Pressured by their members, professional associations for physicians and nurses, which historically have eschewed the labor movement, are joining its ranks.
In June, four societies, including the American Medical Association, took steps to work with unions or create collective-bargaining units to try to combat the economic forces their members say compromise patient care (See chart, p. 14).
All said they hope to stem attrition or increase membership by offering new services and a stronger voice.
The trend could strengthen the bargaining clout of other unionized healthcare workers, whose ranks have swelled in the past five years.
Physicians and nurses are welcome additions, labor leaders say, because they are in healthcare for the long haul and know how it has changed. Physicians in particular have clout with hospital boards and local politicians, which can be leveraged when other unions are at the negotiating table.
"When you work together, you have a lot more power," said Mark Levy, executive director of the Committee of Interns and Residents, whose own union-along with five other healthcare unions-belongs to a coalition in New Jersey.
But it could be tough getting doctors to rush to the union cause. The AMA has repeatedly distanced itself from what its officials call "traditional labor unions," saying its collective bargaining will focus on patient care rather than pocketbooks.
"I think doctors unions have to clearly demonstrate that this isn't simply about making more money," said Andy Stern, president of the Service Employees International Union, which has committed $1 million to organize physicians this year. "I think they have a special burden to be advocates for their patients. If not, like some of the professional sports association unions, they'll just be seen as greedy and self-centered."
Stern said the AMA "has found itself too often as an isolated voice for itself."
Professional associations that do collective bargaining risk an identity crisis if their leaders-who are often supervisors-aren't sympathetic to clinicians.
In 1995 the American Nurses Association lost its California affiliate, which said national leadership wasn't doing enough to combat layoffs and staff shortages. Two years later, the ANA's Pennsylvania affiliate split into three parts after losing 2,000 members to the SEIU.
To stem the exodus, ANA delegates voted last month to form a national umbrella group for the 24 remaining bargaining units operated by its state affiliates, which represent 125,000 nurses.
Although the vote of 497-85 was hardly close, the move was bitter medicine for some ANA members who fear the structure might split the organization. Because the National Labor Relations Act bars supervisors from running unions, the labor organization will have a separate governing board.
The ANA also is exploring an affiliation with the AFL-CIO to prevent further SEIU raids. "We want to spend less time fighting with other traditional labor unions," said Kenneth Fitzsimon, administrator for labor relations at the Oregon Nurses Association.
Some predict the AMA will face similar dilemmas. Last month's vote by AMA delegates to create a union thrust the association into the role of union organizer, against the advice of its board of trustees.
The AMA is closely allied with the Association of American Medical Colleges, which represents some of the largest employers of doctors. And AMA leadership includes such physician managers as Executive Vice President E. Ratcliffe "Andy" Anderson, M.D., a former hospital administrator.
The AMA board must sort out such issues as it devises a union structure. A plan of action is expected to be completed in July.
Alternatively, the California Medical Association and the New York State Psychological Association have chosen to cooperate with existing unions rather than form their own.
The CMA considered forming its own bargaining unit at the request of residents who were trying to organize a few years ago, said Roger Eng, M.D., a former CMA resident trustee and former president of a residents' union. But Eng said, "(The CMA) decided to stick with what it does best, which is professional and legislative advocacy."
The state society and the CIR are partners in membership and advocacy, placing the CMA in a curious position. The New York-based residents' union is affiliated with the SEIU, which will compete with the AMA for members.
But CIR leader Levy isn't worried. So far, the state society is holding firmly to its pact, which preceded the AMA's union vote. "The CMA has a proud history of doing things differently than the AMA," Levy said.