Incited by flagging membership and economic pressures on doctors, the American Medical Association House of Delegates defied the advice of its leadership last week by voting to form a national labor union.
The move polarized members and left the association at odds with hospitals and large medical groups.
It also heightened pressure on the AMA to win federal antitrust relief for 325,000 private practitioners who want the right to organize against health plans. Part of the rationale for a union is to position the AMA to represent independent physicians should they become eligible for collective bargaining.
Only about 15% of the nation's post-resident practicing physicians-or about 108,000-are eligible for collective bargaining, according to the AMA. Most are employed by hospitals, and about 32,000 already belong to unions.
In addition, about 10,000 of the nation's 96,000 residents belong to unions. Their eligibility varies by state.
The AMA union will represent employed physicians and also lend support to local negotiating units that would represent residents and fellows. The union would be required to attain self-governance after five years.
The American Hospital Association said the union could splinter hospitals and physicians, which should be working together. AHA Chief Operating Officer Jack Lord, M.D., said the AMA union "certainly will raise the visibility" of the union movement among physicians.
The American Medical Group Association, which represents large physician-run medical groups, also objected to the AMA union.
"We feel that it is a response to physicians feeling powerless and victimized, but that it is an inappropriate response," said AMGA Chairman Ira Davidoff, M.D., medical director at the Bay Valley Medical Group, Hayward, Calif. "I personally don't think anything is going to come of it."
During hours of anguished floor debate, Dale Moquist, M.D., a member of the American Academy of Family Physicians from Bryan, Texas, said the AMA union could be "pitting physician owners against physician employees."
The decision by the AMA's 494-member policymaking body passed easily by a show of hands, with no official count.
It flew in the face of a 73-page report by the AMA Board of Trustees that recommended against forming a union. The report was a response to a house vote last year to "develop a negotiating unit" for all AMA members, a directive that was deemed unworkable.
The board cited potential conflicts between patient care and physician interests, a potential loss of up to $1.5 million over two years if the venture proved unsuccessful, and the AMA's lack of experience in collective bargaining.
Another problem, the report said, is the AMA's no-strike policy, which would put it at a competitive disadvantage with other unions.
During a news conference following the vote, AMA President Nancy Dickey, M.D., said physicians would count on "the power of public opinion and the press" to sway employers.
Still, there could be wiggle room. The AMA ethical directives prohibit withholding "essential medical services," which are not clearly defined, and an amendment to insert specific anti-strike language was quashed.
Last week's action comes as national labor unions try to attract doctors. Earlier this year, the Service Employees International Union formed a coordinating body for its physician unions and announced it would spend $1 million per year to organize employed physicians (March 8, p. 17). Meanwhile, an affiliate of the American Federation of State, County and Municipal Employees union, the Tallahassee, Fla.-based Federation of Physicians and Dentists, has been organizing nonemployed physicians.
Leaders of both physician unions said last week they would consider an alliance with the AMA, but AMA Board of Trustees Chairman Randolph Smoak, M.D., said the AMA wasn't interested.
Supporters argued that the AMA union would provide an alternative to traditional unions and boost group membership.
"Our association needs to move forward, and this is a defining moment," said Gary Krieger, M.D., a San Pedro, Calif., pediatrician who said he's in solo practice. "Four-hundred thousand physicians in this country no longer believe the AMA represents them."
Delegates from the right-to-work states of Florida and Texas argued that creating a union would undermine the AMA's credibility with conservative legislators and hurt attempts to win antitrust relief for private practitioners.
"It will cut us off at the knees if we come back with a national labor organization," said Allen Bohn, M.D., a general surgeon from Arlington, Texas.
Past AMA President Daniel Johnson, M.D., pleaded for the house to accept a measure that would give the AMA an option of supporting local negotiating units, which some delegates felt would mitigate political damage.
Others opposed a union on principle.
"We are a noble profession. We have high ideals. The public expects us to live up to them," said Terence McCoy, M.D., a Tallahassee, Fla., family practitioner.
Smoak said the board would produce a plan of action within 30 days. He said union members probably would be required to join the AMA and also pay union dues. The union is expected to cost $1 million per year to operate, but Smoak said those costs could escalate.