Healthcare Labor Unions-Has the Time Come?

Labor unions in America look like they are making a comeback. Employees at  Starbucks stores, Amazon warehouses, Trader Joe's, and REI, grad students, Uber and Lyft drivers and employees at the Medieval Times have voted to unionize. Hollywood actors and writers, the United Auto Workers, and Kaiser Permanente employees have been on strike (1). Headline writers began declaring things like, "Employees everywhere are organizing" and that the United States was seeing a "union boom” (2). In September, the White House asserted "Organized labor appears to be having a moment" (2). However, the Bureau of Labor Statistics recently released its union data for 2022 and the data shows that the share of American workers in a union has continued to decline (2). Last year, the union membership rate fell by 0.2 percentage points to 10.1% — the lowest on record.

Despite an increase in union efforts since the pandemic, healthcare workers — particularly doctors — have been slow to join unions. Doctors Council bills itself as the largest physician union in the country with 3500 members according to Joe Crane, national organizing director. However, Crane estimated that only about 3% of US physicians are currently union members. A minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape's APRN compensation report last year. In a rare alliance, more than 500 physicians, NPs, and PAs at Allina Health primary care and urgent care clinics in Minneapolis, Minnesota, recently filed a petition with the National Labor Relations Board to hold a union election. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD. The Allina healthcare providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.

The economist, Suresh Naidu, and his colleagues have found influential evidence showing that unions played a critical role in boosting wages for American workers and reducing income inequality in the early-to-mid 20th century (3). However, "American labor law just puts an enormous barrier in the way of workers joining a union," Naidu says. "So you need to convince 50% plus one of your coworkers to join a union if you want a union.” That alone can entail a difficult and time-intensive campaign process. Our labor laws make it relatively easy for employers to short-circuit organizing efforts (3). Even when some of their tactics are technically illegal, companies are given wide latitude to thwart unionizing with minimal legal sanctions (3). Union organizers are forced to strategize and organize outside their workplace and figure out how to convince coworkers to join the fight without getting penalized or fired.

The obstacles to forming a union have only grown in recent decades. Around 27 states have passed "Right to Work" laws, which make forming a union more difficult in states with those laws and provide a refuge for companies looking to escape unions in states without those laws (2). Globalization has given companies the option to close-up shop and move overseas. Automation has given companies the option to replace workers with machines. Deregulation has increased industry competition and weakened unions' ability to extract concessions from monopolistic companies. Various changes to labor law, by the U.S. Congress, by state legislatures, and by the federal courts, have made it harder for unions to grow and thrive. Corporations now spend millions and millions on highly paid consultants, developing effective tactics to suppress unionizing efforts and pressure their workers into submission. Once workers form a union, it now takes an average of 465 days for the union to sign a contract with their employer.

Doctors, nurses and healthcare workers tend to underestimate their potential to influence healthcare. If doctors formed a union, many of my colleagues, myself included, would be opposed to an all-out strike since this would likely harm patients. However, the present healthcare system depends on the flow of paperwork with business interests relying on doctors and nurses to generate. Refusing to fill out billing sheets, discharge patients, participate in non-patient care hospital activities are just some of the ways doctors and nurses could impact the system without denying care to patients. A recent strike against Kaiser drove a settlement in 3 days with an increase in wages and an agreement to improve staffing levels (1). The threat of another pandemic and the need for healthcare workers to care for these patients despite chronic understaffing, leaves management backed into a corner.

