But there are plenty of ethical questions involved.
Said Arthur L. Caplan in Medscape:
“I'm not saying that unionization is wrong. I think you can start to see the case for it more and more. Unions have one powerful weapon, which is withholding services and strikes. For many in healthcare, that's just a no-no. You cannot put patients at risk. You cannot put their lives at risk. You shouldn't be delaying unnecessary surgeries by withholding services, by going on strike, or going on slowdowns. Many doctors and nurses will just say, ‘That is the height of immorality. I cannot do that.’”
With that in mind, I gathered four physicians for a roundtable discussion on the issues of unionizing and potentially striking to improve the medical industry.
- Dr. Jim Dahle: The founder of The White Coat Investor and an emergency medicine doctor.
- Dr. Nisha Mehta: A radiologist who is also an international keynote speaker, the founder of Physician Side Gigs, and a physician advocate who focuses on issues related to life in medicine and the changing healthcare landscape.
- Dr. Charles Patterson: A WCI columnist who has an extensive background in primary care and military medicine. For context, the residents and nurses at his current civilian institution are unionized, though he is in the military and is forbidden from unionizing (or endorsing the same) per 10 U.S. Code § 976. Also, the views expressed by him are those of the author and do not reflect any official position of the Department of Defense or the US government. These writings are not authorized, approved, or endorsed by any of the above entities. Further, they are not intended to encourage nor endorse any activity in conflict with the Federal Code, UCMJ, nor any governing legislation.
- Dr. David Graham: A retired infectious diseases doctor, he’s now a Certified Financial Planner and blogs at FIPhysician.com.
Here were the questions I posed to them.
#1 Should Doctors Strike for Better Working Conditions?
Josh Katzowitz: To me, it seems that the Millennial and now the Gen Z generations are more apt to set work boundaries and stick with them than Baby Boomers and Gen Xers are/were. This more recent trend of residents/doctors using their power to advocate for better work situations: Is that a good thing for medicine? Is it ethical regarding patient care?
Jim Dahle: As fewer and fewer doctors own their businesses, nobody should be surprised to see them acting like labor, and that includes banding together with other employees to stand up to their employers. As someone who has been in an ownership position far more often than an employee position over the years, I am also aware of the problems that unions can create. Sometimes they charge the employees high fees and don't provide much value. They can also ensure that the laziest employees do just as well as the hardest-working ones. But when an employer is not treating employees well, they often feel pushed to start a union, and federal law gives them that right.
As far as ethics, doctors have a duty not to abandon their patients. So, any “strike” must take precautions to ensure that does not happen. A strike could just be refusing to do elective cases and still be ethical. Or perhaps doctors could continue to take care of their patients but deliberately undercode/bill (or delay charting) the care they are doing so that the employer's income goes down until their demands are met. NHS docs in the UK strike all the time, and if we ever have truly socialized medicine, I'm sure it'll happen here, too.
Nisha Mehta: From a PR perspective, it’s a really hard thing to understand. Why are people who are compensated really well and who have a noble profession like medicine, where they are serving patients, how can they walk away from that? On the other side, people are leaving medicine left and right. Something like 40% of physicians want to leave medicine in the next two years. Something is broken. Despite the fact we’ve been talking about people burning out, we’re not seeing an easing of that. Whatever solutions we have are not addressing that; we don’t have a sustainable healthcare system. We have a system that people don’t want to be a part of. Something has to change.
What that appropriate vehicle for change should be is what clinicians need to figure out. Doctors are starting to take a page from nursing unions and other groups of healthcare professionals who can unionize and use collective bargaining power. Should every physician walk out? No, absolutely not. That would be horrendous. Doctors couldn’t stomach that. We all feel ethically obligated to our patients. But can you make a statement without compromising patient care? You probably can. How do you have that delicate balance? It might take physicians learning to say no.
