With private practice perceived as an almost impossible option for medical students and new doctors, an increasing number of physicians are expected to join the labor pool in coming years.
Since a pivotal National Labor Relations Board ruling in November 1999, residents, interns and fellows are considered employees, a status that provides them with legal protection to form collective bargaining units. For some of those young doctors, part of their education now includes learning how to negotiate the terms of their current and impending employment. They're turning to physician unions to teach them how to make a deal.
"As many as 90% of doctors who complete their residency today are going to be employed," says Susan Adelman, M.D., a pediatric surgeon in Detroit and president of Physicians for Responsible Negotiation, the union formed by the AMA in 1999. "Where the doctors can sit down and come to a satisfactory agreement with their employers, they don't need collective bargaining. But where their employers are obdurate, doctors will realize that they are protected by labor laws and that they can collectively bargain legally."
The AMA's 2000-2002 Socioeconomic Monitoring System survey of 3,341 medical doctors reports that 38.2% are employed, the bulk of those by a group practice, private hospital, medical school or the government. Figures from the federal Bureau of Labor Statistics show that 43.6%, or 313,180, of all practicing medical doctors and osteopathy doctors are on a payroll, not including group owners or managers.
Adelman says the two groups of residents that have approached PRN weren't angry about their treatment, they just wanted to negotiate a new contract. "They think this is the future, that this is a type of skill they need to develop while they are residents," Adelman says.
Comprising one of those groups are the 170 housestaff members at Advocate-Lutheran General Hospital in Park Ridge, Ill. Meetul Shah, M.D., a third-year family practice resident and president of the LGH Housestaff Association, says Lutheran General residents were treated well until the administration made midyear changes to residents' 2000 contract without their input.
Residents who previously had free health insurance were upset to find they would have to begin paying for it--some as much as $1,000 for family coverage, Shah says. The change in location of their free parking lot made some residents with early and late shifts nervous about walking to and from their cars in distant, poorly lit areas.
"We were at a loss as to what to do," Shah says. "Mostly it was a lack of voice that moved us to speak up and stick together."
Lutheran General spokesperson Marcia Opal says the new lot, which had to be moved because of an emergency room expansion project, is only across the street and notes that most other hospital employees have to pay for parking. Opal also says the hospital provided residents a stipend of several hundred dollars for the first year to help offset the health benefit charges.
The Lutheran General residents approached PRN in the spring of 2000. As the first to test the new legal waters at a private hospital, their early labor lessons are teaching them that the process of forming a collective bargaining unit can be slow and painful, especially when facing employer resistance.
The ballots of a two-day election conducted in early December to determine whether PRN will represent the Lutheran General residents have been impounded while the National Labor Relations Board investigates an appeal made by the hospital concerning a group of rotating residents. Counting of ballots will be delayed until the labor board determines whether to include the group. They are surgery and pathology residents, sponsored by Metropolitan Group Hospitals, who rotate through Lutheran General for just a few months. The board will not say when it will make that decision, which could result in a new election.
Lutheran General argues that the rotating residents should be counted. Shah and Adelman say whether they are included in the vote is immaterial because the residents already have the numbers needed to win the election. The hospital is merely sending up smoke screens, they say.
While Lutheran General's housestaff plays the waiting game (Shah says he expects to finish his residency by the time the major issues are resolved), the influence of physician unions on the healthcare system overall is unclear. Union enrollment numbers are still relatively low--less than 10% of all physicians, says Robert Weinmann, president of the Oakland, Calif.-based Union of American Physicians and Dentists. That would mean about 70,000 of the 719,000 medical doctors and osteopathy doctors that the Bureau of Labor Statistics says currently are treating patients, a number that seems optimistically high.
Eric Scherzer, director of United Salaried Physicians and Dentists in New York, estimates that more than 30,000 physicians are in unions, with about 11,000 of those being residents and interns. Though the numbers vary depending on who you talk to, the general consensus is that union membership among doctors has increased steadily in the past five years.
Adelman is enthusiastic about PRN's growth potential and says the union is developing affiliation agreements with labor groups being established by local and state medical associations. The Medical Society of the State of New York is the first group to move on this, voting in November to form an affiliation with PRN. At this stage, the relationship appears primarily to provide an educational resource for MSSNY members--they can consult with PRN on labor issues and questions before making the decision to unionize. PRN sees this as an opportunity for building grassroots contacts and support.
Mark Fox, M.D., an otolaryngologist in Scarsdale, N.Y., and chair of MSSNY's task force on collective bargaining, says although employed physicians are a small portion of the society's membership, many of them have turned to the state association for guidance.
