In order to form a more perfect union

I am a “Coal Miner's Daughter.”

Well, technically, a coal miner's granddaughter, although that movie always spoke to me as an illustration of what my life could have been like had my grandparents made different decisions. My grandfather, after spending his childhood and early adulthood as a coal miner in eastern Kentucky—even being featured in a book, “Coal Camp Kids Coming Up Hard and Making It”—decided to take my grandmother, whose father happened to manage the local coal mine, out of Kentucky to travel around the country and help organize unions for those in industries with difficult working conditions. In a sense, union organization was what opened my mother's world up to a wider one that, in turn, offered me greater opportunities for education, travel, and more.

Labor unions for coal miners and others in various industries have been instrumental in the United States by ending practices such as child labor, implementing a minimum wage, and shortening the required workday. In general, labor unions are organizations that bargain collectively on behalf of their members. While they are most prevalent in industries like manufacturing, service, and mining, there are also many “white collar” labor unions representing professionals in legal occupations, governmental roles, health care, and technical occupations.

In the health care sector, there is substantial unionization, with 13.2% of health care workers reporting either being a member of a labor union or a nonmember covered by a union contract. Physician unions came about in the 1950s to organize physicians and dentists who were public employees in New York City, ultimately forming the Doctors Council, which then became affiliated with the Service Employees International Union in 1999.

The U.S. health care system has undergone major changes over the last 20 years, including consolidation of hospitals, health systems, and insurers; corporate and private equity investment; loss of clinical independence by physicians; increased clinician burnout; and staffing conditions that worsened during the COVID-19 pandemic. Recognizing this, ACP determined the need to review and update our policy related to unionization of physicians and collective bargaining. “Empowering Physicians Through Collective Action: A Position Paper of the American College of Physicians” was published on April 29 in Annals of Internal Medicine. This paper builds upon and updates ACP's prior policy on the topic, which largely resided in our Ethics Manual and focused more directly on strikes and other joint actions by physicians, stating, “Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available.”

This new paper takes a more nuanced approach in recognition of how the health care environment has evolved and therefore makes the following recommendation: “Stepwise actions, from refusal to perform administrative or billing duties to concerted refusals to work, should only be considered once all other negotiating tactics have been exhausted, and efforts have been made by all involved parties to ensure safe patient care.”

The paper goes on to discuss the importance of engaging in mediation or arbitration prior to any sort of work stoppage or strike and notes that there have been times when physician strikes have promoted physician interests above those of their patients. Refusals to perform administrative or billing duties can be a meaningful approach during the negotiation process that would likely have less impact on patient care. However, when all other negotiating tactics have been exhausted, it may be necessary for physicians to strike. In this case, ACP notes that it is critical for physicians to clearly articulate how these work stoppages are intended to benefit patient care.

Further, a large majority of physicians in the bargaining unit need to agree to this action, and they need to provide ample notice to the patients, the public, and the organizational management and develop a system to ensure access to patient care. The bottom line is that physician strikes are a method of last resort that must be transparent and come with contingency plans.

In fact, the first recommendation in this paper states that “the primary objective of collective empowerment actions by physicians should be to ensure that patients have access to safe, affordable, high-quality care.” Further, collective empowerment actions should be used when needed to improve quality of care, health equity, the patient-physician relationship, and physician well-being. Therefore, ACP's position has evolved to one that overall supports physician unionization when these parameters are met and when physicians are provided the choice of whether or not to join a union, ideally with other aligned health care professionals.

With that said, the College also recognizes the need for ongoing research into the effects of physician collective empowerment actions on patients and their access to care. We also continue to recommend that physicians explore other options such as public advocacy and organized protests, in addition to or in lieu of unionization. It is also critically important that practicing physicians be included in executive positions on hospital and health system governing boards and be able to communicate effectively with leaders in these systems about patient care and safety, working conditions, administrative decisions, and clinical policy.

While strikes are one action that a physician union can take, there are other actions and activities that physicians can engage in to elevate their voice. Two innovative ideas outlined in the paper are labor-management partnerships (LMPs) and professional association-union “dual affiliation” models.

Under LMPs, employee physicians and their employers make an intentional effort to ensure that employees have an active say in decisions on technology, finance, workforce challenges, and other issues. The longest-running example of this type of arrangement is the Kaiser Permanente Labor Management Partnership, which was established in 1997 to avoid a nationwide strike.

Dual-affiliation models were first considered in the late 1990s as well. In this case, the professional association (e.g., ACP) would work to promote physician professionalism and autonomy, while the union would bargain for physician wages, benefits, hours, et cetera. Individual physicians affiliated with both the association and the union would need to determine their relative commitment to each effort. This type of professional association-union paradigm does exist in other professions; for example, several state nursing associations have affiliated with labor unions.

One ongoing challenge for physicians who do wish to join or form a union is the definition of “supervisor.” The National Labor Relations Act of 1935 exempts supervisors from joining or forming a labor union or other bargaining unit. As stated in the new position paper, ACP believes that “frontline physicians should not be considered supervisors solely because they provide clinical leadership to a health care team.” Therefore, we are supportive of efforts to narrow the definitions of supervisor for the purposes of collective bargaining.

I wonder sometimes what my grandfather would think about physician unionization, given that the author of the book in which he was featured wrote, “[D]octoring in the coal camp was as much guess-and-by-God as tried-and-true-therapeutics.” However, I know that if he were aware of the challenges physicians now face within their health systems, he would be right there by their side helping. My grandfather was known as a difficult man to most, but there was never a question about his sense of fairness and pursuit of what was right. This is how I know that ACP's evolved position has landed in the right place: in support of our members who feel they need to organize themselves to ensure high-quality and safe patient care, while also protecting their own well-being. All of these things can and should be pursued at once—and sometimes unionization may be the answer.