I do believe very strongly that the altruism of physicians is taken advantage of. People believe doctors would never say no . . . We all see everything in the immediate moment. We see the patient in front of us. If we’re never able to say no, then it’s bad for everyone. It’s bad for clinicians; it’s bad for patient care . . . Doctors have to get comfortable with the idea of being able to say no in a palatable format that actually advocates for patient care
Charles Patterson: The medical system has changed dramatically in the last 40 years. With the rise of HMOs, the increase in administrative interference, and the focus on profit and efficiency that accompanies the business of medicine, the traditional concept of “physician as a vocation” has devolved into “physician as a cog in a wheel.” This paradigm shift has produced a generation of astute young physicians who see the game for what it is. If the C-suite is going to treat physicians like workers, then it must also be prepared to reap what they sow on a societal level. As I've written about in previous articles, if physicians carry a unique responsibility to patients, then patients and society hold a profound responsibility to physicians. This is an ethical matter, but I view the response from young physicians as amoral.
David Graham: Before throwing around words like “good” or “ethical,” I want to start at the beginning: where does the actual problem lie in healthcare? To me, the system is broken. Costs spiral, and quality is not as good as it could be. Younger physicians are right to think that they should have a life during their training. During my training, we routinely missed holidays, birthdays (our own usually), and many other special occasions for 8-12 years. This was before work-hour limits and knowledge of burnout. Now that we know the statistics on burnout and physician suicide, we can talk about what is good and ethical. We must set work boundaries. As I like to say, the hospital will never love you back.
#2 Will Less Training Make Doctors Less Competent?
Katzowitz: Some would argue that today's residents and young doctors won't be as competent because they've had less training (seems like 30-hour resident shifts and 100-hour work weeks are not as common (if they're not already vestiges of the past)). Some would argue that they will be less likely to suffer from burnout because they're more focused on work-life balance and theoretically can have longer, more successful careers. What do you think?
Dahle: The classic saying is, “Do you know the problem with Q2 call? You miss half the good cases.” Yes, if doctors work less in training, they will not be as well trained. But that's only up to a certain point. Ask any of us who worked 120 hours as a medical student or resident how valuable those last 40 hours were. At a certain point, you are no longer in learning mode; you're in survival mode, and there's not much learning happening. Where you draw the line is hard to say for sure, but I would much rather do a three-year residency of 60- or 80-hour weeks than a five-year residency of 40-hour weeks, and the training is probably equivalent.
The first thing I tell a burned-out doctor is, “Why don't you cut back to full-time?” The No. 1 treatment I know of for burnout is to work less. So yes, working less would probably lead to less burnout for most people. There are consequences to working less, though; it's not a free lunch as a solution. It exacerbates physician shortages and maldistributions. If residencies aren't extended, it could result in relatively poorly trained doctors. And it generally results in doctors making less money.
Mehta: At every stage of how medical education evolves institutionally, there has to be a close examination of what things add value and what things are contributing to the training experience and which don’t. If there are things that are not contributing to medical education, you have to be examining those things. You don’t take away from the experiences that really make you a better clinician. Surgeons shouldn’t be taken out of OR time. But are there experiences in their training schedule that didn’t contribute in any meaningful way? Are we taking a good enough look to see what was necessary? Do we need to be adding more of other certain aspects, like healthcare finance or business, and scaling back the depth of bio-chem we need to know? Those have to be examined.
You do have a limited amount of time and you need to make sure when you’re training the next generation of doctors that you’re equipping them with the tools that nobody else in the system has so they can use that knowledge they have in the most powerful way possible. There are a lot of arguments that we need to start specializing a little bit earlier in our pathway. That’s something that needs to be looked at as we have more physician shortages.
Patterson: A lot depends on the training program. Despite reporting that work-hour restrictions are being adhered to, I know that the culture of some programs requires excess time in the hospital. Regardless, preparedness for independent practice upon graduating from training has always been and will continue to be dependent on clinical exposure and the individual trainee. As a general observation, I would say that a greater threat to preparedness would be the inane systems processes that encumber trainees and are of little to no actual value. Want to make physicians better? Let them practice: ensconce them in myriad and complicated clinical presentations, challenge their knowledge base, and alleviate as possible the ridiculous scut work and documentation burden.
Graham: I retired from medicine last year at the age of 48. We know there has been a large post-COVID flight from healthcare, and there are a lot of physicians who will age out of practice in the next few decades. To me, it seems like the challenge will be for careers in medicine to improve enough to keep the interest of physicians. After all, many of us are realizing we have much more than just clinical talents and can tackle any number of other, more fulfilling careers. We know about the loss of autonomy and status for physicians who, not infrequently, feel like cogs in the corporate wheel. What can physicians do to improve their work conditions? One option is to unionize.
