Time to Rethink Physician Unions in the Wake of COVID-19

Physicians and other frontline health professionals around the world risked their lives to serve those who needed medical attention from SARS-CoV-2. As physicians, we were strained in hospitals and other healthcare settings across the country, overburdened by the sheer volume of patients. Early on, healthcare settings struggled to ensure the safety of their workers, who were often at high risk for COVID-19 infection. Ensuring adequate protection was challenging given the uncertainty of the virus, requiring physicians to rely on a patchwork of local resources, including their practices, hospitals, or public health systems, to provide the equipment they needed.

Physicians and other health professionals beset by these challenges often had no effective means to express concerns. Although physician professional associations such as the American Medical Association (AMA) and American College of Physicians (ACP) provide a national voice for physicians and advocate for relevant payment policy changes, they rarely offer a clear or effective voice at the local level where these challenges arose. This difficulty may have been felt by physicians working in large provider organizations. Most private sector physicians now work in such organizations and may have limited power to control their work environment and safeguard their ability to deliver high-quality patient care. In view of limited alternatives to ensure such physicians have an effective voice for their professional concerns, this is an excellent time to consider the benefits of physicians organizing into a doctors’ union.

Primacy of the Physician-Patient Relationship

With the rise in control of physician practices by large corporations there is concern that the physician-patient relationship, already strained by the fractured U.S. healthcare system, may further erode. Inherent to the physician’s responsibilities in this relationship is the vast asymmetry in information between the physician recommending a service and the patient who must act on this recommendation. For efficient, effective, and compassionate care, patients must trust the physician to provide appropriate clinical recommendations specific to their needs and to not be unduly motivated by personal financial gain. The ACP’s recent position paper on financial profit in medicine sends a strong message that, “[p]hysicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high- quality, appropriate care within the guardrails of medical professionalism and ethics.”¹

The rapid rise in physician management by larger healthcare organizations widens the potential gap between the physicians who discharge these professional responsibilities at the point of care and the managers who control the clinical settings. This may result in these physicians having less power in controlling their work environment, with the corporate decision-makers often distant from the settings, professionals, and patients impacted by these decisions.² Management decisions made at these large and complex organizations may create even greater risks that could run counter to the physician’s professional responsibilities to their patients. The repercussions of these management decisions can undermine the fundamental tenets of the physician-patient relationship. These problems can be challenging when responding to even routine variations in clinical demands, such as those brought on by seasonal influenza surges.

Provider Consolidation Woes

The COVID-19 pandemic exposed additional weaknesses in the fragmented and fractured U.S. healthcare delivery system. For example, the many practice organizations relying on traditional fee-for-service reimbursement struggled with requirements to curtail face-to-face services. The pandemic necessitated the rapid transition to telehealth visits, posing severe challenges to medical practices slow to respond, with various anecdotes suggesting larger health systems adapted more quickly.³

There is extensive evidence supporting the advantages of smaller, independent physician practices and that consolidation of smaller practices may be associated with higher burnout rates from a poorer work environment.⁴ Nonetheless, it seems likely that the diverse financial struggles of smaller physician practices may force more of them into consolidation under larger organizations, for profit and non-profit alike. As a result, there may be further constraints on physician control of their work environment and ability to fulfill their professional responsibilities to patients.

What Options Do Physicians Have?

Physicians within large organizations often have little control over their practice settings where mangers are distant from the frontline, leading to decisions with negative impacts on patient care. These physicians may feel powerless to take action to improve their work environment; some have even expressed concerns about job termination for speaking up.

In some communities, physicians may have few or no options to shift to alternative settings to serve patients. For example, large organizations often rely on non-compete agreements to limit their physicians’ options to practice in the community. As single healthcare systems start to dominate local communities, some physicians will face the prospect of uprooting their professional and personal lives in response to poor corporate management (e.g., moving their family from the community). In markets where these systems cannot enforce such non-compete arrangements, concerned physicians may still face the daunting task of joining (or even establishing) a private practice in competition with the dominant local provider.

As we have seen with the COVID-19 pandemic, clinical work environments can change quickly with the need for major adjustments to staffing, professional responsibilities, and schedules. While the hope is that the responsible managers of clinical settings ensure the proper support, safety and well-being of the clinicians, the size and speed of change in many large healthcare organizations is not reassuring. Thus far, physician professional societies, such as the AMA, have not been organized or governed to address the local concerns of such physicians. Nor have concrete policy proposals emerged to create regulations that ensure these growing healthcare systems effectively address such concerns expressed by health professionals at the point of care.

Where Organizing Can Help

By organizing into a unified voice, physicians in these large organizations could gain leverage to negotiate greater professional control over clinical settings and the resources needed to ensure high-quality patient care. Organizing has numerous advantages including ensuring an appropriate professional workload and sense of control and engagement, thus fighting burnout for frontline clinicians. These changes may improve health outcomes, and provide a more consistent and concrete avenue to advocate for our patients and effect real, sustainable change.⁵ Prior experience from house staff unions has shown that unions can provide better pay and benefits, and potentially lead to higher quality care.⁵

The AMA once created a nationwide physician union but there was little support due to the complexities of the U.S. healthcare workforce. The Union of Physicians and Dentists is the largest independent physician union in the United States; but, with only 4,000 members, it pales in comparison to large professional societies, such as the AMA. While these professional societies have strong and powerful lobbies to impact federal policy change, they lack the power needed by employed physicians to secure adequate support and benefits for their workplaces.

Employed physicians in large healthcare systems or multi-specialty group practices do offer benefits but in the wake of COVID-19 and the corporatization of healthcare through provider consolidation and private equity acquisitions, physicians need to advocate and bargain for themselves more. Organizing into a union, for instance, can provide the negotiating power needed to improve working environments and general well-being by giving doctors back their agency and maintaining their moral obligation to patients.⁴ Happier doctors could lead to better care delivery and happier patients.

Now What?

COVID-19 has accelerated many aspects of healthcare innovation out of necessity. Now is the time for physicians to band together not only to form a unified voice beyond policy lobbying but also to ensure their well-being. With a unified voice, physicians can continue to care for patients safely and effectively and counter the corporate winds that may corrode their professional responsibilities. COVID-19 exposed weaknesses in the healthcare system that relies on physicians and the many other frontline workers to bear through. With collective action, physicians can provide the high-quality care patients need while caring for themselves.

Disclaimer: Opinions expressed by Dr. Meiri are his own and not reflective in any way of the U.S. Government or Department of Veterans Affairs.