"We had meetings with almost all of the existing unions," Fox says. "And we felt for a number of reasons, including potential conflicts of interest with healthcare members of other labor unions, that the professionalism of PRN was something many of our physicians considering a labor union would be interested in." Fox points out the AMA's ethical principles and PRN's no-strike policy as examples.
There also is a sense, Fox says, that if antitrust laws are changed at the state or federal level, a union would be beneficial even to independent physicians negotiating with managed care plans. "We'd like to have an organization that is ready, willing and able to do that when the laws are changed," says Fox.
Barry Liebowitz, M.D., president of Doctors Council, a New York-based union representing about 3,500 physicians, dentists and other providers, agrees that momentum and support for physician unions is building. He boasts that Doctors Council has lost only one campaign of eight it has conducted in the past five years, that it can't find enough organizers to meet demand, and that the union has managed to raise physician salaries in each of the contracts it has negotiated.
"Beyond all that, it's the due process that really carries a tremendous amount of weight," Liebowitz says. "That gives physicians the most mental security--knowing that they will not be summarily dismissed. What's written in stone in all of our contracts is due process."
Liebowitz points out that Doctors Council, the Committee of Interns and Residents, and the United Salaried Physicians and Dentists, partners under the umbrella organization of the Service Employees International Union-affiliated National Doctors Alliance, do not go out looking for people to organize. "We go where we are called," Liebowitz says.
Yet another player in the union movement is the Tallahassee, Fla.-based Federation of Physicians and Dentists, which organizes employed physicians but also has made a point to help independent practitioners get better contracts without violating antitrust laws, according to FPD's president, Jack Seddon.
For nonsalaried physicians, Seddon says, FPD deals with the insurance companies as a third party messenger to get better language, greater enforceability and better reimbursement rates in provider agreements. By conducting surveys, identifying the highest and lowest rates in a region and sharing that fee information (the payers must remain unidentified), the union does everything except collectively bargain, he says.
Seddon says new unions like PRN must tread carefully for fear of antitrust violations but that the 20-year-old FPD and others have figured out how to avoid legal pitfalls by using negotiating models that stay within the limits of antitrust law.
Jeffrey Goldman, who has represented hospitals as a labor attorney for the Chicago law firm of Fox and Grove Chartered, says the physician union trend of today hearkens to a simple labor truism: Every employer gets the union it deserves.
"If a medical organization treats its employees inappropriately, it's going to come back to them, whether it be a grievance procedure or through the accreditation process," Goldman says. "When people are unhappy, they look for a way of voicing their unhappiness."
Goldman says residents would be better off using the Accreditation Council on Graduate Medical Education's institutional requirements concerning the working conditions for housestaff, which include establishing a forum to discuss their grievances. The American Association of Medical Colleges also advocates the ACGME process, arguing that it is less adversarial than union negotiations. Some major differences between the two approaches are that unions are legally protected and also have the option to strike.
A counter opinion on the strength of physician unions is that of American Hospital Association spokesperson Rick Wade, who says that the impact of physician unions on hospitals thus far is not significant.
"Thirty percent of hospitals are operating in the red, another 30% are just doing OK--there are a whole series of pressures from managed care and insurance companies that have many hospitals focused on survival," Wade says. "When you're working to unionize and extract things from these hospitals, that's not a very bright prospect. If one of the things you're campaigning for is to hire new staff or increase salaries, what are you bargaining for that you can reasonably expect to receive?"
In Wade's opinion, much of the physician union movement is growing out of conscious choices doctors make about the economic terms of their practice.
"Their level of frustration is pretty high," he says. "Many are looking for economic shelter with a hospital only to learn that managed care is doing the same thing or worse to them--so the shelter is not there. That's when unionization takes on a little bit larger life."
PRN's Adelman says medical organizations are perhaps more concerned than they let on. "I think that there's more of a sentinel effect than we can measure," Adelman says. "Employers are going to be very mindful of the terms of their contracts because they don't necessarily want to see us."
As for Shah and his fellow residents at Lutheran General, he acknowledges that many would say the hardships they face are merely the dues all residents must pay.
"I don't think that's necessarily a good excuse," Shah says. "We're by no means the worst treated residents in Chicago, but, that said, it doesn't mean we should allow ourselves to be treated less well."
Shah says he assumes he will get a job when he completes his residency and that someone else will be signing his paycheck. But it appears the labor fight may have taken a toll on his optimism.
"I hope I have a job in July," he says, wondering if a union organizer is the first candidate an employer would choose.