Why do Physicians Want to Unionize?

Why do Physicians Want to Unionize?

Prior to the industrial revolution, production always occurred on a small scale. Individual members or small teams were responsible for production. However, technology allowed for the emergence of a centered production system – the factory.

This necessitated industrial management to coordinate the efforts of individual employees and integrate those efforts with the performance that new machines were capable of to maximize productivity. However, this focus on productivity often led the individuals to feel under-valued and taken advantage of.

The first trade union in the U.S. was formed in Philadelphia in 1794 as a response to wage reductions of journeymen tailors. These tailors were trading some of their autonomy in their work for bargaining power to demand higher wages for their work. Since this inception, unions have focused on protecting the rights of its members as well as stopping exploitation by employers.

Similarities in Healthcare

In today’s healthcare system, something similar seems to be happening. Hospital systems are designed to deliver healthcare as effectively, efficiently, and to as many patients as possible. For physicians, this has led to the implementation of the RVU model where wages are more directly tied to the “productivity” of the physician.

However, “more productivity” in this scenario is more accurately defined as “more billing”. This shifts the physicians’ focus from connecting with their patients and practicing medicine to centering it on seeing the highest number of patients, or performing the most procedures possible within an allotted amount of time. This shift away from practicing the craft of medicine can arguably account for a large chunk of the increased unnecessary diagnostic testing that takes place in hospitals. All of these changes have occurred in the name of productivity.

In addition to this focus on productivity, the healthcare system has become enormously more complex in recent years. Invariably, this increase in complexity brings along more hassles. How many hours have you spent on the phone trying to obtain prior authorizations for a medication that is clearly indicated for a patient? The list of hassles in this system seems endless and ever growing. While the focus on productivity likely contributes to a lesser degree, I would argue that the complexity and hassle factors in the current medical system are a larger contributor to physician burnout.

But let’s get back to productivity. The healthcare system must define productivity in this new system. As a result, everything is measured and everything is a metric. We all know that it is critically important for patients with STEMI’s to get from the ED to the Cath lab as fast as possible, but how does that patient’s care change when that time is being measured and reported as a quality metric that can affect pay? What effect does that extra pressure have on the physician? The pressure to produce is no longer just about the patient’s best interest.

There is enough blame to go around. This new system is a management failure and physician failure. Management treats professionals as factory production workers. The focus is on production and metrics such as “quality” and “patient experience”, meanwhile physicians are under more pressure than ever, and the subsequent moral injury and burnout is at an all-time high. The most recent study in the national burnout survey series co-authored by the AMA shows how the COVID-19 pandemic magnified long-standing issues that have accelerated the U.S. physician burnout rate. At the end of 2021, nearly 63% of physicians reported symptoms of burnout, up from 38% in 2020. Physicians can’t simply lead their staff and hold each other accountable as professionals anymore. It has become more about “me, me, me”, because that is how the system is set up.

Alright, deep breath. So, what is there to do? We are all familiar with just how much inertia the healthcare system has – just how impossible it feels to make changes. It seems the only thing to do is to negotiate in good faith. To listen to the staff, physicians, patients, and management to resolve these conflicts.

Pros and Cons of Unions

So, what does this have to do with unions? What are the arguments for the role of physician unions?

• To improve working conditions: Physicians are increasingly working longer hours in stressful environments. Unionization can help improve working conditions by negotiating for shorter hours, better pay, and more support staff.
• To protect income: Physicians have an expected income level in return for their years of education, level of experience, and liabilities they carry every time they care for a patient.
• To protect patient care: Unionized physicians believe that they are better able to advocate for patient care by speaking out against policies that would harm patients, such as cuts to insurance coverage or staffing.
• To have a voice in the healthcare system: Physicians are often at the mercy of hospital administrators and insurance companies. Unionization may give physicians a stronger voice in the healthcare system and allow them to advocate for changes that will improve the quality of care for all patients.
• To address management’s performance: Physicians sometimes feel that management is not listening to their concerns, providing them with the resources they need to do their jobs, is demanding too much of them, or not treating them fairly.

It is important to note here that not all physicians are in favor of unionization. Some believe that unionization will lead to higher costs for patients and make it more difficult to provide quality care. However, the number of physicians choosing to unionize is growing, and it is likely that unionization will continue to be a major issue in the healthcare system in the years to come.

The Path Forward

In a value-based model, volume is no longer relevant. So should be the RVU. There will be other challenges ahead – risks will be shared among more people and shifted on to people previously unfamiliar with them.

Administrators: Treat your physicians as professionals with recognition, and fair compensation. Move away from this focus on production. Furthermore, be transparent with physicians and involve them in the leadership and management of the healthcare system.

Physicians want to be involved in decision-making because it affects them and – more importantly – their patients.

Physicians: Take leadership! Act as clinical professionals and weed out the low-quality and low-productivity performers. You don’t need “quality metrics” to tell you who these people are – they reveal themselves. Hold each other accountable for quality, safety, experience and productivity.

Ultimately, whether physicians unionize or not is a decision that they make for themselves. However, management can play a role in influencing whether physicians feel the need to unionize or not. Here are some things that healthcare leaders can do:

• Create a positive work environment where physicians feel valued and respected. This means providing physicians with opportunities for growth and development, giving them a voice in decision-making, and treating them fairly.
• Invest in front line physician leadership. There is a direct correlation between physician dissatisfaction and ineffective front line clinical leadership.
• Address physician concerns in a timely and fair manner. If physicians have concerns, management should take them seriously and work to address them. There is a perception that since physicians are highly compensated, they should not complain – this is wrong.
• Place more physicians in leadership roles.
• Create an equal dyad structure with physicians and managers co-managing.
• Be transparent with physicians about your organization’s finances and decisions. Physicians are more likely to trust administration if they feel they are being kept in the loop about what is going on in the organization.
• Encourage open communication between physicians and administration. Physicians should feel comfortable coming to management with their concerns and ideas.
• Create an environment where physicians can have a reasonable work/life harmony or balance. Younger generations do not want to live the way their fathers and mothers did. They want to go to their kids’ soccer games and recitals. They want to be present in their children’s lives. This means providing physicians with opportunities to have flexible schedules with reasonable on-call and work hour expectations.

By taking these steps, healthcare leaders can help create a positive work environment where physicians feel valued and respected, and where they are less likely to feel the need to unionize.