#3 Can Doctors Stop Private Equity from Taking Over?
Katzowitz: Lots of doctors bemoan the influence of private equity taking over large parts of medicine. Is unionizing and collective bargaining one way for doctors to maintain some semblance of power?
Dahle: Not sure it's really all that different working for a private equity-owned company or a typical hospital, but doctors selling their practices to either should expect less control over their work and lower pay after doing so. Not so bad if you're at the end of your career, but probably a bad trade at the beginning.
Mehta: I would argue that most physicians with issues with private equity are not complaining as much about the effects on their salaries as much as concerns about the impact on the system when profits are at the center of the healthcare business model. The healthcare supply and demand forces of just how many doctors are available may already be on their way to correcting some of the salary issues. Although this is very field dependent at the moment, almost all fields are exploring new practice models. If you’re looking at the signing bonuses that a lot of new doctors are getting, you can see everybody is having a hard time recruiting doctors. The bigger question is how we are able to collectively advocate for all these other things that are wrong in healthcare, and how do we change things that keep people wanting to be a part of the system? People don’t leave because they’re making $225,000 instead of $250,000; they leave because they feel like they’re part of a system that they don’t stand behind. Doctors have always worked long hours. What’s burning them out is the erosion of the doctor-patient relationship, the loss of autonomy, and the ever-increasing administrative burdens and barriers to doing what's best for their patients.
Patterson: The answer to the influence of HMOs and PE culture is physician leadership. We allowed this monstrosity to take hold in American medicine; we codified it into federal law under the guise of patient-centeredness, and now we must lay in the bed we made. And it’s not just private equity. Hospitals controlled by businesses will run like businesses. Hospitals controlled by physicians will run like hospitals. To reiterate, we need physician leadership that can deftly navigate these murky waters and allow clinicians to focus on what really matters: the patient in front of them.
Graham: I bemoan the perverse incentives in healthcare that make it so much about the money that private equity is buying out physician practices. We can better align payment systems by remuneration for actual healthcare rather than ill care. In my small town and in many small towns in rural USA, however, the hospital is the largest employer in the region. I know my town will suffer if we turn down the spigot of medical payments. But neither patients, insurance companies, nor healthcare systems have incentives to control healthcare costs.
I'm not sure unions will protect us from people trying to make money in healthcare. It will take something much more radical than that. What percent of GDP will healthcare be when we do something radical to healthcare?
#4 Are Unions the Right Answer for Doctors?
Katzowitz: Anything else you want to add?
Dahle: Unions aren't a magic elixir that solves all physician problems. Physician unions have been around for a while, both for residents and non-residents. If they were universally good, they'd be a lot more common than they currently are.
Mehta: I’m not an advocate for everybody in medicine walking out. That’s not the answer. But how do we strategically say no that pushes the needle on the urgency to fix the things that are broken in the healthcare system? What are impactful campaigns we can adopt to encourage patients and clinicians to come together to advocate for change? . . . It's ridiculous that we spend so much of our advocacy time having to protect—not even increase—our reimbursement. Doctor salaries make up less than 8% of total healthcare expenditures. We need to highlight where some of these other healthcare dollars are going to the public and start pushing for changes that place the focus back on patient care and eliminate policies that just line the pockets of third parties who want a piece of this huge chunk of the GDP (around 20%) to the detriment of the healthcare system as a whole. That in and of itself will go a long way toward improving physician well-being.
Graham: Residency programs are incentivized to get as much work out of residents as they can. For us, we trade out our time in residency for future income. But if you want work-life balance in the future, too, then your potential future income may not be such that you are willing to make current sacrifices to your work-life balance. A complex web, but young physicians should band together and demand treatment that provides adequate time and space—and value for the current cost of being a resident physician.
What do you think about physicians unionizing and potentially striking? Is it ethical? What other ways can physicians better their working conditions and increase their pay? Comment below![Editor's Note: For comments, complaints, suggestions, or plaudits, email Josh Katzowitz at [email protected].]