Under these pressures and given the attitude of many doctors and nurses that they are healthcare professionals, not blue-collar workers, it is not surprising that the majority of doctors and nurses are not unionized. However, among my own social group of retired physicians the reluctance to join unions may be waning. One of my most conservative colleagues put it this way, “What choice do we have? Doctors have lost control of medicine and business interests have exploited their control over medicine to take advantage of us and our patients.” Many healthcare workers felt betrayed after the recent COVID-19 pandemic (5). They sacrificed much but received no rewards or even thanks for their sacrifices. Regardless, complaining about the situation is unlikely to change anything. Business interests are unlikely to relinquish control since they are making money, in some cases huge amounts of money. Unions may be one way to reverse the “hyperfinancialization” of medicine and return to a not-for-profit service for patients.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Selena Simmons-Duffin S. After historic strike, Kaiser Permanente workers win 21% raise over 4 years. NPR. October 14, 2023. Available at: https://www.npr.org/sections/health-shots/2023/10/13/1205788228/kaiser-permanente-strike-contract-deal-reached (accessed 10/23/23).
2. Rosalsky G. You may have heard of the 'union boom.' The numbers tell a different story. NPR. February 28, 2023. Available at: https://www.npr.org/sections/money/2023/02/28/1159663461/you-may-have-heard-of-the-union-boom-the-numbers-tell-a-different-story#:~:text=Headline%20writers%20began%20declaring%20things,its%20union%20data%20for%202022. (accessed 9/30/23).
3. Farber HS, Herbst D, Kuzimenko I, Naidu S. Unions and Inequality over the Twentieth Century: New Evidence from Survey Data. The Quarterly Journal of Economics. 2021; 136 (3):1325–1385. [CrossRef]
4. Associated Press. Kaiser Permanente Reaches a Tentative Deal with Health Care Worker Unions After a Recent Strike. October 13, 2023. Available at: https://apnews.com/article/kaiser-permanente-health-care-workers-strike-411aa1f084c19725f29ff87766e99704 (accessed 10/14/23).
5. Griffin M, Hamilton P, Harness O, Credland N, McMurray R. ‘Running Towards the Bullets’: Moral Injury in Critical Care Nursing in the COVID-19 Pandemic. J Manag Inq. 2023 Jun 26:10564926231182566. [CrossRef] [PubMed]

Cite as: Robbins RA. Healthcare Labor Unions-Has the Time Come? Southwest J Pulm Crit Care Sleep. 2023;27(5):59-61. doi: https://doi.org/10.13175/swjpccs047-23 PDF 

Why My Experience as a Patient Led Me to Join Osler’s Alliance

There are a number of books and articles written by doctors that relate their own experience as patients. Count this as another although I promise it will not be nearly as entertaining as “The House of God”. Over a month ago I became short of breath and a chest x-ray revealed left lower lobe consolidation. Despite lack of fever, it seemed that an infectious process was most likely, and when multiple tests for COVID-19 were negative, it was felt by my pulmonary physician to be most likely coccidioidomycosis despite a negative cocci serology. After beginning on empirical therapy with fluconazole for nearly a month, I am feeling better.

Most of us know that there is considerable laboratory to laboratory variation in serologic tests for Valley Fever (1). However, when my initial cocci serology was negative, efforts to send it a good reference lab such as Pappagianis’ Lab at UC Davis became nearly impossible. After making an appointment at Sonora Quest and waiting a week for an appointment to get my blood drawn, it was apparently sent to Davis, but when payment was not assured, it was not run. I would have been paid for it out of pocket but there seemed no way to communicate this.

Similarly, it took 3 visits to a commercial outpatient radiology practice, Simon Med, to get a routine chest x-ray. I can understand the need for appointments for CT scans. However, routine x-rays were so backed up that I waited several hours to get a chest x-ray performed although I did get an electronic copy. Fortunately, I am able to read my own chest x-ray and did not need to wait for a radiologist’s report which arrived on a Tuesday after the chest x-ray was taken late on a Friday.

Honestly, I had no idea that our patients were receiving such poor care. Delays of this magnitude go beyond what I view as acceptable. Overall, I think my doctors are great but I have concerns about an overall decline in patient care. It should not take a week to get routine labs drawn. Sick people should not be making multiple trips to get a simple chest x-ray. This may be another symptom of the hyperfinancializaton of medicine where patient care is sacrificed for profit. The hospital labs and x-ray departments of years ago were run by physicians and mostly concerned with patient care and not losing money. Today with businessmen controlling nearly all aspects of healthcare patient care is less important than maximizing profits.

I worry that our businessmen/managers are buying medical practices and directly supervising healthcare professionals. Healthcare is a business to them, no different than selling hamburgers at McDonalds. Their goals of increasing income and reducing expenses to maximize profits while hiding behind the façade of a non-profit organization is quite apparent. However, what is equally clear is that there is a lack of medical knowledge in these medical managers and decisions can be “penny wise but dollar foolish”. Look at the decision to not pay for a more reliable cocci serology which costs $80. They have spent more than this on fluconazole. Bad medicine is usually costly.  

The COVID-19 pandemic has brought to light many of the inadequacies of business interests dominating medicine (2). Hospitals are overflowing and inadequate personnel with inadequate personal protective equipment are available to care for them. Those remaining providers are expected to just “pick up the slack”.

Although I have long lamented (some say whined) about the businessmen’s mismanagement of medicine, what could we do? Business interests seemed to control the hospitals, the insurance companies, Centers for Medicare and Medicaid Services (CMS), and the licensing boards. We were being squeezed and trainees just beginning practice were in no position either financially or professionally to confront business interests which could end their career.

I appear to not be the only one who feels way. Last year, Eric Topol MD, founder and director of the Scripps Research Translational Institute and editor-in-chief of Medscape, wrote a piece published in The New Yorker, "Why Doctors Should Organize” (3). In it, he explained his view that the nation's nearly 900,000 practicing doctors needed to organize to bring back the doctor-patient relationship that existed before the business part of medicine took over its soul. Physician organizations such as the American Medical Association (AMA) represents only about 17% of US physicians, and have done little for medicine as a profession. The next largest, the American College of Physicians, represents internal-medicine specialists. Most of the smaller societies (e.g., ATS, American College of Chest Physicians) represent a subspecialty and have correspondingly fewer members each. The AMA once represented three-fourths of American doctors; the growth of subspecialty societies may have contributed to its diminishment. In any case, there is no single organization that unifies all doctors. The profession is balkanized into different specialties each hostilely eyeing the other specialty organizations.

Therefore, Topol has led the formation of Osler's Alliance (now Medicine Forward) (4). This organization, named for William Osler, hopes to draw together the nation's doctors, who come from different backgrounds, specialties, and political leanings but agree that the way they interact with patients is not what they envisioned when they decided to devote their lives to medicine.

"Such an organization wouldn't be a trade guild protecting the interests of doctors," Topol wrote. "It would be a doctors' organization devoted to patients (5)."Another organizer of Osler's Alliance, Esther Choo, MD, MPH, an emergency physician and professor at Oregon Health & Science University in Portland, described physicians' widespread daily feeling that "this can't be the way it's supposed to be," but also a lack of empowerment to make changes (5). That's where the numbers come in, she said. A massive group of physicians standing up against practices could force change.

The first step, Choo said, is to break down the fundamental mission into "bite-sized advocacy (5)." That might entail advocating for answers to why increased documentation demands are necessary and how, specifically, they help the patient rather than dutifully complying with directives for more charting.

The leaders emphasize that membership in the group is not about money, which is why it's only $5 a year. Signing up builds support and allows access to chat streams and information in a broad network. "When you start seeing advertisements for health systems that say, 'We give the gift of time to patients and clinicians,' " answered Topol, "then we'll know we're turning the right corner (5)."

If you are a physician or other provider, you might consider joining Osler’s Alliance. What have you and your patients got to lose? Staying the present course would seem to lead to nowhere.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):238-49. doi: http://dx.doi.org/10.13175/swjpcc054-15
2. Dorsett M. Point of no return: COVID-19 and the U.S. healthcare system: An emergency physician's perspective. Sci Adv. 2020 Jun 26;6(26):eabc5354. [CrossRef] [PubMed]
3. Topol E. Why Doctors Should Organize. The New Yorker. August 5, 2019. Available at: https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize (accessed 11/30/20).
4. Osler’s Alliance website. Available at: https://oslersalliance.mn.co/about (accessed 11-30-20).
5. Frellick M. Medical Leaders Launch Grassroots Doctors' Alliance. Medscape. November 25, 2020. Available at https://www.medscape.com/viewarticle/941623 (accessed 12/30/20).

Cite as: Robbins RA. Why My Experience as a Patient Led Me to Join Osler’s Alliance. Southwest J Pulm Crit Care. 2020;21(6):138-40. doi: https://doi.org/10.13175/swjpcc066-20 PDF

Changes in Medicine: the Decline of Physician Autonomy

Reference as: Robbins RA. Changes in medicine: the decline of physician autonomy. Southwest J Pulm Crit Care 2011;3:49-51. (Click here for a PDF version)

Thirty years ago when I left fellowship, there were predominantly two career paths, private practice or academics. I had chosen academics by virtue of doing a fellowship at a heavily research-based program, the National Institutes of Health (NIH). However, even at the NIH many of my colleagues eventually ended up in private practice, which was more lucrative and much more common than the academic practice I chose. Now a third path has become more common, practice as a hospital employee. I became a hospital employee over 30 years ago when I became a part-time, and later, full-time physician at a Department of Veterans Affairs (VA) medical center affiliated with a university. Apparently I was ahead of my time. In an article entitled “Majority of New Physician Jobs Feature Hospital Employment” 56% of physician search assignments by the national physician search firm Merritt Hawkins in 2011 were for hospitals (1). This had increased from 51% in 2010 and 23% in 2006. In contrast, only 2% of the firm's 2011 search assignments featured openings for independent, solo practitioners, down from 17% in 2006. "The era of the independent physician who owns and runs his or her practice is fading," according to Travis Singleton, a senior vice-president at Merritt Hawkins.

The reason that hospitals want to employee physicians is obvious-money. By increasing market share and collecting professional fees, hospitals profit from physician employment. Physicians may be fearful of the cost of setting up a private practice with the increasing uncertainties of reimbursement, making a salaried hospital position attractive. This is especially true for a new physician not wishing to add to the debt incurred during training or seeking less than full-time employment for family or personal reasons (2).

Although quality or efficiency is often touted as a major reason for hospitals to employee physicians, recent research suggests that neither result. Kuo and Goodwin (3) reviewed over 50,000 Medicare admissions and found that hospital length of stay was 0.64 day less and costs $282 lower among patients receiving hospitalist care compared to primary care physician care. However, this reduction in inpatient costs under the care of hospitalists was more than offset by a $332 increase in charges after discharge.  Furthermore, patients cared for by hospitalists were less likely to be discharged to home; more likely to have emergency department visits; more likely to be readmitted to the hospital; less likely to have a follow up visit with their primary care physician; and more likely to be admitted to a nursing facility. As the authors point out this is nothing more than cost shifting, and hospitalists, who are typically hospital employees, may be more susceptible to behaviors that promote cost shifting. Consistent with this concept, O’Malley et al. (4) state that hospital employed physicians increase costs by higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care.

Although the disadvantages of hospital employment are several, “Ultimately, the loss of control over their own professional lives is what irks employed doctors the most…” (5). As someone who worked as a hospital employee for the VA for over 30 years, I found an increasing “master-servant relationship” particularly annoying. Decisions were often based on financial or political considerations by nonphysicians or under-qualified clinicians. For example, some have recommended propofol as a standard in conscious sedation (6). It offers a number of advantages including ease of titration and short duration of action. Propofol has been used by our group for years in the ICU. Our group applied for “privileges” to use propofol for bronchoscopy which was endorsed by the pharmacy and therapeutics committee. Yet, the clinical executive board denied the application which our group found puzzling.  I was later told by a quality assurance nurse that the basis of this decision was that propofol is what killed Michael Jackson.  Hopefully medical decision making meets a higher standard than the singular example of what may have happened to a pop star.

Another example is the guidelines from groups like the Institute for Healthcare Improvement (IHI) that quickly becomes hospital mandates. Many of these guidelines are, at best, weakly evidence based (7). Furthermore, the guidelines are bundled, i.e., several guidelines are grouped together. Bundling makes it difficult, if not impossible, to determine which guidelines are effective. Most have probably had little impact on patient outcomes, but at least one proved to be catastrophic. Tight control of blood sugar in the intensive care unit was mandated and monitored by the VA based on IHI recommendations. However, as demonstrated in the NICE-SUGAR study, tight control actually resulted in a 14% increase in patient mortality (8). This increase in mortality would translate to 9503 excess deaths at all VA hospitals between 2002 and 2009 or about 1 death for every 84 patients treated with tight control of glucose. After publication of the NICE-SUGAR study the IHI dropped the issue from its web site and the VA switched to also monitoring hypoglycemia. One might think that a guideline which resulted in a 14% increase in ICU mortality would cause an outcry to punish those responsible, but instead resulted only in a deafening silence.

I am hopeful that we have trained our young physicians to practice for their patients’ benefit, rather than the financial or political well-being of the hospital. Yet, I fear that the financial pressures of beginning practice and protecting one’s reputation and livelihood may be too great a pressure to resist. Until physicians are not supervised by non- or under-trained administrators in a “master-servant” relationship, incidents such as the increase in ICU mortality secondary to tight control of glucose are bound to reoccur.

Richard A. Robbins MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Crane M. Majority of New Physician Jobs Feature Hospital Employment. Medscape 2011. http://www.medscape.com/viewarticle/744504?sssdmh=dm1.695421&src=nldne (accessed 8-22-11).
2. Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7.
3. Kuo Y-F, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152-9
4. O'Malley AS, Bond AM, Berenson RA. Rising hospital employment of physicians: better quality, higher costs? Center for Studying Health System Change (HSC) 2011. http://www.hschange.com/CONTENT/1230/#ib5 (accessed 8-23-11).
5. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
6. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol 2010;23:494-9.
7. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
8. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.